UPPER AIRWAY OBSTRUCTION RECOGNITION

 Dyspnea
 Stridor
 Voice change
 Decreased or absent breath sounds
 Restlessness
 Hemodynamic instability (late)
 Loss od consciousness (very late)
TRACHEOSTOMY
 A vertical incision as an emergency measure for airway obstruction
 A procedure to ventilate the lungs
 Most common complication
 airway stenosis
 INDICATIONS
 To bypass onstruction
 Long-term mechanical ventialtion
 Pulmonary toiletting  Congenital anomaly
 Neck trauma  Upper airway foreign body
 Tumor  Supraglottic or glottic pathologic
 Bilateral vocal cord paralysis condition
 Laryngeal edema  Subcutaneous emphysema
 Respiratory failure  Sever sleep apnea
 Neurologic dysfunction  requirement of mechanical
ventilation >7 days
 Facilitation of major head and
neck surgery
 Management of secretion
CONTRAINDICATIONS
 Absolute
 Soft tissue infection of
neck
 Anatomic aberrations
 Previous neck surgery
 Relative
 Sever respiratory
distress and refractory
hypoxemia
 Hypercapnia
 Hematological
coagulation disorders
EQUIPMENTS
 Tracheostomy tubes of appropriate type and size
 Trach tube ties or velcro strap
 Dressing supplies
 Hydrogen peroxide, sterile water, normal saline
 Water soluble lubricant
Surgilube or KY jelly
 Blunt-end bandage scissors
 Tweezers or hemostats
 Sterile Q-tips
 Trach care kits and/or pipe cleaners
 Luer lock syringes for cuffed trach tubes
SURGICAL PROCEDURE
 General anesthesia
 Position
supine with a small shoulder roll to provide slight neck extension
Cuff of Endotracheal tube (ETT) is midway at the vocal cord level
 1% lidocaine with 1:100,000 epinephrine solution
 Horizontal or short vertical incision
Centered on the inferior border of the cricoid cartilage
 Placement of Introducer needle
Minimal dissection onto pretracheal tissue
Larynx is stabilized and pulled cephalad
Bronchoscopy
Light reflex
Tip of needle directed caudad into the tracheal luman
 Introduction of Guide wire, Stylet and Initial Tract Dilation
 needle is withdrawn while keeping the cannula in the tracheal lumen
J-tipped guide wire placed under vision
Stylet placed with the safety ridge directed toward tip of wire
Tract dilated with 8 FR dilator
 Dilation with the Blue Rhino Dilator
Loaded on the stylet; tip resting on safetly ridge
Dilator moved in and out
 Placement of the Tracheostomy
 loaded into dilator
Dilator is loaded on the safety ridge of stylet
Placed into tracheal lumen under direct visualization
 Confirmation of placement
 visualizing the carina
 Securing the tube
 2 sutures of 2-0 nylon on each side of the flange
Tracheostomy tape to hold tube in place
POST-OPERATIVE TRACHEOSTOMY CARE
 Maintain patent airway
Frequent atraumatic suction
Humidification of inspired air and oxygen
Mucolytic agents
Coughing and physiotherapy
Occasional bronchial lavage
 Prevent infection and complications
Aseptic tube suction, handling and tube changing
Prophylactic antibiotics
Deflate cuff for 5 minutes every hour
Avoid tube impinging on posterior tracheal wall
COMPLICATIONS
 Immediate (0-24h)
Bleeding
Pneumothorax/Pneumomediastinum
Injury to adjacent structures
 Intermediate (day 1-7)
Bleeding
Tube obstruction
Tube displacement/dislodgement
Subcutaneous emphysema
Atelectasis
 Late (after day 7)
Bleeding
Tracheal stenosis
Tracheomalacia
Tracheo-esophageal fistula
Failure to de-cannulate
Type Description and Use

Universal Double-lumen or double-cannula; most common

3 parts:
• Outer cannula with cuff and pilot tube
• Inner cannula
• Obturator

Single Cannula Slightly longer

For patients who have long thick necks
Requires additional humidification to prevent accumulation of secretions
Fenestrated Opening on the posterior wall ; allows air to flow through the upper airway and
tracheostomy opening
Often used during weaning
Tracheostomy button Short, straight tube; fits into the tracheostomy stoma but does not enter the
tracheal lumen
Used during weaning
Cuffed tube Seals the airway and prevents aspiration of oral or gastric secretions when
inflated
Used when mechanical ventilation is required
Cuffless tube For long-term management
Patient must have effective cough and gag reflexes
Rarely used in acute care

TYPES AND USES OF TRACHEOSTOMY TUBES

CRICOTHYROTOMY
 Establishment of a surgical opening into the airway through the cricothyroid
membrane and placement of a tube for ventilation
 0.01% rate for stenosis; no major complication
 More preferable for emergent airway control
 Simplicity, speed and lower perioperative complication rate
 Primary indication
Failure to intubate by oral or nasal means in the presence of an immediate need
for deifinitive airway management
Inability to mask-ventilate
 Relative contraindications
 <10 years old
 severe neck trauma with inability to palpate the landmarks
 expanding neck hematoma
Preexisting laryngeal disease
 TRACHEOSTOMY CRICOTHYROIDOTOMY

Placement Cervical trachea Cricothyroid membrane

Advantages Airway protection while unconscious Establish a patnent airway

Allows gradual weaning of ventilatory
support (reduced work of breathing)
Disadvantages Unnecessary procedure related
complications
Negative impact on discharge
destination and quality of life
Timing Temporary or permanent
during certain life-
threatening situations
easier and quicker to
perform associated with
fewer complications
Last resort
Only intended to be a
temporizing measure until
a definitive airway can be
established
Temporary