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Tracheostomy
By Ussana Promyothin MD.
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Tracheostomy
• Surgical opening in the trachea for ventilation
Indication• Bypass upper airway obstruction• Clearance secretion at lower respiratory• Prevent aspiration gastric content in absent of laryngeal reflex
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Other indication
• Prolong intubation(1-3wks) children more prolong
• Laryngeal injury
• Fracture face neck area
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• Also
• Improved oral hygiene
• Oral movement for communication
• Reduction damage larynx,nose ,mouth
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Contraindication
• Prolong bleeding
• On anti-coag, anti-pletlet medication
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• Elective tracheostomy• Emergency tracheostomy:
should avoid, expertised surgeon,team• In children: perform only with a secured airway
either from ET tube or bronchoscope in OR• Emergent tracheostomy should be avoided if
possible• Risk to vascular,lung and uncontrolled airway
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Hyperextend the neck,
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2 FB above thyroid notch ring 2,3
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Skin incision,horizontal /vertical
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Find white line,Test tracheostomy cuff
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Clean trachea,aspirate air then push xylocaine
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Stay suture,open trachea by inverted U flap,cross,vertical (in children stay suture on both sides of incision)
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Standby tracheal dilator,suction,
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Post operation care
• Irrigation with saline and suction q 15 mins
• Suction not exceed 15 seconds (block airway and suck Oxygen out)
• Humidification Oxygen (decrease thick mucus)
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• Observe bleeding and subcutaneous emphysema
• Off packing 24-48hrs
• Left tube in place 5-7 days
• Stitch off and off stay suture 7th day
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• Blow Cuff when on ventilation or prevent aspiration
• Not exceed 25 cm H2O
• Clean inner tube
• analgesic
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Complication
Immediate• Apnea :loss hypoxic drive,COPD ventilator• Post obstructive pulmonary edemaPEEP• Pneumothorax chest x-ray post op• Injury to adjacent organ:thyroid ,vessel,
esophagus,recurrent laryngeal nerve
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Pneumothorax
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Early
• Bleeding HT, skin,thyroid,soft tissue• Mucus inner tube• Tracheitis humidification, minimize FiO2,
Stabilize tracheostomy• Cellulitis: wound care,antibiotic• Displacement: pass E-T tube, NG tube
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LateBleeding -innominate vessel:usually in 2wks,high mortality
(low tracheostomy,mobilized tracheostomy tube,high pressure cuff,local infection)
-granulation( stroma, tip of tube)
Tracheoesophageal fistula:risk in retain NG tube
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Type of TracheostomyType/description
permanent ventilator Inner tube
size
jackson yes no yes 4-5
shiley yes yes yes 4-6-8
portex no(7-14days) yes no 7-8
blueline no(1month) yes yes 7-8
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Cricothyrodotomy:maneuver to buy time
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Advantage• Near skin and less dissection
Disadvatage• Trauma to subglottic area• Contraindication:children<12 yrs,infection at
larynx,laryngeal trauma and risk transecting tumor
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Tracheostomy care
• Clean skin around stroma
• Change gauze
• Clean inner tube
• Aware obstruction or slip out of tube
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Weaning tracheostomy tube
• Reason for tracheostomy has resolved
• Stable lung status(O2<40%)
• Effective swallow,gag,and cough reflex
• Adequate nutrition, sleep, psychososial suppor
• Cuff deflate trial
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Method
• Flexible bronchoscope or IDL
• Assess cord movement,granulation,stenosis area
• Admit,size tube down
• Plug tube day,all day night
• Off tube,observe before discharge
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Epistaxis
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Abnormal bleeding per nose
• Cause• Trauma ,nose picking ,nose blowing• URI, allergic rhinitis• Septum deviation• Decongestant ,nasal spray• Foreign body• Tumor• Post surgery
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• Hypertension, artherosclerosis
• Anticoagulation drug,ASA,NSAID
• Decrease plt
• Liver function disease
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Site of bleeding
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MANAGEMENT
• Immediate evaluation :vital sign,airway
• Stop bleeding
• Compress nose,cold pack
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Anterior epistaxis
• Little’s area region
• Ephridine or adrenaline pack (vasoconstrict agent)
• Beware in HT
• CAUTERIZATION
• 30%TCA,silver nitrate, electrical cautery
• Gel foam
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Anterior nasal packing
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Nasal speculum
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Headlight
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Suction
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Anterior nasal packing
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• Vasaline gauze or coated with antibiotic ointment
• Apneanaso-vagal reflex bradycardia,hypotension
• Remove packing 2-4 days later
• Antibiotic and decongestant
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Posterior nasal packing
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Foley catheter
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Posterior nasal packing
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Anterior and posterior nasal packing
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• Posterior packing :oxygen face mask
• Elevate head 30 degree
• Antibiotic cover Staph aureus
• Liquid diet
• Remove packing 3-5 day later
• If high fever ,hypotension, remind toxic shock syndrome
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• Surgery • Ligation artery• Endoscopy
•Angiogram and embolization
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Sinusitis
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Anatomy and function
• Resonance to voice• Humidify and warm air• Increase the area of olfactory • Absorb shock to head• Keep nasal chamber moist• Protect thermal to brain• Contribute facial growth• Lighten bone of skull
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Acute bacterial sinusitis
• Cause
• URI,AR
• Dental infection
• Obtruction ostium: structure,tumor
• Immotile cilia
• Foreign body: NG tube
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Symptom
• Fever
• Maxillofacial pain
• Dental pain
• Otalgia
• Posterior nasal drip
• Nasal congestion
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• Causative agent
• viral
• S.pneumoniae
• H.influenzae
• M.catarrhalis
• Other bacteria
• Fungus
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FILM SINUS
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Management
• Proper antibiotic• Systemic decongestant:maxiphed• Beware: HT, Heart disease, urinary retention• Topical decongestant: not exceed 3 days• Mucolytic agent• Antihistamine if suspected allergy• Normal saline irrigation
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• If failure medication• Antral puncture• For drainage and C/S• CHRONIC BACTERIAL SINUSITIS• Greater than 12 wks duration symptom• Treatment: antibiotic 4-6 wks• CT scan• Surgery : ESS (endoscopic sinus surgery)
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ESS
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Complication sinusitis
• Mucocele
• Orbital complication: cellulitis abscess
• Intracranial complication: meningitis brain abscess