Patient with tracheostomy Presentor: Abraham Sonny Moderator: Dr. Rani Sunder

1. CASE PRESENTATION Patient with tracheostomy Presentor: Abraham Sonny Moderator: Dr. Rani Sunder www.anaesthesia.co.in anaesthesia.co.in@gmail.com

2. Age : 40 years Gender : male Presenting complaint : hoarseness of voice for 8 months. status tracheostomy since 3 months History of present illness : patient noticed hoarseness in his voice 8 months back . increased progressively not associated with stridor

3. No history of dyspnoea dysphagia No history of cough or expectoration. No history of bleeding from tracheostomy site accidental decannulations tube obstruction infection at the stoma site difficulty in replacement/ change of tracheostomy tube Patient was posted for direct laryngoscopic examination and VC biopsy.

4. Past history: Surgical: • patient underwent microlaryngeal surgery 6 months back under GA, u/e. • Was diagnosed as vocal cord papilloma • Symptoms subsided subsequently. • Patient had a recurrence of symptoms 3 months back for which he underwent repeat resection of the lesion. • Towards end of the surgery there was bleeding from operative site which was controlled with adrenaline soaked gauge. • At the end of surgery elective tracheostomy was done for airway protection. Histopathological examination revealed sqamous cell carcinoma and patient was referred to AIIMS.

5. Medical: not a known case of DM. HTN, asthma, TB Personal history : non smoker, non alcoholic Family history : non contributory General physical examination: NO pallor/ icterus/ cyanosis/ edema Patient conscious oriented in time , place and person Sitting comfortably on bed .

6. vitals : PR – 80/min BP- 130/80 mmHg RR – 20/ min afebrile Systemic examination: tracheostomy : 5.0 mm portex uncuffed tracheostomy tube in situ stoma site looks healthy to inspection No evidence of bleeding, local infection

7. respiratory system : Inspection : bilateral air entry equal and adequate. no abnormal pulsations Auscultation : Bilateral air entry equal Normal vesicular breath sounds No crepitations, rhonchi.

8. lab investigations: Hb – 12.3 gm% TLC – 7,500 Platelet count – 249 X 103 BU – 30mg/dl Na – 142 , K – 4.1 (Meq/dl) LFT – within normal limits Chest X ray – normal

9. DIAGNOSIS : recurrent vocal cord papillomatosis (?Squamous cell carcinoma) with status tracheostomy for direct laryngoscopic examination and biopsy of the lesion.

10. TYPES OF TRACHEOSTOMY TUBES metal : stainless steel / silver parts : inner tube, outer tube, obturator. disadvantages : no standard 15mm connector rigid ( can cause injury) no cuff expensive

11. synthetic : PVC / silicone cuffed or uncuffed , with or without inner tube, with or without fenestrations Great Ormond street, Portex, Shiley Advantages : 15 mm connector thermolabile cheaper Other modifications : extra proximal length extra distal length

12. Silver tube

13. Synthetic cuffed tube

14. Synthetic uncuffed tube

15. Fenestrated tube

16. Passy Muir speaking valve

17. Indications for tracheostomy • Upper airway obstruction – secondary to trauma, burns, corrosive poisoning, laryngeal dysfunction, foreign body, infections, inflamatory conditions, neoplasms, postoperative, OSA • Access to pulmonary toilet • Prolonged ventilatory support • Airway protection in head injuried/ comatose patients and in patient who cannot protect their airway.

18. Advantages of tracheostomy over ETT in prolonged mechanical ventillation • decrease in airway resistance and dead space • prolonged intubation promotes formation of laryngeal and subglottic stenoses • Eases airway care and suctioning • Reduces risk of tracheal extubation • Eases tube reinsertion • Facilitates oral communication and speech • Improves oral, nasal, and facial hygiene • Raises patient comfort level

19. Complications of tracheostomy Immediate : • Hemorrhage • Apnea : due to CO washout. Treaed with 5%co or by increasing the dead space. • Pneumothorax • Injury to recurrent laryngeal nerve • Aspiration of blood : prevented by use of cuffed tracheostomy tube. • Injury to esophagus

20. Intermediate : • Bleeding • Accidental decannulation : a serious complication in first week. Reinsertion can lead to formation of blind passage. • Obstruction of tube : crusts, mucus plug • Subcutaneous emphysema : due to tight suturing of wound/ stoma. Treated by releasing sutures. • Local wound infection • Pulmonary infection

21. Late : • Hemorrhage : erosion of major vessel, tracheoarterial fistula (80-90% mortality). • Obstruction : granulations, mucus plug • Tracheal stenosis • Tracheo esophageal fistula • Corrosion of tracheal tube and aspiration of fragments

22. CRUSTING Inspired air filtered, warm and humidified. Become dry and cold Dries tracheal and pulmonary secretions Interferes with ciliary capacity to move mucus blanket Thick tenacious mucus scabs can lead to infection, obstruction, atelectasis and pneumonia. Prevented by proper humidification and hydration

23. GRANULATIONS Appear near the stoma, in the lumen just above the stoma. • Obstruct following decannulation (elective/ accidental) • Blocks the tube • Bleeding during decannulation • Failed decannulation

24. CARE OF TRACHEOSTOMY Suctioning : Glottis is bypassed : so cough reflex lost. Increased mucus secretion To prevent obstruction of tube Size of catheter < half the ID of TT to prevent hypoxia and atelectasis. Time < 15sec Not more than 3 passes Sterile precautions

25. HUMIDIFICATION • To prevent drying of pulmonary secretions • To preserve mucociliary function METHODS • Heated humidifiers : new tracheostomy, dehydrated patients, immobile patients, patient with tenacious secretions

26. Heat moisture exchanger filters: adequately hydrated patients mobile patients not suitable for patients with copious secretions • Nebulizers : with normal saline (ultrasonic nebulizer) 4. Steam tent

27. Tube change: Stoma and tract is well formed with in 7- 10 days . After that changing outer tube is safe In an observational study, Yaremchuk et al reported fewer complications due to granulation tissue after implementation of a policy in which tubes were changed every 2 wks. laryngoscope 2003;113(1):1-10

28. Percutaneous tracheostomy : different methods • In 1985, Ciaglia et al described the percutaneous dilational tracheostomy (PDT). The method is based on needle guidewire airway access followed by serial dilations with sequentially larger dilators. • Schachner et al reported the Rapitrach method in 1989. This method consists of using a dilating forceps device with a beveled metal conus that is designed to advance forcibly over a wire into the airway. • In 1990, Griggs et al reported the guidewire dilating forceps (GWDF) method. This method is based on a forceps similar to that of the Rapitrach method, except without a cutting edge on the tip of the instrument.

29. Other methods • Modified Ciaglia technique (ie, Ciaglia Blue Rhino) have been reported by Byhahn et al. The technique represents a major modification of PDT. Dilation of the stoma is formed in a single step by means of a hydrophilically coated, curved dilator—the Blue Rhino. • In 1993, Fantoni et al presented a new translaryngeal airway access method. This technique passes the dilator between the vocal cords and pushes out through the neck tissues to obtain stoma. It decreases probability of posterior tracheal wall injury.

30. Contraindications for PDT • Absolute : • Need for emergency airway • In children (cartilages soft) • Relative : • High degree of ventillatory support (PEEP>8cm water, FiO2 > 50%) • Unstable cervical spine • Uncorrected coagulopathy • Presence of neck mass or previous neck surgery • History of mediastinal irradiation • Previous history of surgical tracheostomy

31. Cricothyroidotomy • In emergency when obstructed airway cannot be secured through the laryngeal route. technique : • Intravenous catheter • Cricothyroidotomy set • Surgical

32. Mini tracheostomy • Small bore tube (4.0 mm, uncuffed) inserted through the cricothyroid membrane or tracheal stome after decannulation. • Used primarily for tracheal toileting • Can be used for administration of oxygen

33. Comparison of types of tracheostomy

34. Decannulation • Reduce the size of the tube at each tube change . • Assess the airway above the stoma with a fibreoptic endoscope . • Use a fenestrated tube, allowing the patient to breath through the larynx (using a speaking valve or decannulation plug). • Or block the smaller sized plastic tube with a cork or decannulation plug for increasing lengths of time. • The patient should be able to tolerate the blocked tube for at least 24 hours continuously (under strict monitoring in the hospital). • After decannulation, firm and air-tight dressing is applied to allow the tract to close and heal.

35. Vocal cord papilloma • caused by the human papilloma virus • bimodal age distribution • Hoarseness is the most common presenting symptom • papillomas have a high rate of recurrence • Treatment involves repeated debulking of the warty growths • In 3-5% of patients, respiratory papillomas may undergo malignant degeneration to squamous cell carcinoma

36. When to do tracheostomy in prolonged mechanical ventillation ? • Sugerman et al found no difference in duration of mechanical ventillation, ICU stay, mortality, incidence of pneumonia between early(3-5days), late (10-14 days) tracheostomy and orotracheal intubation. J Trauma 1997 • Rumbak et al compared same parameters and concluded that early tracheostomy had significantly better outcome than late. Critical care medicine 2004

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