Chapter 7: Tracheotomy Flashcards
Earliest accounts of a procedure resembling tracheotomy are found in Egyptian tablets
3600 BCE
A sacred Hindu text allude to cutting the neck to access the airway
Rig Veda (2000 to 1000 BCE)
Allude to cutting the neck to access the airway
Ebers Papyrus of Egypt (c. 1550 BCE)
Vehemently opposed to the procedure, citing potential risk to the carotid artery
Hippocrates
A poet who regaled the court with stories of Alexander the Great, who saved a fellow warrior choking on a bone by opening the soldier’s airway with his sword
Homerus of Byzantium
A Greek physician who performed an elective tracheotomy around 100 BCE, but it was not until 340 CE that a firsthand account of the surgery was recorded
Asclepiades
A physician who described making an incision at tracheal rings three and four and pulling the cartilage apart with hooks to allow a patient to breathe more easily
Antyllus of Rome
Best known for his work De Humani Corporis Fabrica, placed a reed into the trachea of a pig and demonstrated lung ventilation by blowing into it I ntermittently
Andreas Vesalius (1543)
He was credited with providing the first documented successful tracheotomy
Antonio Musa Brassavola
He performed the procedure on a patient in 1546 to relieve airway obstruction resulting from a peritonsillar abscess
Antonio Musa Brassavola
One of the first attempts involved in maintaining the opening into the airway by using a short, straight cannula designed by _____.
This tube sat against the common wall between the trachea and esophagus and was prone to create fistulae
Sanctorius (1590)
Curved metal tube was introduced by____
Julius Casserius
Who awoke one morning in 1799 with a severe sore throat. His airway obstructed, and he died shortly thereafter from anemia of acute blood loss
George Washington
Doctors who involved in the treatment of George Washington
James Craik
Gustavus Brown
Elisha Dick
Attitudes toward tracheotomy began to change when outbreaks of diphtheria in Europe resulted in numerous deaths as a result of airway obstruction
Mid-nineteenth century
French surgeons who advocated for a more aggressive use of tracheotomy for airway management
Pierre Bretonneau
Armand Trousseau
A French surgeon who published his experience in 1869, noting that he had “performed the operation in more than 200 cases of diphtheria, and…had the satisfaction of knowing one-fourth of these operations were successful.”
Armand Trousseau
He presented a paper in 1871, in which he described using tracheotomy to provide general anesthesia
Friedrich Trendelenburg
He helped to standardize techniques for performing tracheotomy and establish protocols for the care of these patients (surgical patients)
Chevalier Jackson
He warned against the potential pitfalls of the “high tracheotomy” (cricothyrotomy) and the associated risk of laryngotracheal stenosis
Chevalier Jackson
He also designed a double-lumen metal tube of an anatomically appropriate length and curvature, even going so far as to create tubes with longer shafts that allowed tracheal obstructions to be bypassed
Chevalier Jackson
They published their work on endotracheal intubation based on their experience with patients who sustained facial injuries during World War I
Rowbotham and Magill
Indications for tracheostomy
- Prolonged mechanical ventilator
- Pulmonary toilet
- Surgical access
- Airway obstruction
Potential advantage of tracheotomy in patient who requires long-term ventilation
Decreased need for sedation
Other advantages of tracheotomy include:
Potential for early return to oral nutrition and communication
According to American College of Chest Physicians translaryngeal intubation was recommended if
Fewer than 10 days of ventilation were anticipated
Tracheotomy was recommended if
The need for mechanical ventilation was expected to exceed 21 days
Creation of an opening in the anterior tracheal wall
Tracheotomy
Formalization of a permanent stoma by suturing the edges of the trachea to the skin
Tracheostomy
Vertical incision is marked from the
Inferior aspect of the cricoid and extends 2 to 3 cm inferiorly
Horizontal incision is marked from the
At the approximate level of tracheal ring two, 1 cm below the cricoid
Tracheotomy should be created between the
Second and third or the third and fourth ring
Inferiorly based tracheal flap between rings two and three
Bjork flap
What is the use of Bjork flap?
Help prevent false passage when replacing a dislodged tube
Bjork flap results in
Semipermanent tracheostomas that may require surgical closure after decannulation
First described percutaneous tracheotomy using the Seldinger technique in 1969
Toye and Weinstein
Introduced the dilational percutaneous technique in 1985 that the procedure began to become more commonplace in the ICU
Ciaglia
Percutaneous dilational tracheostomy is contraindicated in children because of the
Collapsible, mobile trachea of the pediatric airway is difficult to localize and stabilize for safe performance
Open tracheotomy is preferred in
- Coagulation abnormalities
- High level of respiratory support
- Cervical spine injuries
Tube configurations are defined by the
- Inner diameter (ID)
- Outer diameter
- Length
- Curvature of the appliance
In dual-cannula systems, the ID refers to the
Diameter of the inner cannula
The ID in single-cannula tube systems is determined by the
ID of the tube itself
ID of the tube determines
Airflow
If the ID is too small, resistance through the tube increases and has an impact on the
Work of breathing
Estimated resistances through size 4, 6, 8, and 10 Shiley tubes are
11.4, 3.96, 1.75, and 0.69 cm H2O/L/s, respectively
Tubes with extra proximal length (horizontal) are designed for
Obese neck or neck masses that displace the trachea posteriorly
Tubes with extra distal length can be used to
Bypass areas of stenosis or malacia distal to the stoma
Are ideal for patients who do not require mechanical ventilation
Uncuffed tubes
These tubes can bypass upper airway obstruction, allow for pulmonary toilet, and accommodate speech
Uncuffed tubes
Are designed to facilitate positive-pressure ventilation
Cuffed tubes
Tracheal mucosa capillary perfusion pressure
Approximately 25 to 30 mm Hg
Cuff pressures above that can result in
Ischemic necrosis, which leads to stenosis
Ideal for patients who need only intermittent positive pressure; the low profile of the cuff, once deflated, allows for easier speech
Tight-to-shaft TTS] tubes
Complications of tracheotomy can be classified as
Early (<7 days) or late (7 )days
Initiation and propagation of fire requires three things:
- a fuel source
- an energy source
- an oxidizing source
Most common cause of bleeding intraoperatively
- Anterior jugular vein injury
2. Bleeding edge of the thyroid
Potential mechanisms of pneumothorax and pneumomediastinum include
- direct injury to the pleura
- dissection of air along the trachea
- rupture of an alveolar bleb
Early complications
- Infection
- Tube Obstruction
- Accidental Decannulation
True or False
Tracheotomy bypasses the natural warming and humidification provided by the nasal passages. The result is desiccation of the tracheal mucosa with decreased mucociliary function
True
Late complications
- Tracheal Stenosis
- Tracheo-innominate Fistula
- Tracheoesophageal Fistula
- Tracheocutaneous Fistula
True or False
When cuff pressure exceeds capillary perfusion pressure, the result is ischemic necrosis and chondritis of the underlying tracheal cartilages
True
Stenoses from PDT
Corkscrew pattern
Tracheo-innominate fistula occurs in about
0.7% of patients in both acute (<2 weeks) and chronic (>2 weeks)
Risk factors for tracheo-innominate fistula
- low placement of the tracheostomy
- malnutrition
- radiation
- steroid usage
- hyperextension of the head
Definitive treatment for tracheo-innominate Fistula
Median sternotomy with ligation of the innominate artery
Tracheoesophageal fistula occurs in
1%
Risk of fistula formation through the party wall is increased when
A large-bore nasogastric tube is also in place
Tracheoesophageal fistula is best managed by
Interposition of viable tissue between the membranous trachea and the esophagus
Increases the risk of a persistent tract after decannulation
- history of radiation exposure
2. use of a Bjork flap
Fistulae should be closed because of the risk of
- aspiration pneumonia
- skin irritation
- difficulties with voicing
