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What is a Tracheostomy?
A surgical opening in the anterior wall of the trachea to facilitate ventilation
Surgical
or
Percutaneous
Tracheostomy
Anatomy of the trachea The trachea is a fibromuscular tube supported by 20 hyaline cartilages which are opened posteriorly. The soft tissue posterior wall is in contact with the oesophagus. Three layers of tissue clothe the cartilages:
A fibrous elastic outer layer. A middle layer of cartilage and bands of smooth muscle that wind around the trachea. There is some tissue containing blood and lymph vessels and autonomic nerves. An inner lining consisting of delicate ciliated columnar epithelium containing mucous secreting globlet cells.
The blood supply is primarily supported by the bracheocephalic artery and through the inferior thyroid and bronchial arteries. The nerve supply is by parasympathetic and sympathetic fibres. The sympathetic system acts in the flight or fight response stimulated by adrenaline. It causes an increase in heart rate and relaxes the bronchi and muscle of the gut wall. The parasympathetic supply to the trachea is by the recurrent laryngeal nerve a branch of the vagus nerve it can slow the heart rate, increase the acidity to the stomach and constrict the bronchi. (Brunt, (1986), p33-34)
Position The trachea begins just below the larynx at approximately the 6th cervical vertebra. It is flexible to accommodate varying depths of ventilation, coughing and speech. The length and width is continually changing to accommodate head, neck and diaphragmatic movements. In adults it is 12-16 cm long and 13-16 mm wide in women and 1620 mm wide in men. (Minsley and Wren 1996) It is slightly to the right of the midline and divides at the carina into the right and left bronchi. The carina lies under the junction of the sternum at the level of the 4th thoracic vertebra. (Kumar and Clark, 1994 p 631)
Tracheostomy
TRACHEOSTOMY TUBES
All tracheostomy tubes consist of a main shaft and a neckplate or flange. The flange rests between the clavicles. Holes on each side allow you to attach tracheostomy ties to secure the tube in place. Tubes are made of semi-flexible plastic, rigid plastic or metal. Semi-flexible plastic tubes conform to the patients anatomy during movement good for patients with tracheal deviations. Rigid tubes are typically used when neck swelling is a problem. The tubes dont bend or collapse with local oedema. Plastic tubes have a built-in 15mm adaptor that extends from the neck plate. This allows respiratory equipment e.g. an ambubag, a T piece oxygen delivery system or a mechanical ventilator, to be attached. Synthetic tubes are made from a non-irritant substance.
The most commonly used cuffed tube in the hospital is the Portex Blue-Line Profile Cuffed Tube, available from stores cost approximately 13 each. Cuffed Portex tubes, with inner tubes are now available in stores and cost approximately 35.
Types of Tubes
Cuffed tubes Un-cuffed Fenestrated Inner cannula Adjustable flange PVC, Silver, Silicone and Rubber Mini Tracheostomies
Cuffed Tubes
Allows ventilation and prevents aspiration High cuff pressure can be damaging Check pilot cuff DO NOT BLOCK THIS TUBE
Cuffed Tubes
Tubes with inflatable cuffs Inflatable cuffs are used when an air-tight seal is required around the tube. The cuff is not to hold the tube in position it is usually required: when the patient is unable to breathe on their own and requires artificial respiration. Unless there is an air-tight seal around the tube, the air being blown into the lungs by the respirator escapes around the sides of the tubes. or when an air-tight seal is necessary to prevent blood and other secretions from running down the sides of the tracheostomy tube into the lungs. During and following surgery to the head and neck, such complications are a real danger and it is for this reason that a cuffed polythene tube is used for the first couple of days postoperatively.
Cuffed Tubes
Cuffed tubes have an inflation line leading to the cuff and pilot balloon that inflates when the cuff contains air, giving an indication of the volume of air in the cuff. What the pilot balloon does not tell you is how much air pressure is in the cuff. You can confirm the correct inflation by listening for air leak or by measuring intracuff pressure with a manometer, (Weilitz and Dettenmeiir, 1994). The presence of an air leak may indicate that the cuff is inadequately inflated.
Un-cuffed Tubes
Maintains airway once aspiration risk has passed Increase airflow to the larynx Which patients: Long term tracheostomy pts Patients who do not require a seal Paediatrics
Uncuffed Tubes
Unable to maintain seal in an emergency situation
Fenestrated Tube
Increases airflow to larynx/ vocalisation Cuffed or un-cuffed These are used for weaning Enables phonation (speaking) The fenestrated tube can be used as such if the patient is tolerating the cuff down To suction always use the non fenestrated inner tube for suctioning Fenestrated are the only tubes (when inner fenestrated tube insitu and cuff is down) that can be intentionally occluded
Inner Cannula
Allows maintenance of tube patency
Aids tube hygiene Close observation
Inner Cannula
Use of an inner cannula: The inner cannula provides a vital safeguard against life-threatening complications of tube obstruction in a cuffed tube and must be present at all times. Tracheostomy tubes without an inner cannula should be avoided wherever possible particularly in the ward environment; this may, however, be impossible to achieve with all patients.
Adjustable Flange
Provide a longer tube offer secure placement of tube in a deep-set trachea Essential for patients with difficult anatomy and on whom the insertion will be complicated; insertion of this tube is usually via the surgical technique (considered to be an unsuitable tube for the percutaneous insertion technique) The Portex PVC adjustable flange tube does not have an inner cannula. These tubes are inserted in patients with very difficult anatomy and therefore subsequent tube changes should be considered carefully.
Adjustable Flange
Silver Negus
Metal Tracheostomy Tubes These are made of silver because the metal is inert and does not irritate the tissues. The most commonly used silver tube is the Silver-Negus. The sizes of the tubes for adults vary from 28-36 FG. The letters FG stand for French gauge. The number represents the circumference of the inner tube measured in millimetres. As a rough guide, the FG size is 4 times the portex size. The tubes have a normal inner tube and a speaking tube with a small valve on. Speaking tubes should not be used to sleep in because of the danger of the valve blocking and occluding the airway. Silver tubes cost approximately 200 each. Each set is individual and pieces are not interchangeable. If a piece is lost it can cost 100 at least to replace. The tubes also need repairing and maintaining occasionally. Manufacturers of plastic tubes claim silver tubes are not as comfortable as plastic but they have no evidence to support this.
Tracheostomy (antique)
Mini Tracheostomy
Minitracheostomy (cricothyroidotomy) is for the treatment or prevention of sputum retention after thoracotomy, laparotomy or neurological insult. It is an alternative to naso-laryngeal suction or regular flexible bronchoscopy. A cannula with an internal diametre of 4 mm is inserted.
Mini Tracheostomy
Patient able to breathe normally Patient can talk and eat / drink The tube does not prevent expectoration Use only size 10 or less suction catheter. Suction will take longer but patient can breathe during the procedure
Portex minitracheostomy
Mini Tracheostomy