Tracheostomy

• Tracheostomy


  An artificial surgically made airway performed by making a hole in the anterior wall of trachea and the insertion of tracheostomy tube which may be permanent and temporary

  
• Indications for tracheostomy tubes


  • Long-term intermittent positive pressure ventilation
  • Upper airway obstruction that cannot be bypassed with an oral/ nasal tracheal tube
  • Maintenance of an airway and to protect the lungs in patients with impaired pharyngeal or laryngeal reflexes (e.g. laryngectomy , face trauma burne)
  • Long-term control of excessive bronchial secretions especially in patients with a reduced level of consciousness
  • To facilitate weaning from a ventilator
• Tracheostomy tracheal tubes


  • Curved plastic tubes usually inserted through the second, third and fourth tracheal cartilage rings
  • Different sizes to fit neonates to adults
  • Older uncuffed metal tracheostomy tubes made of a

  
• Components of tracheostomy tubes


  • An introducer used for insertion
  • Wings attached to the proximal part of the tube to fix it in place with a ribbon or suture
  • Can be cuffed or uncuffed, the former have a pilot balloon
  • Proximal end can have a standard 15-mm connector
  • Tip is usually cut square, rather than beveled to decrease the risk of obstruction
  • Some types had suctioning lumen which opens just above the cuff
  • Some tubes have an changeable inner cannula

  
• Complications of tracheostomy

  • Immediate: hemorrhage, tube misplacement, occlusion of tube by cuff herniation, occlusion of the tube tip against carina or tracheal wall, pneumothorax
  • Delayed: blockage of the tube by secretions, infection of the stoma, overinflation of the cuff leads to ulceration and distension of the trachea
  • Late: granulomata of the trachea, persistent sinus at the tracheostomy site, tracheal dilatation, tracheal stenosis at the cuff site, scar formation

  
• Benefits of tracheostomy


  • Increased patient comfort
  • Less need for sedation
  • Improved access for oral hygiene
  • Possibility of oral nutrition
  • Bronchial suctioning aided
  • Reduced dead space
  • Reduced airway resistance
  • Reduced risk of glottic trauma
• Fenestrated tracheostomy tube


  • Fenestration (window) in the greater curvature channels air to the vocal cords allowing the patient to speak
  • After deflation of the cuff, the patient can breathe around the cuff and through the fenestration as well as through the stoma, reducing airway resistance and assisting in weaning
  • Some tubes have a fenestrated inner cannula

  
• Tracheostomy care


  • Stoma care: goal is hygiene and asepsis, barrier cream applied to the local surrounding skin, cotton and wall should be avoided
  • Tube care: cleaning with normal saline in inner cannula type, pressure should be measured every shift for cuffed type
  • Humidification
  • Suctioning: done after physiotherapy and nebulization with low pressure for less than 10 seconds
• Cricothyrotomy tube

  A cuffed 6-mm tube inserted into the trachea through the cricothyroid cartilage in certain emergencies to get patent airway
• Risk factors for electrical dangers in the operating room


  • Consider a wet area
  • Electrically fully equipped
  • Patient is anesthetized and helpless
  • Both medical staff and patient at risk due to full exposure to electrodes and electrical equipment
  • Low intensity power that can cause significant damage
  • Presence of flammable gases and oxygen
  • Current is invisible
• Types of electrical shock


  • Macroshock: large current able to go through skin and tissues to heart
  • Microshock: small current able to go through direct connection to heart
• Effects of electrocution


  • 1 mA: tingling pain
  • 5 mA: pain
  • 15 mA: tonic muscle contraction and pain
  • 50 mA: tonic contraction of respiratory muscles and respiratory arrest
  • 75–100 mA: ventricular fibrillation
  • 1000 mA: extensive burns and charring
• Damage caused by electrical shock


  • Disruption of the normal electrical function of cells
  • Dissipation of electrical energy throughout all the tissues of the body leading to a rise in temperature
• Factors affecting severity of electrical shock


  • Size of current (number of amperes)
  • Current pathway (where it flows)
  • Duration of contact
  • Type of current (AC or DC) and its frequency
• Safety measures for electrical equipment


  • Use lowest setting that be effective
  • Active electrode should be free of kinks
  • Place dispersive pad under well vascularized muscle mass not boy or hairy or scar sites near surgical site as possible and be sure no tent or gaps
  • Inspect machine for frayed or broken wires before use