Tracheostomy/Laryngectomy

Question 1

Describe Stridor

Answer 1

• Inspiratory, expiratory, biphasic (level of larynx)

Question 2

Describe Stertor

Answer 2

• Orophayngeal obstruction

Question 3

Initial management of supraglottic infection

Answer 3

15 L non-rebreathe
Nebulised adrenaline • 1:1000 in 5 mls saline
Steroid IV
• Max dose IV dexamethasone
Summon most senior ENT surgeon and anaesthetist

• Add antibiotics IV
• Get patient to place of safety
• Close observation (NOT SIDE ROOM) • HDU
• Specialist ENT ward
• Resus in A&E

Question 4

Signs of supraglottic infection

Answer 4

• Inspiratory stridor
• Sitting forward drooling
• Toxic T38
• Sore throat 24 hours rapidly deteriorated
• Sats 94% room air
• RR30
• No neck oedema, few LN tender upper deep cervical region bilaterally

Question 5

Emergency airway management options

Answer 5

• Intubation with gaseous induction • Rigid Bronchoscopy
• Cricothyroidotomy
• Tracheostomy

Inhalational anaesthetic to protect airway- avoid paralysis

Question 6

What is a Tracheostomy?

Answer 6

A window in the trachea to allow ventilation

Question 7

What are the Indications for Tracheostomy?

Answer 7

Upper airway obstruction
• Infection
• Tumour

To maintain safe airway
• Post trauma

Respiratoryfailure/paralysis/neurogeniccauses

Weaning from artificial ventilation

Secretions
• Poor cough effort

Question 8

Early Complications Tracheostomy

Answer 8

• Bleeding
• Infection
• Displacement
• Pneumothorax
• Occlusion
• Surgical emphysema

Question 9

Delayed Complications Tracheostomy

Answer 9

Delayed <7 days
• Blockage
• Displacement
• Pneumonia
• Skin ulceration
• tracheosophageal fistula

Question 10

Functions of nose

Answer 10

• Warm
• Humidify
• Prepare the air for optimum gaseous exchange in the lungs
• Without it –
• dry, crusty airway,
• reduced cilia motility with dry cold air leads to crusting

Question 11

Tracheostomy Physiology

Answer 11

• Reduction of dead space by up to 50%
• Reduce the work of breathing
• Bypass obstruction (ENT/Max Fax)
• Protect the incompetent airway/neurological

Question 12

Types of Tracheostomy Tubes

Answer 12

• Single cannula/dual cannula (inner tube) • Fenestrated/non-fenestrated
• Cuffed/non-cuffed

Question 13

Purpose of a cuffed tracheotomy tube

Answer 13

• Help prevent aspiration
• Common first tube , keep inflated first 12-24 hours then reassess
• Monitor pressure
• Aim 25-34 mmH2O (checked)
• Record after every inflation/deflation/replacement

Question 14

Suction in NEW tracheostomies (first 24-28 hours)

Answer 14

• Trained nurse in attendance 24-48 hours
• Excess secretions inevitable • FB reaction
• Cold, dry air
• Suction is required every 2 hours, but may be required as often as every 30 mins if secretions copious/thick
• New tracheostomy patients will need humidification for at least 48 hours
• Humidification needed to: • prevent dry crusting
• Aid O2 transfer
• Loosen secretions
• Saline nebs

Question 15

Resp/Cardiac Arrest in tracheostomy patients

Answer 15

• O2 to tracheostomy (NECK BREATHERS)!
• Check tube is not blocked, if it is:

Remove inner cannula (if present) Suction
Remove tube if completely occluded Cover stoma and ventilate via oral / nasal airway
OR
Replace tube with cuffed tube if competent

• Tube not blocked:
Resp/Cardiac Arrest
• Is tube cuffed?
• YES – inflate it
• NO – change to cuffed tube if competent.
• Manually ventilate patient using a catheter mount and self inflating bag.