TRACHEOSTOMY

A tracheostomy is a surgical opening in the anterior wall of the trachea just below the larynx. It provides an alternative airway, bypassing the upper passages

ANATOMY AND PHYSIOLOGY

At the back of the mouth and nose the air passages form the pharynx, which continues into the larynx (voice box). The larynx may be felt as the Adam's apple in front of the neck. The trachea is a tube that runs from the bottom of the larynx into the chest where it divides into the bronchi, the tubes that go to each of the lungs. The thyroid gland lies in front of the trachea. The esophagus (foodpipe) lies behind it. The innominate artery passes in front of the lower tracheal rings of the trachea. This artery is a branch of the aorta (the major artery coming from the heart) and gives rise to the arteries to the right side of the brain and right arm. The trachea is a rigid structure formed from rings of cartilage to ensure that the airway always remains open. Its function is to maintain and protect the airway. The trachea is lined with mucus glands, which humidifies air as it passes through the trachea and catches small particles before they reach the lungs. The trachea also has specialized hair like structures called cilia that move rhythmically to sweep mucus and particles back up to the throat. The trachea also has many defensive cells that kill organisms that enter the trachea. The trachea is supplied by nerves that are part of the cough reflex that helps get rid or irritants.

PURPOSE

Obstruction of the air passages may occur as a result of:

Swallowing of a foreign material or improper swallowing of food Swelling of the air passages due to allergy Loss of trachea stiffness due to weakening of the tracheal rings, which may be either present at birth or from prolonged placement of a tube in the trachea (see Anesthesia) Injury to the face and upper airways Obstruction usually takes place in the larynx, which is the narrowest part of the air passages

Patients on a ventilator (breathing machine) for a long time

May be sedated and may not be able to cough to clear secretions from the lung and trachea which causes plugging of the air passages May vomit and aspirate food into the lungs causing pneumonia May need increased delivery of oxygen. A tracheotomy bypasses the larynx and delivers air directly into the trachea May develop ulcers around the mouth as well as weakness and narrowing of the larynx and upper trachea from prolonged pressure of the breathing tubes that pass through the mouth

Cancers of the upper airway may cause obstruction that may require a tracheostomy. Surgery for cancers of the upper airway also frequently require a tracheostomy

 Indications for surgery Emergent indications for a tracheostomy are few. In situations of acute obstruction of the airway due to trauma or allergic swelling, an immediate airway is better obtained by intubating (inserting a tube) the trachea by mouth or nose. Sometimes it may be necessary to guide the tube into the trachea using a flexible bronchoscope (a camera on a flexible tube). If necessary, a cricothyroidectomy, which is a small incision in the lower larynx, may be made to allow air passage. These measures may be temporary until the patient is stable enough to undergo a tracheostomy in the operating room A tracheostomy is advisable for patients who have been on a ventilator for over 5-7 days. A tracheostomy helps in suctioning of secretions, increased delivery of air to the lungs, prevention of aspiration in case the patient vomits and prevention of complications associated with endotracheal tubes through the mouth. Patients with cancers of the upper airway undergoing surgery may need bypass of their airway circuit, with creation of a permanent tracheostomy.

PROCEDURE
The surgical procedure of inserting a tracheostomy tube into a patient's trachea is called a tracheotomy. In either case an opening is made through the neck into the trachea (windpipe) and the tracheostomy tube is inserted into the hole and directed down towards the lungs. This procedure is performed in the Operating Theatre by a Surgeon using the open technique or in the Intensive Care Unit by an Intensive Care Doctor, called a percutaneous tracheotomy.

Surgical Procedure
Before performing a tracheostomy the site of obstruction should be determined to be above the site of the tracheostomy. Patients with large or short necks may be difficult to operate upon Bleeding disorders or an enlarged thyroid gland should be evaluated The procedure is usually done under general anesthesia in the operating room. However, if the patient is sedated on a ventilator, it may be done under local anesthetic, even at the patient's bedside The patient is placed supine (on the back) with the head extended to expose the front of the neck The incision is made over the second tracheal ring below the larynx. The incision may be made from side to side or up and down

 The underlying small muscles in front of the trachea are spread to the side Sometimes the isthmus (thin middle portion) of the thyroid may have to be cut to expose the second tracheal ring Once the trachea is exposed, an incision is made through the second and sometimes third tracheal cartilage rings. The incision may be in the form of a flap or a small segment The tracheostomy tube, the metal or plastic tube to be placed in the trachea, is measured for size to fit the trachea The anesthetist slowly withdraws the endotracheal tube through the mouth. As soon as the tube is pulled above the level of the second cartilage, the tracheostomy tube is pushed into the trachea and directed downwards. The tube contains an obturator (central portion) that has a cone shaped nose to guide the tube into the trachea. The obturator is removed after the tube is inserted

 The tracheostomy tube has a balloon at its end, which is inflated to prevent secretions from getting into the lungs The tube from the breathing machine or oxygen tube is connected to the tracheostomy tube. Sutures are used to close the skin incision and a cloth tape is tied around the neck to secure the tube

Complications
Tracheostomies can become contaminated and improper care can lead to infection of the skin, trachea or lungs Bleeding may occur from injury to a high innominate artery, jugular veins or thyroid gland. Prolonged use of a tracheostomy tube may cause stenosis (narrowing) of the trachea from scarring or tracheomalacia (floppiness of the trachea). Pneumothorax (air between the lung and chest wall) may occur following tracheostomy. This occurs more frequently in children

 Obstruction of the tube can occur from a blood clot or mucous plug and if the end of the tube presses against the back wall of the trachea The tube may come out. This is a very serious complication since the patient may not be able to breath Tracheoesophageal fistula (connection between the trachea and the esophagus) can occur if the tube erodes through the back of the trachea and into the esophagus. Dysphagia (difficulty in swallowing) may occur from pressure of the tube on the back of the trachea Poor laryngeal function may result from prolonged use of a tracheostomy

Care After Surgery

It is very important to keep the tracheostomy clear of secretions The tracheostomy tube has a double lumen (a tube within a tube) made of plastic. The inner tube may be removed for cleaning. It is also important to suction out the tracheostomy several times a day to clear secretions The air going through the tracheostomy is humidified to prevent the trachea from drying up The dressing around the tracheostomy opening is changed daily and kept dry As the patient recovers and does not need ventilator assistance, the patient may become apprehensive. It is not possible to talk with a tracheostomy tube in place as air is bypassed from the voice box and this may be distressing to a patient

 Fenestrated tubes (tubes with a side-hole through them) allow air to pass through the tube into the voice box. As the patient recovers, the opening in the neck may be capped and the patient may be able to talk As the patient recovers, the tracheostomy tube may be changed at the bedside into a smaller size and eventually removed. The opening in the neck closes by itself in about a week Patients who have permanent tracheostomies are taught to care for their tubes. They should not to go swimming and should be careful while taking a bath to prevent water from entering the tube and causing aspiration pneumonia

What To Expect After a Tracheostomy

Depending on the patients overall health, you may stay in the hospital for 3 to 10 days or more after getting a tracheostomy. It can take up to 2 weeks for a tracheostomy to fully form, or mature. Eating Until the tracheostomy is mature, the pt. won't be able to eat normally. Instead of food, he/she may be given nutrients through an intravenous (IV) line inserted into a vein in the body. Or, the pt. may get food through a feeding tube. After the tracheostomy has matured, the pt. may work with a speech therapist to regain their ability to swallow normally.

Communicating The pt. won't be able to talk right after the procedure. Even after the tracheostomy has matured, pt. will still have trouble speaking. The trach tube interferes with the normal voice process. It prevents air from the lungs from flowing over the voice box. However, once the tracheostomy has matured, a speech therapist or other health professional will show the pt. ways in which he/she can use his/her voice to speak clearly. One option is a speaking valve that attaches to the trach tube. The valve lets air enter the tracheostomy, pass into the windpipe and up over the voice box, and then exit the mouth or nose. Certain types of cuffed trach tubes also can help the pt. speak.

TRACHEOSTOMY TUBES
A tracheostomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma. Have an outer cannula that is inserted into the trachea and a flange that rests against the neck and allows the tube to be secured in place with tapes or ties. All tubes have an obturator, used to insert the outer cannula and then removed. The obturator is kept at the clients bedside in case the tube becomes dislodged and needs to be reinserted. Some tubes have an inner cannula that may be removed for periodic cleaning.

Types of Tubes
Cuffed tubes Un-cuffed Fenestrated

 Cuffed tubes Patients who need ventilation (assisted breathing with a respirator or breathing machine) require tracheostomy tubes that are blocked and sealed by what is called a cuff (also called a balloon) located on the lower outer cannula. The cuff blocks any air from flowing around the tube and assures that the patient is well oxygenated. All the air must therefore flow in and out through the tube itself. A pilot tube attached to the cuff stays outside the body and is used to inflate or deflate the cuff

 Tubes with inflatable cuffs Inflatable cuffs are used when an airtight seal is required around the tube. It is usually required: when the patient is unable to breathe on their own and requires artificial respiration. when an air-tight seal is necessary to prevent blood and other secretions from running down the sides of the tracheostomy tube into the lungs. Allows ventilation and prevents aspiration Have an inflation line leading to the cuff and pilot balloon that inflates when the cuff contains air, giving an indication of the volume of air in the cuff.

Cuffed Tubes

Disadvantages of Cuffed Tubes

Traditionally single tubes with no inner tubes are used. The cuff exerts a pressure on the surrounding tissues when it is inflated. In time, this pressure can cause damage to the tissues, resulting in necrosis, a fistula or stenosis in the trachea. Hourly deflation of the cuff was thought to lessen tracheal damage but this was shown to be ineffective. (Powaser, 1976, Bryant et al, 1971, Jenicek, 1973). The patient cannot speak when the cuff is inflated as no air can go past the vocal cords

Un-cuffed Tubes
Maintains airway once aspiration risk has passed Increase airflow to the larynx Unable to maintain seal in an emergency situation Indications: Long term tracheostomy pts Patients who do not require a seal Paediatrics

Fenestrated Tube
Increases airflow to larynx/ vocalisation Cuffed or un-cuffed These are used for weaning Enables phonation (speaking) The fenestrated tube can be used as such if the patient is tolerating the cuff down To suction always use the non fenestrated inner tube for suctioning Fenestrated are the only tubes (when inner fenestrated tube insitu and cuff is down) that can be intentionally occluded

PARTS
Inner Cannula Allows maintenance of tube patency
Aids tube hygiene Close observation

Allows fenestrated tubes to be used earlier

Inner Cannula
Use of an inner cannula: The inner cannula provides a vital safeguard against life-threatening complications of tube obstruction in a cuffed tube and must be present at all times.

Changing the Inner Cannula

If copious secretions- check every 4 hours (more if indicated) Remove and clean using sterile water and replace as soon as possible If tube is kinked or damaged replace with new sterile inner tube Other issues- brushes, cleaning fluids, infection and storage of inner cannula

Adjustable Flange
Provide a longer tube offer secure placement of tube in a deep-set trachea Essential for patients with difficult anatomy and on whom the insertion will be complicated; insertion of this tube is usually via the surgical technique (considered to be an unsuitable tube for the percutaneous insertion technique) The Portex PVC adjustable flange tube does not have an inner cannula. These tubes are inserted in patients with very difficult anatomy and therefore subsequent tube changes should be considered carefully.

Deflating the Cuff

Why? To assess the patients ability to maintain their own airway. To assess the patients ability to cope with their secretions. Follow trache guidelines ie. Cuff down 24 hours prior to decannulation Blue dye test should be performed at this stage to assess swallow.

Deflating the Cuff

Who? Doctor OR nurse, who are competent.

Removing the Tracheostomy Tube

Removing the Tracheostomy Tube

Who? Doctor, Nurse or Physio who are competent. How? Ensure cuff fully deflated Explanation to patient Equipment dressing, gauze, O2 mask, stitch cutter. Oximeter

Tracheostomy Care
To maintain airway patency To maintain cleanliness and prevent infection at the tracheostomy site To facilitate and prevent skin excoriation around the tracheostomy incision To promote comfort Initially,

SUCTIONING
To maintain a patent airway and prevent airway obstructions To promote respiratory function To prevent pneumonia that may result from accumulated secretions