Tracheotomies

Introduction

Tracheotomy Indications

• bypass upper airway obstruction (eg, sleep apnea, tumor)

• prevent complications from prolonged intubation (eg, mucosal ulceration, laryngeal stenosis, granulomas)

• assist with tracheal-bronchial suctioning (pulmonary toilet)

• provide protection from aspiration

• eliminate dead space (CNS depression)

The Pediatric Tracheotomy

• prolonged intubation generally preferred over tracheotomy in neonates up to 6 months (high risk of subglottic stenosis)

• may consider performing tracheotomy with a rigid bronchoscope to provide rigidity and facilitate dissection

• consider endoscopy every 3 months for pediatric tracheotomy to evaluate for stenosis

Tracheotomy Complications

• Intraoperative Complications: vessel injury (hemorrhage), pneumothorax, pneumomediastinum

• Immediate Postoperative Complications: postoperative pulmonary edema from release of pressure (Rx: positive pressure ventilation), acute obstruction (mucous plug), loss of airway (tracheotomy tube not secured)

• Long-term Complications: tracheal stenosis, granulation tissue, tracheal-innominate artery erosion, subglottic stenosis

Tracheotomy Management

Tracheotomy Care

• Maintain Airway: especially for first 48 hours to prevent accidental loss of airway; suture tracheotomy to neck skin, tight tracheotomy ties, clean inner cannula, first tracheotomy change may be considered after 3—5 days to allow the tract to form

• Humidity: prevents tracheal crusting and mucous plugs, initially saline should also be dropped into tube every 3—4 hours

• Pulmonary Toilet (.Aseptic Technique Suctioning): tracheotomy tubes disrupt ciliary function, decrease subglottal pressure required for an adequate cough, and increase risk of microaspiration; requires regular suctioning of the tracheal airway, especially for the first few days

• Skin Care: cuff dressings may be considered to prevent skin breakdown

• Check Cuff Pressure: cuff pressure should be less than capillary pressure (<25 cm H2O) to prevent pressure necrosis (subglottic stenosis, tracheal-innominate artery erosion, tracheomalacia)

• Feeding: no solid food ingestion when cuff is inflated; capping tracheotomy tube facilitates swallowing

Decannulation

• tracheotomy tubes should be removed as soon as possible (especially in children) to prevent long-term sequelae such as tracheal ulceration, subglottic stenosis, tracheomalacia, etc

• prior to decannulation patient should undergo tracheotomy tube downsizing and a trial of capping (24 hours for 7 consecutive days without respiratory difficulties)

• original indication for tracheotomy must be resolved

• consider flexible nasopharyngoscopy to evaluate airway patency (evaluate subglottis with retroflexed look through the stoma)

• place airtight dressing to seal stoma after removal of tracheotomy tube

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