Patient with Tracheostomy case presentation

1
Patient with Tracheostomycase presentation

• Presentor Dr.Praveen
• ModeratorDr.G.Prasad

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2
Case presentation

• Name- Mr. Sudhakar, Age -18 years
• Sex- male, Place U.P
• Occupation-student, Informant-Mother
• Chief complaints
• Bleeding from the nose since 1 year
• Nasal obstruction since 6 months

3
History of present illness

• 1.Bleeding from the nose since 1 year
• insidious in onset
• Episodic ,gradually progressive-started with once
  in a month to once in a week
• Beginned with bleeding from right nostril , later
  developed bleeding from the left nostril too
• The amount ranged from 10ml to 50ml

4

• Later developed blood coming from mouth during
  episodes of nasal bleeding,
• Initially bleeding episodes subsided on their
  own, later twice required nasal packing to
  control the bleeding from local doctor
• Never required any iv fluids or any blood
  transfusions after bleeding episodes

5
History of present illness

• 2. Nasal obstruction since 6 months
• Insidious in onset
• Gradually progressive,
• Initially started with obstruction of right
  nostril, later progressed to involve the left
  nostril also
• H/O mouth breathing snoring

6

• H/O respiratory distress 4 months back
  (April-07), during an episode of nasal bleeding
• Required an emergency operation to relieve
  obstruction by making tracheostomy in the neck

7

• H/O decreased hearing from the right ear
• H/O swelling of right cheek
• ?
• No H/O Hoarseness of voice
• No H/O cough with expectoration or blood
  streaked sputum

8

• No H/O vomiting of blood
• No H/O passing blood in the urine/ stool
• No H/O protrusion of eyeball
• No H/O, any focal neurological deficit
• No H/O, Headache/ Vomiting/Blurring of vision/
  Convulsions

9
Treatment history

• Required twice nasal packing to control bleeding
  ( by local doctors)
• Required tracheostomy to relieve respiratory
  distress (in AIIMS-casualty)

10

• Past medical history
• No H/S/O tuberculosis / jaundice/HTN
• Family history
• No H/O bleeding tendency in the family

11

• Personal history
• Vegetarian
• Non smoker/ non alcoholic
• Bowel bladder habits- regular
• Sleep sound
• Appetite- good

12
Clinical examination

• Patient is a adolescent male, moderately built
  nourished, conscious, oriented to time, place
  person
• pallor , no icterus/ cyanosis/cervical
• lymphadenopathy/
  oedema
• No clubbing
• PR-88/min,
• BP- 140/90mmHg
• RR-24/min
• Afebrile

13
Local examination

• External appearance- broad nasal bridge
• Fullness of the right side of nose
• Swelling of the right cheek
• Decreased fogging at the right nostril
• Oral cavity- NAD

14
Systemic examination

• Respiratory system
• Trachea was in midline
• B/L chest movements were equal
• B/L air entry ,NVBS equal in
• 
  corresponding areas
• B/L conducted sounds

15

• Cardiovascular system
• Apex beat- left-5th intercostal space in
• mid
  clavicular line
• S1, S2 heard, in mitral aortic areas,
• 
  NO murmurs

16
Per abdominal examination

• Soft
• No organomegaly

17
Central nervous system

• Conscious, oriented
• Cranial nerves Normal
• No focal neurological deficit

18
Airway examination

• Tracheostomy tube (7.5mm,PVC, uncuffed) in situ
• Stoma site looks healthy
• No evidence of infection or bleeding

19
Provisional diagnosis

• JUVENILE NASOPHARYNGEAL ANGIOFIBROMA WITH STATUS
  TRACHEOSTOMY
• D/D Infected polyps
• Carcinoma nasopharynx
• Rhabdomyosarcoma

20
Laboratory investigations

• Hb- 9.1 gm
• Platelets-2,40,000/ mm3
• Blood urea-22mg
• Serum creatinine- 1.1mg
• Na -144meq/L, K- 4.4meq/L
• Sr.bilirubin -0.9mg
• Proteins total- 8.9gm, albumin-4.7gm ,
• SGOT- 203 IU/L, SGPT-306 IU/L, ALP-295 IU/L

21

• USG-Abdomen- normal study,
• Viral markers- anti HAV-IgM Negative
• HBsAg Negative,
• anti HEV IgM-
  Negative
• HIV (12)-Negetive
• X ray Chest normal

22
CECT- coronal axial

• Large soft mass centered in the region of
  pterygopalatine fossa with extension into the
  infratemporal fossa, nasal cavity, sphenoid,
  ethmoid sinuses, right orbit, vidian canal,
  foramen rotundum right middle cranial fossa

23
MRI- PNS

• Findings consistent with juvenile nasopharyngeal
  angiofibroma with extension into right orbit,
  middle cranial fossa, infratemporal fossa,
  sphenoid sinuses, oropharynx nasal cavity

24
Final diagnosis

• JUVENILE NASOPHARYNGEAL ANGIOFIBROMA WITH INTRA
  CRANIAL EXTENSION WITH STATUS TRACHEOSTOMY

25
What is a Tracheostomy?-definition

• A tracheostomy is a artificial (usually)
  surgically created airway fashioned by making a
  hole in the anterior wall of the trachea and the
  insertion of a tracheostomy tube, which may or
  may not be permanent

26
Tracheostomy history
Europian J of cardio-thoracic sx..2007

• The oldest known reference identifying a
  procedure akin to a tracheostomy is found in a
  sacred Hindu book from the 2nd millennium before
  Christ
• The first successful tracheostomy was recorded in
  1546 by Italian physician
• ( Antonio Moussa Brasavola) for a patient
  suffering from laryngeal abscess

27
Tracheostomy - history

• In mid 1800s, this procedure was performed on
  children with diphtheria
• Dr. Chevalier Jackson Established safe guidelines
  Basics still used today, Described
• Long incision
• Avoidance of the cricoid
• Division of the isthmus
• Slow, careful surgery
• Post-op care

28
Why Perform a Tracheostomy?
- indications

1. Upper airway obstruction
2. Retained secretions
3. Respiratory insufficiency

29
Indications- contd

• Upper airway obstruction
• Infections Acute laryngotracheo
  bronhitis,
• Acute
  epiglottitis
• Ludwigs angina,
• Peritonsillar,
  retropharyngeal abscess
• Trauma External injury to larynx trachea
• Fracture
  mandible, or maxillofacial trauma

30
Indications-Upper airway obstruction

• Neoplasms Benign or malignant neoplasms of
  larynx , pharynx,, upper trachea, thyroid
• Foreign body larynx
• Oedema of larynx steam, irritant, fumes or
  gases, allergy, radiation
• Congenital anomalies-laryngeal web.cysts,

31
Indicationscontd

• Retained secretions
• Inability to cough coma due to any cause
• Paralysis of respiratory muscles
• Spasm of respiratory muscles
• Painful cough chest injuries
• Aspiration of pharyngeal secretions

32
Tracheostomy -contra indications

• Skin infection
• Prior major neck surgery which completely
  obscures the anatomy

33
Anatomy of the neck

• Anatomy of the neck with thyroid, the cricoid,
  the isthmus of thyroid gland
• The tracheostomy is carried out at least one to
  two rings beyond the cricoid

34

• Tracheo bronchial tree

35
How To Create a Tracheostomy ?
Methods

• Cricothyroidotomy
• For Urgent Procedures
• Percutaneous Tracheostomy
• Can be done in the ICU at the bedside
• Surgical Tracheostomy
• Subthyroid incision to trachea between 2nd and
  3rd tracheal rings

36
Timing of tracheostomy

• Timing of tracheostomy is influenced by the
  indication for the procedure
• Early tracheostomy significantly reduced duration
  of artificial ventilation length of stay in in
  ICU
• systemic review metaanalysis of studies of
  the timings oftracheostomy Br Med J 2005

37
Timing of tracheostomy

• In RCT comparing early (lt48hrs) Vs
• Late (14-16days) tracheostomy in patients with
• respiratory failure
• ?the early group had a significantly decreased
  mortality, pneumonia time of mechanical
  ventilation
• Crit Care Med 2004

38
Timing of tracheostomy

• A systemic review meta-analysis comparing early
  Vs late tracheostomy in trauma patients found no
  difference in days on mechanical ventilation ,
  length of ICU stay, frequency of pneumonia
• A systemic review meta-analysis.. Am
  Surg 2006
• Recommendation
• in critically ill adult patients requiring
  prolonged mechanical
• ventilation, tracheostomy performed at an early
  stage
• (within 1 week ) may shorten the duration of
  artificial ventilation
• length of ICU stay
• European J of Cardio-thoracic surgery2007

39
Types of tracheostomy

• 1. Emergency tracheostomy
• 2. Elective tracheostomy
• ? therapeutic
• ? prophylactic

40
Types of tracheostomy.contd

• Emergency tracheostomy
• ? when airway obstruction is complete or almost
  complete
• ? there is an urgent need to establish the airway
• ? intubation or laryngotomy are either not
  possible or feasible

41

• Elective tracheostomy
• Therapeutic
• to relieve obstruction
• -- to remove tracheobronchial secretions
• Prophylactic- To guard against
• ? anticipated respiratory obstruction or
• ? Aspiration of blood or pharyngeal secretions
  such as extensive Sx of tongue, floor of mouth,
  mandibular resection

42

• Permanent tracheostomy
• B/L abductor paralysis
• Laryngeal stenosis
• COPD patients
• Obstructive sleep apnea

43
Tracheostomy ..high..mid..low.

• High tracheostomy
• Above the level of thyroid isthmus
• It violates the 1st tracheal ring of trachea
• Tracheostomy at this site can cause
  perichondritis of the cricoid cartilage
  subglottic stenosis
• Indication- carcinoma of the larynx

44
Tracheostomy

• Mid tracheostomy
• Preferred
• Done through the 2nd 3rd rings,
• Needs division of thyroid isthmus or its
  retraction to expose trachea
• Low tracheostomy
• Done below the level of isthmus
• Trachea is deep at this level close to several
  large vessels
• Tracheostomy tube may impinge on suprasternal
  notch

45
Functions of tracheostomy

• Alternate pathway for breathing
• Improves the alveolar ventilation
• Protects the airway
• Permits the removal of tracheobronchial
  secretions
• For IPPV beyond 72hrs- tracheostomy is superior
  to intubation
• Definitive airway in difficult airway situations

46
Advantages over ETT

• Improvement of respiratory mechanics
• facilitates weaning by reduced work of
  breathing
• ( decrease in flow resistance),
• intrinsic PEEP is also reduced
• Am J Respir Crit Care Med 1999
• Reduced laryngeal ulceration
• Endotracheal intubation can result in
  severe injury of the upper airway
• Improved nutrition, enhanced mobility speech

47
Advantages over ETT..

• Improved patient comfort
• less sedation is required in patients
  mechanically ventilated
• Patient can be nursed outside ICU
• Clearance of secretion.

48
Disadvantages of tracheostomy over ETT intubation

• Surgical procedure with its procedure related
  complications
• Stomal complications
• Tracheo- innominate artery fistula formation
• Tracheoesophageal fistula formation

49
Surgical tracheostomy
50
Surgical tracheostomy

• Underlying medical conditions should be
  stabilized prior to the procedure to allow for
  safe transport to from the OT
• Routine monitoring as well as invasive monitoring
  already in place should be maintained during the
  procedure transport

51
Surgical tracheostomy

• All essential monitoring is established
• Anesthesia should include adequate sedation
  analgesia, inhalational / iv induction, muscle
  relaxation..SOS
• Positioning-supine with pillow under the
  shoulder roll under the neck

52
Surgical tracheostomy-

• 3-5cm transvers skin incision 1cm below the
  cricoid cartilage
• Strap muscles retracted laterally
• The thyroid isthmus retracted superiorly/
  inferiorly/ divided

53
Surgical tracheostomy

• The ETT slowly withdrawn to just above the
  tracheostomy incision
• End tidal CO2 monitoring is crucial during the
  procedure to ensure a patent airway
• The endotracheal tube should not be completely
  removed from the airway until correct placement
  of Tracheostomy tube is conformed secured

54
Percutaneous tracheostomy

• In 1985, Ciaglia et al described the percutaneous
  dilational tracheostomy (PDT).
• The method is based on needle guide wire airway
  access followed by serial dilations with
  sequentially larger dilators.

55
Percutaneous tracheostomy

• Schachner et al reported the Rapitrach method in
  1989.
• This method consists of using a dilating forceps
  device with a beveled metal conus that is
  designed to advance forcibly over a wire into the
  airway.

56
Percutaneous tracheostomy

• In 1990, Griggs et al reported the guidewire
  dilating forceps (GWDF) method.
• This method is based on a forceps similar to that
  of the Rapitrach method, except without a cutting
  edge on the tip of the instrument.

57
Percutaneous tracheostomy

• Modified Ciaglia technique (ie, Ciaglia Blue
  Rhino) have been reported by Byhahn et al.
• The technique represents a major modification of
  PDT. Dilation of the stoma is formed in a single
  step by means of a hydrophilically coated, curved
  dilatorthe Blue Rhino.

58
PDT

• In 1993, Fantoni et al presented a new
  translaryngeal airway access method.
• This technique passes the dilator between the
  vocal cords and pushes out through the neck
  tissues to obtain stoma. It decreases probability
  of posterior tracheal wall injury.

59
PDT

• Patients undergoing percutaneous tracheostomy
• at the bedside should be chosen carefully
• Stable vital signs, able to tolerate sedating
  medications
• Normal neck anatomy, no prior neck or airway
  surgery
• Normal body habitus
• Absence of coagulopathy, normal platelet counts

60
PDT-set
61
Steps of PDT

• Trachea punctured with needle
• Guide wire passed
• Graded dilators passed over the guide wire
• Tracheostomy tube passed
• The whole procedure can be done while visualizing
  the trachea with a fibrescope through the
  endotracheal tube.

62
PDT

• Advantages 
• Shorter procedure
• Elimination of scheduling difficulty
• Precludes necessity to shift critical patient to
  OT
• Half as expensive as surgical Tracheostomy

• Disadvantages
• Needs special equipment
• Can be done only in intubated patients
• Contra indicated in children
• Contraindicated in cervical spine fractures as
  neck cannot be hyperextended.

63
Contraindications for PDT

• Absolute
• Need for emergency airway
• In children (cartilages soft)
• Midline neck mass
• Non intubated patients
• Relative
• High degree of ventilatory support (PEEPgt20cm
  water, FiO2 gt 50)
• Unstable cervical spine
• Uncorrected coagulopathy
• Presence of neck mass or previous neck surgery
• History of mediastinal irradiation
• Previous history of surgical tracheostomy

64
PDT Vs Surgical tracheostomy

• When elective tracheostomy is indicated in
  critically ill patients, the technique of PDT
  offers important advantages over ST,
• With PDT less clinically significant wound
  infection is observed compared with ST, probably
  related to less tissue trauma tighter fit
  between cannula skin
• - Crit Care 2006

65

• There is no difference in bleeding in PDT Vs ST
• PDT appears at least as a safe as ST, as measured
  in terms of peri-procedural complications
• The occurrence of long term complications is
  probably not affected by the choice of technique,
• A few studies suggest a reduction in tracheal
  stenosis with PDT
• PDT is cost saving compared with ST

66
Cricothyroidotomy

• A technique for providing an opening in the
  cricothyroid membrane for the purpose of gaining
  access to the airway
• Indications
• ? When orotracheal or nasotracheal and / or
• fiberoptic bronchoscopy failed (CV,CI
  situation)
• ? In whom endotracheal intubation is
• impossible or contraindicated

67
Cricothyroidotomy- techniques

• Trans tracheal catheter ventilation
• Percutaneous dilatational cricothyrotomy
• Surgical cricothyrotomy

68
Cricothyroidotomy

• Advantages
• Simple
• Takes lt 1 min to perform
• Ambulance/casualty/
• ED/ nurses can perform it

• Disadvantages
• Subglottic oedema
• Subglottic stenosis

69
Cricothyrodotomy
70
Cricothyroidotomy- contraindications

• Patients who are intubated translaryngeally for
  more than 3 days (...subglottic stenosis)
• Preexisting laryngeal diseases
• cancer, acute or chronic inflammation
• Distorted anatomy in the neck
• Bleeding diathesis or any coagulopathy
• Pediatric patients
• anatomical landmarks difficult to
  identify

71
Needle cricothyrotomy
72
Minitracheostomy

• Small bore tube (4.0 mm, uncuffed) inserted
  through the cricothyroid membrane or tracheal
  stoma after decannulation.
• Used primarily for tracheal toileting
• Can be used for administration of oxygen
• It is generally uncuffed tube generally
  unsuitable for provision of PPV

73
Postoperative care

• Constant supervision
• For any bleeding, displacement or blocking of the
  tube
• Removal of secretions

74
Postoperative care

• 2 .Suction
• Frequency depends upon amount of secretions
• Suction injury to tracheal mucosa is avoided

75
Postoperative care

• 3. Prevention of crusting tracheitis
• Proper humidification by use of
• Humidifiers( HME)
• Steam tent,
• Ultrasonic nebulization, or
• Keeping the boiling kettle in the room

76
Care of the tracheostomy tubes

• Inner cannula should be removed and cleaned as
  and when indicated for the first 3 days
• Outer tube,unless blocked or displaced, should
  not be removed for the 3-4 days to allow a track
  to be formed when tube placement will become easy

77
Changing a tracheostomy tube

• If the current tube become plugged or
• If a different size is needed
• Assemble prepare equipment
• Explain the procedure to the patient
• Remove thr old tubes
• Insert the new tube
• Secure the tube
• Reassess the patient

78
Daily Tracheostomy care

1. Assemble check equipments
2. Explain the procedure to the patient
3. Suctioning the secretions
4. Cleaning of the inner cannula
5. Cleaning the stoma site
6. Changing the ties
7. Replacing the inner cannula
8. Reassessing the patient

79
Pediatric tracheostomy
80
Pediatric tracheostomyindications

• Upper airway obstruction
• Choanal atresia, macroglssia, cleft plate,
  laryngomalacia, laryngeal stenosis, laryngeal
  webs, subglottic stenosis, vascular ring,
  tracheal hypoplasia, vocal cord paralysis,
• angioneurotic oedema, anaphylaxis,
  infections, trauma, neoplastic conditions
• Pulmonary toilet assisted ventilation
• Cong heart disease, esophageal atresia due to TE
  fistula, hypoplastic lung due to diaphragmatic
  hernia, head injuries, CNS infections,
  neuromucular disorders

81
Pediatric tracheostomy

• Trachea of infant child is soft compressible
  ? difficult to identify
• Do not over extend the neck during positioning ?
  injury may occur to pleura, innominate vessels
• Before incising the trachea ? silk sutures are
  placed on either side of midline
• Do not insert knife too deep as the tracheal
  lumen is small, ? injury may occur to posterior
  tracheal wall or even oesophagus ?
  tracheo-oesophageal fistula

82
Pediatric tracheostomy

• Trachea is simply incised, without excising a
  circular piece of tracheal wall
• Avoid infolding of anterior tracheal wall when
  inserting the tracheostomy tubes
• Should select the proper size of the tube
• Use soft sialastic or portex tubes, metallic
  tubes causes more trauma
• Take a postoperatve X ray, neck chest , to
  ascertain the position of tracheostomy tube

83
Immediate Problems

• Pneumothorax
• Wound infection (reasonable common)
• Bleeding ( 5)
• Usually only in coagulopathic patients
• Difficult insertion
• Accidental decannulation
• hypoxia and possible difficult re-insertion
• Occlusion due to secretions

84
Immediate Problems..contd

• Air embolism
• Aspiration
• Surgical emphysema

85
Long Term Problems

• Subglottic stenosis
• Incidence decreased by low pressure cuffs
• Incidence increased by cricothyroidotomy over
  surgical tracheostomy
• Tracheal stenosis (1-2)
• Oesophago-tracheal fistula
• Increased bacterial colonisation of the airways

86
Long Term Problems..contd

• Vocal cord dysfunction
• Chronic
• Recurrent laryngeal nerve injury
• Temporary
• Stomal granulations and scarring
• Non healing of wound
• Erosion into the innominate artery (lt1)
• Occurs in 1st and 2nd week
• Swallowing Problems

87
Benefits of a Tracheostomy

• More comfortable and more stable
• Tube size can be larger (less resistance)
• Allows tubes to be changed more easily
• Better quality suctioning
• Depending on indication for tube and the type of
  tube, patients can eat and talk
• Can promote oral nutrition

88
Decannulation

• When ventilation or suctioning no longer needed,
  and patient can control their own airway and not
  be at risk for aspiration
• Can occur when patient has
• Stable arterial blood gases
• Absence of distress
• Haemodynamiv stability
• PaC02lt60 mmHg
• Absence of psychiatric disorder
• Adequate swallowing
• Able to expectorate

89
Decannulation

• Reduce the size of the tube at each tube change
• .
• Assess the airway above the stoma with a
  fibreoptic endoscope .
• Use a fenestrated tube, allowing the patient to
  breath through the larynx (using a speaking valve
  or decannulation plug).
• Or block the smaller sized plastic tube with a
  cork or decannulation plug for increasing lengths
  of time.
• The patient should be able to tolerate the
  blocked tube for at least 24 hours continuously
  (under strict monitoring in the hospital).
• After decannulation, firm and air-tight dressing
  is applied to allow the tract to close and heal.

90
Difficult or failed decannulation

• Persistence of the condition that originally
  necessitated the tracheostomy
• Anterior tracheal wall dislocation
• Granulation tissue around the stoma
• Edema of the tracheal mucosa
• Emotional dependence on tracheostomy

• Inability to tolerate upper airway resistance on
  decannulation
• Subglottic stenosis
• Tracheomalacia
• Incoordination of the laryngeal opening reflux
• Impaired development of the larynx as a result of
  long standing tracheostomy

91
Types of Tracheostomy Tubes

• Cuffed, Uncuffed, Fenestrated, Unfenestrated
• Cuffed required for
• Aspiration risk
• PPV
• Fenestrated
• Facilitates weaning
• Allows vocalisation

92
Tracheostomy tubes

• Metal
• stainless steel / silver
• parts inner tube, outer tube, obturator.
• disadvantages
• no standard 15mm connector-to attach ventilator
• rigid ( can cause injury)
• no cuff
• expensive

93
Tracheostomy tubes

• Synthetic PVC / silicone
• cuffed or uncuffed ,
• with or without inner tube,
• with or without fenestrations
• Great Ormond street, Portex, Shiley
• Advantages 15 mm connector
• thermolabile- soften at
  body temperature
• cheaper
• Other modifications extra proximal length
• extra distal
  length

94
Fenestreted tube

• Similar in construction to standard TT
• Additional opening in the posterior portion of
  the tube above the cuff
• With the inner cannula removed, cuff deflated,
  tracheostomy air passage occluded patient can
  inhale exhale through fenestrations ?preparing
  the patient for decannulation
• ?allows phonation

95
Types of cuffs

1. Low volume, high pressure
2. Large volume, low pressure
3. Foam cuffs

96
(No Transcript)
97
Comparison of types of tracheostomy
Surgical tracheostomy Percutaneous dilation Crico thyroidotomy Mini tracheostomy
SITE 2nd 3rd or 3rd 4th 1st and 2nd or 2nd 3rd Cricothyroid membrane Cricothyroid membrane
method Surgical dissection Cut the trachea Puncture and dilatation under FOB guidance Puncture with needle Cut the membrane
Elective or emergency Always elective (in OT or ICU setting For emergency access to airway Tracheal toileting Oxygen delivery
98
In Summary

• Most traches are elective for a specific cause
  (or perhaps multiple causes)
• Not free of complications which can be early
  (immediate) or late
• Have many benefits over a conventional ETT
• May be permanent or temporary
• Cuffed or uncuffed, fenestrated or unfenestrated

99
Thank You
100
Preoperative tracheostomy-indications

• Massive cystic hygroma
• Ludwigs angina
• Massive thyroid enlargement
• Carcinoma maxilla

101
Post operative tracheostomy-
indications

• Carcinoma larynx following laryngectomy
• Massive thyroid enlargement- if more than 3
  tracheal cartilages are eroded or calcified

102
Lung separation in a patient with tracheostomy

• Patient with a permanent tracheostomy is
  scheduled for surgery on the lung that requires
  isolation
• E.g.. Those who have undergone resection of a
  tumor in the floor of the mouth or on the base of
  the tongue, followed by extensive reconstruction
  surgery with creation of permanent tracheostomy
• .on routine follow up .lung
  lesion
• that requires diagnostic
  procedure ??

103
Conventional DLTs

• Designed to be inserted through the mouth, not
  through the tracheal stoma
• The standard DLTs are usually too stiff to
  negotiate the curve required for insertion
  through a tracheal stoma and are difficult to
  position

104
Solution ..

• A separately inserted bronchial blocker either
  within or alongside a single lumen tube that has
  been placed through the tracheostomy,
• Passing fogarty catheter through tracheostomy
  into a main stem bronchus

105
Siato et al.

• Described a spiral, wire reinforced DLT, made of
  silicone, that is designed for placement through
  a tracheostomy

106
Tracheostomy history

• The word Tracheostomy-1649
• Derived from Greek - Tracheia arteria - rough
  artery
• Stoma to finish with an opening or mouth
• 1500 B.C
• First reference Hindu book of medicine
• Rig Veda

107
Tracheostomy history

• 800 B.C. Homer described Alexander the Great
  Punctured the trachea of soldier with the point
  of his sword to relieve choking
• 400 B.C. Hippocrates Condemned the tracheotomy
  because of fear of injuring the carotid

108
Tracheostomy history

• 100 B.C. Asclepiades of Bithynia
• First elective tracheotomy ? Patient died
• 100 A.D. Antyluss and Galen
• Described making the tracheal incision between
  the 3rd and 4th rings

109
Tracheostomy history

• 1620. Nicholas Habicot
• First book written exclusively on tracheostomy
• First pediatric tracheostomy- 108 pages

• Dr. Chevalier Jackson
• Established safe guidelines
• Basics still used today
• Described
• Long incision
• Avoidance of the cricoid
• Division of the isthmus
• Slow, careful surgery
• Post-op care

110
Tracheostomy history

• 1957 . Sheldon et al. First described
  Percutaneous Tracheostomy
• published in JAMA
• Special trocar which was blindly inserted into
  the trachea
• No guide-wire used

• 1969 Toye and Weinstein et al.
• First described
• Seldinger technique percutaneous
  tracheostomy
• Published in Surgery
• Incisional rather than dilational

111
High Frequency Ventilation

• frequency ventilation is a type of mechanical
  ventilation that employs very high respiratory
  rates (gt150 breaths per minute) and very small
  tidal volumes (usually below anatomical dead
  space).
• The primary goal of HFV is to achieve
  ventilation and oxygenation at a reduced risk of
  ventilator induced lung injury (VILI). This is
  commonly referred to as lung protective
  ventilation.

112
High Frequency Ventilation

• High Frequency Oscillatory Ventilation is
  characterized by high respiratory rates generally
  between 3-6 hertz (180-360 breaths per minute).
• In HFOV the pressure oscillates (60-90
  cmH20)around the constant distending pressure
  (equivalent to the PEEP - usually around 20-30
  cmH20).
• Thus gas is pushed into the lung during
  inspiration, and then pulled out during
  expiration.
• HFOV generates tidal volumes of 1-3 mL/kg less
  than the dead space of the lung. Different
  mechanisms of gas transfer come into play in HFOV
  compared to normal mechanical ventilation.
• It is used in patients who have hypoxia
  refractory to normal mechanical ventilation and
  in particular in patients with pneumothorax.

113
High Frequency Ventilation

• High Frequency Jet Ventilation employs a small
  cannula placed in the airway at the opening of
  the endotracheal tube
• A high pressure jet of gas flows out of the
  cannula and into the airway. This jet of gas
  occurs for a very brief duration, about 0.02
  seconds, and at a very high frequency 10-20
  hertz.
• Conventional mechanical breaths are frequently
  required to aid in ventilation.

114
High Frequency Ventilation

• High Frequency Flow Interruption is similar to
  HFJV but the gas control mechanism is different.
• Frequently a rotating bar or ball with a small
  opening is placed in the path of a high pressure
  gas. As the bar or ball rotates and the opening
  lines-up with the gas flow, a small, brief pulse
  of gas is allowed to enter the airway.
• Frequencies for HFFI are typically limited to
  maximum of about 15 hertz.

115
High Frequency Ventilation

• High Frequency Positive Pressure Ventilation is
  typically utilized by using a conventional
  ventilator at the upper frequency range of the
  device (typically 90-100 breaths per minute).
• A conventional breath type is used and tidal
  volumes are usually higher than (HFOV, HFJV and
  HFFI).
• With newer and specifically designed devices
  becoming popular, HFPPV is rarely used clinically
  any more.

116
Use of adjuncts to PDT

• Preoperative USG
• USG of the neck may identify structures at risk
  for haemorrhage, such as aberrant blood vessels
• USG may be particularly useful before PDT is
  undertaken in selected patients with variant
  arterial anatomy
• Till date there are no RCT to recommend routine
  use of USG before PDT

117
Use of adjuncts to PDT

• Bronchoscopy (level 1C)
• Bronchoscopy may provide certain benefits, such
  as confirmation of needle placement, dilatation
  tube placement
• No study has yet examined whether the addition of
  bronchoscopy leads to decrease in procedural
  complications

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