Management of Tracheostimized Patients.

8/10/2019 Management of Tracheostimized Patients.

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TRACHEOSTOMY AND

MANAGEMENT OF

TRACHEOSTIMIZED

PATIENTS

DR BILAWAL KHAN HOUSE OFFICER

ENT B WARD.Khyber Teaching Hospital Peshawar.

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TRACHEOSTOMY

The term tracheotomy is used to refer to

the creation of a surgical opening into the

trachea. Tracheostomy is used when aformal opening or stoma is made.In

common use the terms are

interchangeable.

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HISTORY OF

TRACHEOSTOMY.

Tracheostomy was performed in ancienttimes and the recordings of such events

have been documented by Asclepades,the Greek Physician in 100 BC.It wasonly towards the end of 19thCentury thatperoral intubation was re introduced and

became an increasingly more possiblewith the invention and subsequentmodification of laryngoscope.

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History of Tracheostomy.

The development of tracheostomy has been divided intofive periods.

1. Period of Legend. 200BC to AD1546.

2. Period of Fear. 1546 to 1833. during whichoperation was performed only by brave, few often atthe risk of their reputation.

3. Period of Drama. 1833 to 1932. during whichprocedure was generally performed only inemergency situations on acutely obstructed patients.

4. Period of Enthusiasm. 1932 to 1965. during whichthe adage if you think tracheostomy..do itbecame popular.

5. Period of Rationalization. 1965 to the presentduring which the relative merits of intubation weretracheostomy were debated. 4


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INDICATIONS OF

TRACHEOSTOMY.

Upper airwayobstruction.

Mechanicalrespiratoryinsufficency.

Respiratorydifficulties due tosecretions.

Elective.

Respiratoryobstruction.

Respiratory failure.

Respiratoryparalysis.

Removal of retained

secretions. Reduction of dead

space.

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CRICOTHYROTOMY.

In the emergency situations any medical orparamedical worker may on occasion findthemselves confronted with the need to

alleviate acute upper airway obstruction, eitherin hospital or out in the community.

If there is

Suspicion of acute airway problem.

Worsening stridor.

Reducing self ventilation.

Then perform Cricothyrotomy.

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Cricothyrotomy.

Procedure).

Extend the Neck.

Palpate the cricoid arch;Enter just above it.

Enter larynx just above the cricoid. Midline incision using either blade or I.V

cannula.

Knife may be rotated through 900to keep the

incision open. Convert to formal tracheostomy as soon as

possible.

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Complications of

Cricothyrotomy.

PERICHONDRITIS.

SUBGLOTTIC OEDEMA.

STENOSIS.

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OPEN TRACHEOSTOMY.

Local Anesthesia.

Avoid injecting the trachea (cough reflex)

Avoid paratracheal gutter ( recurrent laryngealnerve RLN may exacerbate obstruction.

General Anesthesia.

Gas induction. Never give any muscle relaxant until airway is

secured.

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TRACHEOSTOMY. STEPS).

1. Collar incision 2cm>suprasternal

notch.

2. Elevate platysma, divide strap

muscles in midline.

3. Thyroid isthmus may be avoidable,otherwise divide.

4. Palpate and expose the trachea.

5. Alert Anesthesist, suction ready. 10


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TRACHEOSTOMY. Steps).

6. Child- insert two stay sutures, verticalincision.

7. Adult- horizontal incision, third trachealspace-may need to exise part of onetracheal ring.

8. Insert tube connect to anesthetic circuit.

9. Tape stay sutures to the chest in a child.10. Loose sutures on skin.

11. Suture and tape tube.

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STEPS OF

TRACHEOSTOMY.

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STEPS OF

TRACHEOSTOMY.

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TRACHEOSTOMY TUBES.

CUFFED/ UNCUFFED.

FENESTRATED/ UNFENESTRATED.

SPEAKING VALVE.

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TRACHOSTOMY TUBES.

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TRACHEOSTOMY TUBES.

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TRACHEOSTOMY TUBES.

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TRACHESTOMY TUBES.

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TRACHEOSTOMY TUBES.

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TRACHEOSTOMY CARE.

1. Nursing care.

2. Fixation of the tracheostomy tube.

3. Removal of secretions.

4. Humidifications.

5. Changing of tracheostomy tube.6. Care of inflatable cuff.

7. Breathing exersices.20


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COMPLICATIONS OF

TRACHEOSTOMY.

INTERMEDIATE. Dislodgement / displacement of tube.

Surgical emphysema of the neck.

Pneumothorax/Pneumomediastinum.

Scabs and crusts.

Infection.

Tracheal necrosis.

Tracheoarterial fistula.

Tracheo-oesophageal fistula.

Dysphagia.

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COMPLICATIONS OF

TRACHEOSTOMY.

LATE.

Stenosis of the trachea.

Difficulty with decannulation.

Tracheocutaneous fistula/scars.

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DECANNULATION.

PRINCIPLES

Tube size reduced before decannulation.

Tube is corked off for increasing periods.

Self ventilating for at least one full night.

No further need for tracheal suction.

Remove tube, plug tracheostomy site.

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CASE REPORT 1).

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CASE REPORT 1).

Saleem Ullah 50 years of age from Bannu

Presented in June 2005 with.

Hoarseness of voice

Shortness of Breath

Noisy Breathing Mild Cough

Indirect and Direct Laryngoscopy Showed

Mass on right vocal cord, which was mobile, there was no cervicallymphadenopathy.

Biopsy of the leison confirms squamous cell carcinoma of the glottisand the patient was staged as T1 N0M0. Patient was referred forradiotherapy where he had completed 35 doses of radiation. Fewweeks ago he again presented with Hoarseness of voice andStridor.This time when Direct Laryngoscopy was performed,therewas a fungating growth of right vocal cord , anterior commissureand anterior end of left vocal cord.Biopsy was taken and to relieve

the air way TRACHEOSTOMY was performed. 26


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CASE REPORT 2)

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CASE REPORT 2).

Ghulam Qadir 50 years male from D.I.Khan presented to our unit on15-1-06, with

Difficulty in Swallowing for solids and liqiuds.

Shortness of Breath.

Stridor.

Weight loss.

Generalized weakness.

On examination patient was anaemic and wasted because ofdysphagia.His x-rays neck showed increased prevertebral softtissue shadow,Indirect laryngoscopy showed pooling of saliva with

restricted vocal cords movement. On direct laryngoscopy ,andoesophagoscopy there was a huge mass in the post cricoid regioninvolving left half of the larynx and extending to the upper end ofthe oesophagus. Biopsy of the mass confirmed squamous cellcarcinoma of the hypopharynx.Due to involvement of the larynxTRACHESTOMY was perfomed, and For feeding purposesNasogastric Tube was passed.

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CASE REPORT 3).

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CASE REPORT 3).

Tawnga 60 years of age from Board Peshawar presented to our uniton 5-1-06 with.

Swelling in front of neck.

Shortness of breath off/on.

Dysphagia off/on.

On clinical examination it was a mulitnodular goitre causing pressureon the trachea. Blood investgations and thyroid scan showedmultinodular euthyroid.

Subtotal thyroidectomy was performed on 8-1-06 , the recovery wasuneventful. On third post operative day she developed stridor,

Indirect laryngoscopy showed left vocal cord palsy with sluggishmovements in right vocal cord. Patient was restricted to the bed toavoid any shortness of breath. But gradually the condion of patientworsened and she was unable to do some stressful activitybecause of stridor and shortness of breath. Direct laryngoscopyshowed bilateral abductor paralysis of vocal cords, and the cordswere in median position with a chink of airway. To relieve her

airway TRACHEOSTOMYwas performed and a tracheostomytube with s eakin valve was laced.

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CASE REPORT 4).

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CASE REPORT 4).

AbdulMalik 50years male from south waziristan presentedto our unit on 20-12-05 with

Difficulty in breathing.

Difficulty in swallowing.

Previously 06 months ago he was diagnosed as a case ofcarcinoma larynx of T1N0M0. Patient was referred toIRNUM for radiotherapy. He completed the full courseof radiations. At this time there was recurrence of thetumour involving whole of the left side of larynx with

invasion of the laryngeal framework . Now the tumourclassified as T4N0M0. Total laryngectomy wasperformed in our unit on 26-12-05. and permanentTRACHEOSTOMY was done.

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THANKS

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Management of Tracheostimized Patients.

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