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Tracheotomy - Tracheostomy

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Tracheotomy/Tracheostomy

return to: Tracheostomy and Upper Airway Management Symposium July 30 2016 IAO and SOHN Iowa City Iowa

Trachea Surgical Protocols;

Tracheotomy Change in Clinic Videos

see also: Tracheotomy Clinic

see also instructions for patients: Tracheostomy Home Care Booklet

Tracheostomy Patient Education Video

and: Tracheotomy stoma care Tracheostomal care Tracheostomy stomal care

and: Tracheotomy tube with suction port above cuff Portex Blue Line Ultra Suctionaid BLUS

and: Emergency Tracheotomy Tray Emergency Tracheotomy Set

and: Sleep Study with Tracheotomy

and Fenestrated tracheostomy tube tracheotomy employing fenestrated trach

Montgomery Cannula Canula Tracheotomy

Hood stoma stent tracheostomy stent

Tracheotomy (epithelial lined tracheostomy) with laryngeal suspension for ankylosing spondylitis

Trach Lore Panel Hoffman slides April 19 2018

Trachea Surgical Protocols

Tracheotomy/Tracheostomy

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. In combination with other head and neck procedures where postoperative airway obstruction (edema or other) is a concern.
      2. As an alternative to prolonged endotracheal intubation; usually a consideration after 1 week of intubation (in adults), if prolonged ventilatory support is likely.
      3. Severe obstructive sleep apnea, refractory to other methods.
      4. Obstruction of the upper airway, secondary to infection, trauma, or tumor (such as facial or laryngeal fracture, deep neck abscess, subglottic hemangioma)
      5. Anterior craniofacial resections to help avoid pneumocephalus postoperatively (controversy as to whether it is necessary)
      6. Prolonged need for ventilatory support (neuromuscular disease, pulmonary disease)  note difficulty in determining timing for intervention with tracheostomy: Indications and Timing for tracheostomy
      7. Need for improved pulmonary toilet
      8. Bilateral vocal cord paralysis, posterior glottic scarring.
    2. Contraindications
      1. Situations where endotracheal intubation can be easily achieved and can be used to stabilize the airway; the airway obstruction may be short-lived, and a tracheotomy may be avoided (selected cases of epiglottitis, angioneurotic edema of the airway).
      2. Relative contraindication is an uncontrolled coagulopathy.
      3. Inability to access trachea through neck due to severe burn, obstructive tumor, necrotic tissue due to radiation/chemo, other.
  2. PREOPERATIVE PREPARATION
    1. Emergent Cases
      1. Appropriate airway management is complex and determined by multiple considerations. A common theme to all airway cases is to have multiple back-up plans prepared if the initial one or two options turns out to be untenable. The use of a vertical incision for a tracheotomy helps prepare for the back-up approach of a crico-thyrotomy by either pulling the skin superiorly above the cricoid or extending the incision superiorly.
      2. Perform in operating suite, if possible.
      3. If emergent cricothyroidotomy is performed, patient should be taken to the operating room once stabilized. This allows for revision of the tracheotomy and performance of direct laryngoscopy to assess for any laryngeal or tracheal injury.
      4. In emergent cases there may not be adequate time to 'clear' the cervical spine. Stabilization of the spine is important in these cases.
    2. Planned Procedures
      1. Provide preoperative tracheotomy care teaching to patient and/or care provider.
      2. Assess patient's neck anatomy with attention to landmarks and presence of significant submental fat. Removal of excess fat is considered part of the procedure.
      3. Palpation of the anterior base of neck is paramount in order to identify potential anomalous brachiocephalic arteries.
    3. Consent
      1. Explain the need for establishment of alternate airway to the patient. Describe the surgical technique, especially if awake tracheotomy is planned.. Explain that the patient will not be able to talk with the tube in place when the balloon is inflated, but may be able to do so later after the first tracheotomy change, depending on the anatomy.
      2. Describe potential complications
        1. Bleeding, infection
        2. Scar formation
        3. Tracheal stenosis
        4. Accidental decannulation
        5. Pneumothorax/pneumomediastinum
        6. Injury to surrounding structures (esophagus, recurrent laryngeal nerve, major vessels)
        7. Tracheocutaneous fistula
  3. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
        1. Use ENT Supply Pack instead of the Basic soft tissue pack
    2. Instrumentation and Equipment
      1. Standard
        1. Tracheotomy Tray
        2. Bipolar Forceps Trays
      2. Special
        1. Syringe, Luer tip, 10/12 cc, disposable
    3. Medications (specific to nursing)
      1. 1% lidocaine with 1:100,000 epinephrine
      2. 4% lidocaine, plain
    4. Prep and Drape
      1. Standard prep, 10% providone iodine
      2. Drape
        1. Head drape
        2. Towels to square off incision site on neck, from chin to chest, from shoulder to shoulder
        3. Drape off mouth, either for anesthesia access to the endotracheal tube or to allow easy breathing by an awake patient
        4. Split sheet
    5. Drains and Dressings
      1. None
    6. Special Considerations
      1. Have a variety of types and sizes of trachs available.
      2. Test cuff on trach tube with 5 cc of air and place in cup of water. If bubbles are seen, the tube is faulty.
      3. Moisten tube with saline before giving to surgeon to insert.
      4. Be sure obturator is taped to patient's chest or shoulder before patient leaves the room.
      5. May suture tracheotomy tube to keep in place. If ties are used, cut tie in half and then fold one end of each 1.5 inches and cut through the fold 1 inch horizontally (facilitates tying of trach tube).
  4. ANESTHESIA CONSIDERATIONS
    1. Be prepared for alternative methods to secure the airway including: awake fiberoptic intubation, use of the Glide scope, retrograde placement of introducer through cricothyroid membrane. In very rare extreme cases, may consider cardiopulmonary bypass to be established before airway management.
    2. Must have easy access to tube to allow removal at time of entry into trachea.
    3. Sterile tubing may be needed, depending on timing and order of tracheotomy relative to other procedures.
    4. In awake tracheotomy, IV sedation should be utilized with caution, or not at all, so as not to depress airway reflexes.
  5. OPERATIVE PROCEDURE Dictation template
    1. Table positioned with head toward anesthesiologist; may need to alter this if tracheotomy is being performed as part of another head and neck procedure.
    2. Place shoulder roll (if no C-spine injury is present).
    3. Awake patients may need to be positioned with head up or in sitting position, if supine position is not tolerated.
    4. Landmarks should be palpated and marked: thyroid notch, cricoid, and suprasternal notch.
    5. Planned incision site should be marked and injected with 1% lidocaine with 1:100,000 epinephrine.
    6. Vertical incision made approximately 1 cm above suprasternal notch. This may need to be altered, based on patient's anatomy. Alternatively, a horizontal incision may be used. The vertical incision offers the following advantages: 1) more direct midline route (easier) and 2) less tethering of the larynx (theoretical advantage). The scar resulting from the tracheotomy has less to do with the orientation of the skin incision and more to do with subsequent wound care and the development of granulation tissue.
    7. Dissection is carried down in midline through subcutaneous tissues. This can be achieved by hemostat dissection with retraction by Army-Navy retractors.
    8. We advocate "defatting" the subcutaneous tissues by grasping the adipose tissue in the midline with an Allis clamp and removing a cylinder of fat down to the level of the strap muscles. This is achieved with monopolar cautery. This minimizes the amount of tissue between skin and tracheal wall.
    9. Anterior jugular veins can be retracted laterally or ligated, if necessary.
    10. Once the strap muscles are identified, they are divided by a combination of electrocautery and blunt dissection through the median raphe and retracted laterally.
    11. The thyroid isthmus is then encountered. This should be dissected free from the underlying trachea and surrounding soft tissue. It is occasionally reasonable to retract the isthmus superiorly and perform the tracheotomy below the gland.
    12. In most cases, we divide the thyroid isthmus after creating a tunnel by hemostat dissection between the gland and the underlying tracheal wall. The isthmus is clamped with two large hemostats and divided. The edges are then tied off with a running "baseball" suture of 3-0 silk.
    13. Once the anterior tracheal wall is identified, overlying soft tissue can be cleaned off the surface with Kittners.
    14. A tracheal hook is then placed beneath the cricoid cartilage to stabilize and elevate the trachea. In an awake patient, it is helpful to inject additional lidocaine into the cricoid prior to placement of the hook. It is also helpful to inject plain topical 4% lidocaine into the tracheal lumen or to administer additional IV anesthetic agents to decrease cough upon manipulation and entry into the trachea.
    15. Entry into the trachea can now be performed. Once the trachea has been entered, any cauterization should be done with care. In an oxygen-rich field, an airway fire could result. The FiO2 should be lowered by the anesthesiologist.
    16. Alert the anesthesiologist, so that s/he may be prepared to remove the endotracheal tube when necessary. Entry into the trachea should be controlled, with an attempt made to avoid injury to the underlying endotracheal tube cuff, especially in the critically ill patient. One method of preventing injury to the endotracheal tube cuff is to have the anesthesiologist advance the tube 4 to 5 cm while the initial tracheal incision is made. Once entered, the endotracheal tube can be returned to its original position and left in place until the tracheotomy tube is to be placed.
    17. In children, a vertical incision is made in the midline. Retraction sutures are then placed on either side of the incision with 4-0 prolene sutures. These should be labeled "right" and "left" and taped to the patient's chest at the conclusion of the procedure. Removal of any cartilage should be avoided in children.
    18. In adults, a window of cartilage may be removed - however the senior author (HH) prefers to use a Bjork flap in most cases (see 's' below).  The anterior second tracheal ring or third tracheal ring is usually chosen. In calcified tracheas, heavy scissors may be necessary to make cuts through the rings. Care should be taken to avoid extension of cuts too far laterally. Too large of an excision may conceivably predispose to tracheal scarring or collapse once the tracheotomy tube is removed. The tracheal window is grasped with an Allis clamp prior to making the final cut to avoid loss of the fragment into the airway.
    19. Alternatively, and preferably (HH) an anteriorly-based flap (Bjork flap) may be created by incising between the tracheal rings (ideally between 2nd and 3rd - with decision re: location based on anatomic constraints) and then making parallel vertical cuts laterally through the second ring. The free end of the second ring is then secured to the dermis of the lower skin flap with 3-0 vicryl sutures.Recent study supported the value of a Bjork flap to decrease the risk of post-treacheostomy tracheal stenosis (Li et al 2018)
    20. Once the tracheal entry site is secured, the endotracheal tube should be partially removed, so that the tip lies just superior to the tracheotomy site. This may be most expeditiously accomplished by the surgical team rather than the anesthesia team.
    21. The tracheostomy tube with obturator should then be placed. In most circumstances, use of the tracheal dilator for insertion is not necessary. The obturator is then removed, and an inner cannula is placed. The endotracheal tube is then removed. Placement of the tube should be confirmed by watching for CO2 return on the anesthesia monitor and/or auscultation of the lungs. Once confirmed, the tracheal hook is carefully removed.
    22. Final hemostasis is achieved, working around the tube.
    23. The tracheotomy tube is then secured in place with 2-0 silk sutures placed at each corner to the underlying skin. Tracheal ties can also be placed for added security. If a pedicled or neurovascular anastomosis has been performed in the neck, tracheal ties are not used.
    24. The tracheotomy incision is left open to avoid subcutaneous emphysema.
  6. POSTOPERATIVE CARE
    1. A drain sponge may be placed around the tube to collect secretions.
    2. The cuff should be deflated after 24 hours in nonventilated patients.
    3. First tracheotomy change done between day 4 and 7. A thin patient who has a secure Bjork flap may get and earlier tracheotomy change than an obese patient. Stay sutures may be removed at this time.
    4. (see Tracheotomy change video)
    5. Tracheostomy care should be taught again to patient prior to discharge (see Tracheostomy Home Care Booklet Protocol).
    6. Please see Airway Monitoring protocol
  7. DICTATION TEMPLATE
    1. Informed consent was reviewed. The patient was delivered to the OR and placed in the supine position. The table remained in place with the HOB toward anesthesia. As patient was without a C-spine injury, a shoulder roll was placed. Landmarks were palpated and marked including the: thyroid notch, cricoid, and suprasternal notch. Planned incision site was marked and injected with 1 cc of 1% lidocaine with 1:100,000 epinephrine. A #15 blade was used to create a vertical incision approximately 2 cm above suprasternal notch. Dissection was carried out at midline through subcutaneous tissues with the use of hemostats. This area was defatted with monopolar cautery down to the level of the strap muscles. The strap muscles were identified, and divided by blunt dissection through the median raphe and retracted laterally. The thyroid isthmus was then encountered and dissected free from the underlying trachea and surrounding soft tissue. It was clamped and divided with monopolar cautery. Both edges were stitched with a baseball stitch, and hemostasis was achieved. The anterior tracheal wall was identified, and the overlying soft tissue was cleaned off the surface with Kittners. The tracheal rings were identified, and the ET tube was advanced. A tracheal hook was then placed beneath the cricoid cartilage to stabilize and elevate the trachea. A window was created at the level of the second tracheal ring using a #15 blade and curved Mayo scissors. The endotracheal tube was partially removed, so that the tip was just superior to the tracheotomy site. A number 8 Shiley tracheostomy tube with obturator was then placed. The inner canula was placed, cuff inflated, and placement of the tube was confirmed with CO2 return on the anesthesia monitor. The tracheal hook was carefully removed. Final hemostasis was achieved. The tracheotomy tube was then secured in place with 2-0 silk sutures placed at each corner to the underlying skin. A tracheal tie was also placed. The procedure was complete.
  8. SUGGESTED READING
    1. Lore JM. The trachea and mediastinum: tracheostomy. In: Atlas of Head and Neck Surgery. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1988:811-818.
    2. Wenig BL, Applebaum EL. Indications for and technique of tracheotomy. Clin Chest Med. 1991;1293:545-553.
    3. Rana S, Pendem S, Pogodzinski MS, Hubmayr RD, Gajic O. Tracheostomy in critically ill patients. Mayo Clin Proc. 2005 Dec; 80(12):1632-8
    4. Fabrizio Giuseppe Bonanno Techniques for emergency tracheostomy Int. J. Care Injured (2008)39, 375-378
    5. Li M, Yiu Y, Merril T, Yildiz V, seSilva B and Matrka L: Rick Factors for Posttracheostomy Tracheal Stenosis. Otolaryngology -Head and Neck Surgery 2018. Vol.159(4) 698-704
    6. Joshua Tokita, Raymond Kung, Kalpaj Parekh, Henry Hoffman  Resection of the Innominate Artery to Prevent an Impending Tracheoinnominate Fistula and to Permit Tracheotomy in a Patient With Subglottic Stenosis and High-Riding Innominate Ann Otol Rhinol Laryngol. 2014 Sep;123(9):658-61. doi: 10.1177/0003489414528670. Epub 2014 May 13.