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Managing the Artificial Airway. RC 275. Tracheotomy/Tracheostomy. When intubation can’t be done or the need for the airway is indefinitely long Traditional surgical incision or PDT (Percutaneous Dilatational Tracheotomy)

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Presentation Transcript
tracheotomy tracheostomy
Tracheotomy/Tracheostomy
  • When intubation can’t be done or the need for the airway is indefinitely long
  • Traditional surgical incision or PDT (Percutaneous Dilatational Tracheotomy)
    • PDT may not be as damaging to tracheal cartilage
rcp s role during the procedure
RCP’s Role During the Procedure
  • Monitor the patient!
    • Maintain adequate ventilation and oxygenation
  • Assist physician as needed
try to leave the fresh trach undisturbed for 48 hours

Try to leave the fresh trach undisturbed for 48 hours

Suctioning obviously must be performed but as gently as possible

complications associated with et and trach tubes

Complications Associated with ET and Trach Tubes

Can be due to the insertion procedure or from having the tube in the airway

intubation complications
Intubation Complications
  • Trauma to oral cavity, pharynx, and vocal cords
  • Bleeding
  • Laryngospasm
  • Sub-Q Emphysema (from perforation of trachea)
  • Improper tube placement
  • Contamination/Infection
tracheotomy complications
Tracheotomy Complications
  • Bleeding (can be life-threatening)
  • Pneumothorax
  • Sub-Q Emphysema
  • Contamination/Infection
complications due to irritation from the tube and cuff
Complications due to irritation from the tube and cuff
  • Contamination/Infection
  • Obstructed Tube
  • Tracheitis (sore throat)
  • Glottic and/or sub-glottic edema (may not manifest until tube is removed)
  • Vocal cord damage (ET tubes only)
    • Paralysis, polyps, granuloma formation
complications due to high cuff pressures
Complications Due to High Cuff Pressures
  • Normal Mean Hemodynamics in the Tracheal Mucosa
    • Lymphatic: 5mmhg
    • Venous: 18 mmhg
    • Arterial: 30 mmhg
  • Impeding/occluding arterial flow causes ischemia!
  • Impeding/occluding lymphatic or venous flow causes edema
effects of excessive cuff pressure
Effects of Excessive Cuff Pressure
  • Ischemia
  • Inflammation
  • Necrosis
  • Fibrosis
  • Stenosis
  • Tracheal Malacia
  • T-E Fistula
cuff pressure should not exceed 25 30 cmh2o

Cuff Pressure Should NOT Exceed 25-30 cmH2O!

The pressure in the cuff should be checked often, eg each ventilator check

cuff inflation management techniques
Cuff Inflation Management Techniques
  • MOV – Minimal Occlusive Volume
  • MLT- Minimal Leak Technique
mov minimal occlusive volume
MOV- Minimal Occlusive Volume
  • Air is slowly added to cuff until either pressure cycling occurs (if applicable) or exhaled volume equals inhaled tidal volume
  • Cuff pressure is then checked to make sure it does not exceed 25-30 cmH20 and adjusted to still allow pressure cycling or returned exhaled volume
minimal leak technique
Minimal Leak Technique
  • Like MOV except after cycling or volume return is achieved, a slight amount of air is removed to cause either:
    • (1) a loss of no more than 50 ml of set Vt
    • (2) An audible leak heard around trachea
again these techniques should be utilized each time the cuff is checked

Again, these techniques should be utilized each time the cuff is checked

If high pressures are needed initially, the artificial airway is probably too small

If cuff pressures gradually increase, damage to the trachea may be occurring

extubation

Extubation

Done when none of the four indications for an artificial airway exist

extubation technique
Have suction, BVM and O2, and intubation supplies ready(including tracheotomy tray)

In Fowler’s or semi-Fowler’s, suction through tube and pharynx

Loosen tape and deflate cuff

Insert new suction catheter into tube and have patient take a deep breath

Apply suction as tube is pulled out and have patient cough at the same time

Monitor vitals and respiratory status

Extubation Technique
possible complications
Possible Complications
  • Inspiratory stridor due to glottic or sub-glottic edema
    • Stridor that develops immediately after extubation is an ominous sign
  • Laryngospasm/Bronchospasm
  • Dyspnea
post extubation treatment
Post-Extubation Treatment
  • O2 Therapy
  • For stridor, nebulized racemic epinephrine and a steroid
  • If distress is not helped by nebulized drugs, re-intubate
  • If not possible, tracheotomy