INTRODUCTION • Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea • It is considered synonymous with tracheotomy
UPPER AIRWAY OBSTRUCTION -RECOGNITION • Dyspnea • Stridor • Voice change • Decreased or absent breath sounds • Restlessness • Hemodynamic instability (late) • Loss of consciousness (very late)
INDICATIONS FOR TRACHEOSTOMY • To bypass obstruction • Long-term Mechanical ventilation • Neck trauma • Tumour • Bilateral vocal cord paralysis • Laryngeal Edema • Respiratory failure
FORMS OF TRACHEOSTOMY • Emergency tracheostomy • Urgent tracheostomy • Elective tracheostomy
POSTOPERATIVE DETAILS • Postoperative care is critical. • Copious secretions is the normal • Suctioning every 15 minutes may be required • Suctioning should be shallow initially • Suctioning should be limited to no more than 15 seconds
POSTOPERATIVE DETAILS 2 • Humidified oxygen helps prevent inspissation of the secretions. • Mucolytic agents may be employed. • If uncorrected, mucus plugging of the inner cannula can cause a life-threatening obstruction.
POSTOPERATIVE DETAILS 3 • The original tube is left sutured in place for 5-7 days to allow the tract to heal. • Then the sutures are removed, and the tube is replaced. • The site should be kept clean and dry to minimize infection • Patient and family education should begin
FOLLOW-UP CARE • Speaking: should be encouraged when cuff is deflated • Swallowing: Swallowing is more difficult • Evaluate risk of aspiration before feeding • Educate: both patient and family • Equipment: for discharge
SUCTIONING • "STERILE TECHNIQUE" - the use of a sterile catheter and sterile gloves for each suctioning procedure. • "CLEAN TECHNIQUE" - the use of a clean catheter and nonsterile, disposable gloves or freshly washed, clean hands for the procedure. • “MODIFIED CLEAN TECHNIQUE" - nonsterile gloves and sterile catheters).
SUCTIONING DEPTH • SHALLOW SUCTIONING – suctioning at the hub of the tracheostomy tube to remove secretions coughed up to the opening of the tracheostomy tube. • The PRE-MEASURED TECHNIQUE - the catheter is inserted to a pre-measured depth, with the most distal side holes just exiting the tip of the tracheostomy tube. • DEEP SUCTIONING - the insertion of the catheter until resistance is met, withdrawing the catheter slightly before suction is applied.
WHEN IS SUCTIONING REQUIRED? • Whenever patient is unable to clear secretions by coughing • Bleeding down the airway
WHEN TO SUCTION 1 • Mucus bubbling in trachyostomy tube • Audible gargling sounds • Difficult breathing • Restlessness • Gurgles heard on auscultation • Low SpO2
WHEN T SUCTION 2 • Stridor or changes in breathing • Cyanosis • Increased ventilator inspiratory pressure (for patient on ventilator, a high pressure alarm may sound) • Patient request
INSTILLING • Introduction of normal saline into the airway to aid removal of thick, tenacious secretions. • TENACIOUS SECRETIONS • Systemic hydration • Humidification • Chest physiotherapy • Suctioning, coughs and assisted coughs • Mucolytic agents
COMPLICATIONS • IMMEDIATE • EARLY • LATE
COMPLICATIONS 1 • IMMEDIATE • Bleeding • Pneumothorax/Pneumomediastinum • Injury to adjacent structures
COMPLICATIONS 2 • EARLY • Bleeding • Tube obstruction • Tube displacement/dislodgement • Subcutaneous Emphysema • Atelectasis
COMPLICATIONS 3 • LATE • Bleeding • Tracheal stenosis • Tracheomalacia • Tracheo-esophageal fistula • Failure to de-cannulate