Tracheostomy and Surgical Airway Management Department of Otolaryngology

Tracheostomy and Surgical Airway Management Department of Otolaryngology- Head and Neck Surgery

What is a tracheostomy and surgical airway? § An opening created at the neck into the windpipe (trachea) that allows for air exchange § There are multiple reasons why patients need this including: § Respiratory failure and need for ventilator assistance § Head and neck cancer and other disease § Airway narrowing ©Used with permission of Mayo Foundation for Medical Education and Research. All rights reserved 2

What is a tracheostomy and surgical airway? § There are serious consequences of suboptimal care, including death § It is our responsibility as physicians, nurses, therapists, and providers to be educated on how to care for these patients § In this presentation, we will provide an overview on the basics of managing a tracheostomy and surgical airway 3

Types of surgical airways Tracheostomy (Trach) Stoma Laryngeal stents (T-tubes) Click on the icon to learn more about specifics on your patient’s airway 4

Tracheostomy 5

Equipment required for tracheostomy Spare Tracheostomy (box) Neck Ties Spare Tracheostomy Obturator Inner Cannula 6

Equipment required in patient room Wall Suction Catheters Trach Collar Supplemental O 2 (if needed) Normal Saline Tracheostomy Cleaning Kit Saline Lavage Bullets 7

Tracheostomy There are different types of tracheostomies You should know the following information about your patients trach: 1. Brand 2. Size 3. Cuffed or cuffless 4. Inner cannula or no inner cannula § Disposable vs non-disposable inner cannula 5. Fenestrated or non-fenestrated 6. How long has the patient had a tracheostomy? 7. Why does the patient have a tracheostomy? 8

Tracheostomy: brand size Shiley Portex Bivona XLT Shiley Size: the larger the number, the larger the tracheostomy § 6 -0 tracheostomy fit most adults § Larger or overweight adults may need an XLT (proximal/distal) or 8 -0 tracheostomy § 4 -0 tracheostomy may be placed in preparation for decannulation 9

Tracheostomy: brand (sample box) Shiley Bivona Portex XLT Shiley 10

Tracheostomy: cuff Cuffed § Cuffless Cuff is needed for patients needing mechanical ventilation, any positive pressure (ie CPAP), and in some patients to prevent aspiration § Cuff should not be overinflated as it can cause tracheal injury. Discuss with Respiratory Therapy if concerns 11

Tracheostomy: inner cannula Non-Disposable • Inner cannulas are specific to each trach. Some are reusable and others disposable • Disposable inner cannulas are only cleansed with normal saline (no peroxide) • Disposable inner cannulas should be changed once per day 12

Tracheostomy: fenestrated Non-Fenestrated § Fenestration increases air flow to the mouth and nose, and in appropriate patients allows for better speech § We limit use of fenestrated tracheostomies due to increased risk of airway trauma 13

Tracheostomy: length of time § Knowing the length of time the patient has had a tracheostomy is important § New tracheostomies (within 7 days) need extra care: § Humidification is necessary, as air into the trach is not moistened or warmed by the nose or mouth § Frequent suctioning to help bring up secretions § Bleeding can be seen from the neck incision and secretions may be blood tinged for the first 24 hours § Chronic Tracheostomies § Suctioning can be as needed or only with cleaning 14

Speech with a tracheostomy Speaking Valve (Passy-Muir Valve) § Cuff must be deflated with these devices § Swiftly remove these devices if difficulty breathing develops Cap 15

Stoma 16

Stoma § Stomas result from total laryngectomy, a procedure where the upper windpipe and voice box is removed § Patient is an Obligate Neck Breather § Opening in the neck is the only site of air exchange § Nose and mouth no longer communicate with the airway § Nasal cannula, face mask, or supplemental oxygen to nose or mouth will not help oxygenation Stoma Trachea Place sign above bed: PATIENT IS OBLIGATE NECK BREATHER 17

Stoma Larytube Stoma Vent Open to Air § There a number of dressing options for stomas § After the stoma has “matured” and been present for months, some patients do not use a dressing and leave it open to air 18

Speech with a stoma Tracheoesophageal Voice Prosthesis Electrolarynx § These devices allow patients to communicate after total laryngectomy § Speech therapy can help manage and arrange access to this equipment 19

T-tube 20

T-tube § T-tubes can functions as both a tracheostomy and airway stent § Often used for patient with airway narrowing or stenosis § T-tubes can easily crust or plug without proper care § Respiratory therapy can often help with special care for Ttubes 21

T-tube § T-tubes can functions as both a tracheostomy and airway stent § Often used for patient with airway narrowing or stenosis § T-tubes can easily crust or plug without proper care § Respiratory therapy can often help with special care for Ttubes 22

Emergencies 23

Airway emergencies § Situation: patient has increased work of breathing or SOB § Make sure patient is monitored with central monitor or pulse oximetry § Remove any tracheostomy speaking valve or cap § Mucus plugs and accumulated secretions in the airway is a common problem § Attempt suctioning with a tracheal suction catheter § Try squirting normal saline (2 -3 ml) into the airway to help loosen thick secretions/mucous plugs, then suction the patient § Remove the inner cannula if one is present § Call appropriate codes and CODE ENT 24

Tracheostomy dislodgement § Situation: tracheostomy is accidentally removed and patient cannot breath without tracheostomy in place § You can attempt to replace the tracheostomy. Make sure the obturator (see arrow) is in place § If original tracheostomy cannot be placed, a smaller tracheostomy or endotracheal tube can be temporarily placed § You can attempt intubation from above § Call appropriate codes and CODE ENT 25

Tracheostomy bleeding § Situation: patient has bleeding from around or inside the tracheostomy § New tracheostomies can often bleed from the skin edge or thyroid § Tracheo-innominate fistula § Erosion of the anterior tracheal wall to the innominate artery § Rare but high morbidity § Highest occurrence 2 -3 weeks from tracheostomy § 35% present with a sentinel bleed 26

Tracheostomy bleeding § Situation: patient has bleeding from around or inside the tracheostomy § Place a CUFFED tracheostomy or endotracheal tube § Pass the cuff distal to bleeding and over inflate the balloon § Frequent suctioning to clear blood § Secure IV access for resuscitation § To operating room or interventional radiology for intervention § Call appropriate codes and CODE ENT 27

Tracheal trauma § Situation: blunt or penetrating trauma to the neck § Stridor, voice change, hematoma, hemoptysis/hematemesis, crepitus § Continuous monitor with pulse oximetry § Caution with repositioning or sedating patient § Imaging can be helpful but may turn a stable patient, unstable § Early intervention § Possible operating room for airway management § Call appropriate codes and CODE ENT 28