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Tracheostomy

Tracheostomy. By Ussana Promyothin MD. Tracheostomy. Surgical opening in the trachea for ventilation Indication Bypass upper airway obstruction Clearance secretion at lower respiratory Prevent aspiration gastric content in absent of laryngeal reflex. Other indication

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Tracheostomy

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  1. Tracheostomy By Ussana Promyothin MD.

  2. Tracheostomy Surgical opening in the trachea for ventilation Indication Bypass upper airway obstruction Clearance secretion at lower respiratory Prevent aspiration gastric content in absent of laryngeal reflex

  3. Other indication Prolong intubation(1-3wks) children more prolong Laryngeal injury Fracture face neck area

  4. Also • Improved oral hygiene • Oral movement for communication • Reduction damage larynx,nose ,mouth

  5. Contraindication • Prolong bleeding • On anti-coag, anti-pletlet medication

  6. Elective tracheostomy • Emergency tracheostomy: should avoid, expertised surgeon,team • In children: perform only with a secured airway either from ET tube or bronchoscope in OR • Emergent tracheostomy should be avoided if possible • Risk to vascular,lung and uncontrolled airway

  7. Hyperextend the neck,

  8. 2 FB above thyroid notch ring 2,3

  9. Skin incision,horizontal /vertical

  10. Find white line,Test tracheostomy cuff

  11. Clean trachea,aspirate air then push xylocaine

  12. Stay suture,open trachea by inverted U flap,cross,vertical (in children stay suture on both sides of incision)

  13. Standby tracheal dilator,suction,

  14. Post operation care • Irrigation with saline and suction q 15 mins • Suction not exceed 15 seconds (block airway and suck Oxygen out) • Humidification Oxygen (decrease thick mucus)

  15. Observe bleeding and subcutaneous emphysema • Off packing 24-48hrs • Left tube in place 5-7 days • Stitch off and off stay suture 7th day

  16. Blow Cuff when on ventilation or prevent aspiration • Not exceed 25 cm H2O • Clean inner tube • analgesic

  17. Complication Immediate • Apnea :loss hypoxic drive,COPD  ventilator • Post obstructive pulmonary edemaPEEP • Pneumothorax chest x-ray post op • Injury to adjacent organ:thyroid ,vessel, esophagus,recurrent laryngeal nerve

  18. Pneumothorax

  19. Early • Bleeding HT, skin,thyroid,soft tissue • Mucus inner tube • Tracheitis humidification, minimize FiO2, Stabilize tracheostomy • Cellulitis: wound care,antibiotic • Displacement: pass E-T tube, NG tube

  20. Late Bleeding -innominate vessel:usually in 2wks,highmortality (low tracheostomy,mobilized tracheostomy tube,high pressure cuff,local infection) -granulation( stroma, tip of tube) Tracheoesophageal fistula:risk in retain NG tube

  21. Type of Tracheostomy

  22. Cricothyrodotomy:maneuver to buy time

  23. Advantage • Near skin and less dissection Disadvatage • Trauma to subglottic area • Contraindication:children<12 yrs,infection at larynx,laryngeal trauma and risk transecting tumor

  24. Tracheostomycare • Clean skin around stroma • Change gauze • Clean inner tube • Aware obstruction or slip out of tube

  25. Weaning tracheostomy tube • Reason for tracheostomy has resolved • Stable lung status(O2<40%) • Effective swallow,gag,and cough reflex • Adequate nutrition, sleep, psychososial suppor • Cuff deflate trial

  26. Method • Flexible bronchoscope or IDL • Assess cord movement,granulation,stenosis area • Admit,size tube down • Plug tube day,all day night • Off tube,observe before discharge

  27. Epistaxis

  28. Abnormal bleeding per nose • Cause • Trauma ,nose picking ,nose blowing • URI, allergic rhinitis • Septum deviation • Decongestant ,nasal spray • Foreign body • Tumor • Post surgery

  29. Hypertension, artherosclerosis • Anticoagulation drug,ASA,NSAID • Decrease plt • Liver function disease

  30. Site of bleeding

  31. MANAGEMENT • Immediate evaluation :vital sign,airway • Stop bleeding • Compress nose,cold pack

  32. Anterior epistaxis • Little’s area region • Ephridine or adrenaline pack (vasoconstrict agent) • Beware in HT • CAUTERIZATION • 30%TCA,silver nitrate, electrical cautery • Gel foam

  33. Anterior nasal packing

  34. Nasal speculum

  35. Headlight

  36. Suction

  37. Anterior nasal packing

  38. Vasaline gauze or coated with antibiotic ointment • Apneanaso-vagal reflex bradycardia,hypotension • Remove packing 2-4 days later • Antibiotic and decongestant

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