| Main tracheotomy indications in the FCECON |
• Obstruction of high airways due to cancers or swelling caused by radiotherapy.
• Laryngo-tracheal stenosis.
• Prophylaxis of airway obstruction in the postoperative period of extensive head and neck surgery.
• Prolonged orotracheal intubation, need of mechanical ventilation. Adults: between seven and 15 days of orotracheal intubation, without possibility of ventilation weaning during this period. Children: one can wait for up to four weeks, scheduling an early procedure if there is no foreseen resolution of the cause.
• Difficult airways. |
| Procedure |
• Explain to the patient and family in advance about the procedure, submit the consent form for signature. A copy is in the possession of the family and the other copy of the form must be in the medical record.
• Define the location of the procedure: the tracheotomy is a routine procedure performed in the operating room. In special situations, it can be performed in ICU, or at the bedside in the event of emergencies without transport possibility. Tracheostomy in the operating room without setting the patient on the operating table, doing the procedure on the bed of the patient, is possible in special cases (patients with morbid obesity, in cases in which the mobilization offers risks, such as fractures).
• Team for the procedure: surgeon, auxiliary, scrub nurse, anesthesiologist, nurse.
• Tracheostomy under general anesthesia: patient in IOT and children. Tracheostomy under local anesthesia: patient with airway obstruction, without possibility of IOT.
• Materials needed for a tracheotomy: equipment for monitoring of vital signs (blood pressure, ECG, SpO2, capnograph), lights, goggles, surgical scrubs, surgical gowns, sterile fields, sterile gloves, antiseptics, Kelly clamp, curved scissors, Farabeuf retractors, electric scalpel, anatomic tweezers, toothed tweezers, scalpel handle n# 3 and 15 blade, 3.0 needle nylon suture, suction catheter, vacuum, tracheostomy cannula: when performing a tracheotomy in adults, evaluate the availability of the chosen cannula (plastic with cuff, plastic cuff-free, metallic). Always provide one cannula of the estimated number for the patient, one bigger and one smaller.
• Cannula sizes, considerations: the diameter of the tracheostomy cannula must occupy approximately 2/3 to 3/4 of tracheal lumen, the final size to be set when viewing the trachea. One must evaluate the cannula length in obese patients |
| Technique |
• The preferred position of the patient: supine, in cervical hyperextension, cushion between the shoulder blades and round pad under the head. Always assess if there is any contraindication for this position.
• In case of impossibility of cervical hyperextension, the neck can be set in neutral position. The team must be prepared for a higher technical difficulty in this position.
• Antisepsis should be made from the anterior edge of the jaw to the upper third of the thorax. Laterally, until the lateral edges of the sternocleidomastoid muscles.
• The incision of the skin in adults can be transverse or longitudinal. The choice of incision should be the surgeon’s, according to each patient. In children, the preferred incision is the transverse.
• After the retraction of sterno-hyoid and thyroid muscles, one identifies the thyroid isthmus. Cranial retraction of the isthmus is indicated when possible, but isthmotomy may be carried out if necessary.
• Avoid lateral dissection to the trachea (avoid injury of recurrent laryngeal nerve, internal jugular vein, vagus nerve, carotid artery).
• Avoid inferior dissection (avoid injury of brachycephalic artery and innominate vein).
• The opening of the trachea should ideally be made between the second and fourth tracheal rings.
• Prudent identification of tracheal rings to avoid injury to cricoid cartilage and to first tracheal ring.
• The surgeon defines the technique used in the tracheotomy according to the needs of the patient: transverse opening between the tracheal rings, resection of the anterior portion of the tracheal ring, resection of the upper and lateral flap, maintaining a fixed lower border (Bjork flap). In children, the transverse opening between the tracheal rings is indicated.
• In cases of difficult tracheostomy, the suggestion of a technical approach is the placement of repair sutures in the trachea, externalizing to the skin, aiming to identify the path in cases of decannulation.
• When in children, the use repair sutures in the trachea is routine, even in tracheostomies without technical difficulties, since the repositioning in accidental decannulation are always more difficult in this age group.
• When positioning the tracheostomy cannula, care must be taken not to injure the posterior wall of the trachea.
• Evaluation of the correct positioning of the cannula after its passage is made by capnography or pulmonary auscultation.
• The fixation of the cannula after placement in the trachea is through ribbons around the neck.
• Initial dressing should be done using gauze around the cannula. |
| Complications |
• Materials considered indispensable for the treatment of complications of tracheostomies should be available in places where there are patients with tracheostomy, as well as hospital admission, emergency and ICU sectors: tracheostomy tubes of all sizes (in the adult ward: 5-0, 5-5, 6-0, 6 -5, 7-0, 7-5, 8-0, 8-5; in the pediatric ward: 3-0, 3-5, 4-0, 4-5, 5-0, 5-5), aspiration hose, (in an adult ward: 8, 10, 12, 14; in the pediatric ward: 4, 6, 8), aspirator, small surgery kit, monitoring, Oxygen source, AMBU bag.
• Accidental decannulation: call for help of a professional with experience; if there is no contraindication, place a cushion between the shoulder blades and try to reposition the cannula; if it is not possible to use a cushion, try to reposition in a neutral position; if there are repair sutures, exert a light traction on it and reposition the cannula; in case of repositioning failure, check if there is a professional with experience in the unit and call for help again; monitoring and oxygen supply; make sure all the emergency materials mentioned above are close.
• Post-tracheostomy bleeding: initial evaluation by the currently available physician if the surgeon is not immediately reachable; early evaluation of the surgeon; assess whether bleeding originates around the cannula or in its interior; provide monitoring and oxygenation to the patient; aspirate cannula in case of bleeding originating inside the cannula; evaluate the patient's medical chart if the patient is using anticoagulant drugs.
• Respiratory insufficiency by secretion plug in the cannula: suspect if the patient with tracheostomy has respiratory difficulties; if the patient has a plastic cannula, aspirate it; if there is no improvement or there is resistance in the passage of the tube when trying to aspirate the cannula, nebulize the patient with saline 0.9% and try again the aspiration; if the patient has a metal cannula, remove the inner cannula immediately and clean the cannula; if there is no improvement in the breathing pattern after aspiration and cleaning, it is necessary to change the cannula. If one does not have training in cannula exchange, call for help; provide monitoring and oxygen source immediately, while calling for help. Make available all urgency list materials.
• Pneumothorax and pneumomediastinum after procedure: perform chest X-ray after the procedure, in cases of dyspnea; in children chest radiography is performed routinely in all tracheostomies; if there is pneumothorax, perform closed drainage of the thorax in water seal.
• Tracheo-cutaneous fistula: epithelialization of the path from the orifice of the trachea to the skin, which remains patent after removal of the cannula; clinically diagnosed by the patient's complaint of persistence of airflow and secretion through the tracheostomy orifice after removal of the cannula; evaluation with the surgeon to correct the fistula.
• Tracheoesophageal fistula: one may suspect when food exits through the tracheostomy cannula, or when there are recurrent pneumonias; bronchoscopy and upper endoscopy are indicated when there is a suspected diagnosis.
• Post-tracheostomy dysphagia: if the patient has a cannula with a cuff, assess whether the cuff is not hyperinflated; check for associated laryngo-tracheal aspiration; assessment of speech therapy. |
| Routine care and management of the patient with tracheostomy |
• Care of the metal cannula: remove the inner cannula; cleaning of the inner cannula can be carried out in running water using a brush, provided that the running water is transparent and without residue; neutral soap may be used in this cleaning, and all residue must be removed; after cleaning the cannula, dry it before repositioning; Daily cleaning frequency: Set cleaning frequency according to the patient's expectoration degree.
• Tracheostomy humidification: the presence or absence of crusts and the thickness of the secretion during aspiration of the cannula may help to measure the degree of humidification of the airways; according to thickness and amount of secretion, the patient's nebulization frequency must be defined.
• Aspiration of the cannula. Protective equipment for the professional who will perform the procedure: sterile gloves, mask and goggles, lab coat or disposable apron; inform the procedure to the patient; every patient with tracheostomy should have an aspiration mechanism close to their bed (portable or wall vacuum); disposable sterile aspirating catheter, size selected according to the diameter of the cannula; saline solution for cleaning of aspiration catheter; when aspirating, insert the catheter only until the end of the cannula.
• Tracheostomy dressing: cleaning with saline solution; Use of gauze on the sides of the cannula continuously; foam and hydrocolloid to be evaluated by the nursing team; suggested minimum frequency for dressing around tracheostomy: once daily; observe daily if there is hyperemia in the skin around the tracheostomy and if there is drainage of secretions, and their appearance.
• Tracheostomy cannula replacement: sterile glove, mask, goggles, lab coat or disposable apron for the professional who will perform the exchange; material for aspiration available; one cannula of the same size and other one size smaller; material for dressing; inform the patient about the procedure; remove dressings and clothing that may block the field of vision; cushion in the shoulder blades if there is no contraindication for cervical hyperextension; use of lidocaine gel in the portion of the cannula to be introduced; fitting with a ribbon on the neck; if there is no success in passing a cannula of the same number, try a second time with a smaller cannula and if successful, forward patient for evaluation of the surgeon; check for correct positioning of the cannula after exchange: patient maintaining normal breathing pattern, air outlet through the inner bore of the cannula; if the second attempt with the smaller cannula is unsuccessful, provide an O2 source for patient monitoring; a second person present should call for help in the event of a failure to exchange; frequency of metal cannula replacement: every 30 days; plastic cannula replacement frequency: within 14 days.
• Evaluation of the possibility of phonation of the patient after the tracheostomy: speech-language assessment.
• Decannulation: should be individualized for each patient in FCECON, according to their underlying disease and staging; evaluate if there are schedules of procedures with anesthesia in the next seven to ten days; resolution of the motive that led the patient to tracheostomy; conscious patient; hemodynamic stability; absence of tracheal or glottic stenosis; no signs of laryngotracheal aspiration; all patients should receive speech-language evaluation prior to the decannulation process; In children, bronchoscopy is necessary for decannulation; after decannulation, there is a need for patient follow-up due to the appearance of early and late complications after withdrawal (bleeding, fistulae, stenosis) |
