T C RACHEOSTOMY ARE H ANDBOOK A Guide for the Health Care Provider This TRACHEOSTOMY CARE HANDBOOK is published by SIMSPortex Inc., and contains technical and clinical information essential to tracheostomy care. The handbook is intended as a guide to tracheostomy care and is not intended to be a complete text. It is hoped the handbook will be of value and assistance in instructing students and other personnel involved in care of the tracheostomy patient. 2 SIMS Portex Inc. 1-800-258-5361 History of Tracheostomy There is evidence that surgical incision into the trachea in an attempt to establish an artificial airway was performed by a Roman physician 124 years before the birth of Christ. Three hundred years later, two physicians, Aretaeus and Galen, gave inflammation of the tonsils and larynx as indications for surgical tracheostomy. There are few references to tracheostomy before the 11th century, but one must remember that this was during the Dark Ages. During the 11th century, Albucasis of Cordova successfully sutured the trachea of a servant who had attempted suicide by cutting her throat. The first record of a tracheostomy being performed in Europe was in the 16th century when Antonius Musa Brasavola saved a patient who was suffering from acute edema of the larynx and was in severe respiratory distress. In 1540, Vesalius recorded his success in positive pressure ventilation of an animal through a tracheostomy. As popularity of the operation increased, it was found that although asphyxia was immediately relieved, better long-term results were achieved if the stoma was kept patent for several days. To maintain an open airway, a simple cannula was designed by Fabricius of Aquapendente. This early tracheostomy tube consisted of a short, straight cannula having two wings to prevent it from slipping into the trachea and to secure it around the neck with tapes. The tube was left in place for three or four days. Casserius, a student of Fabricius, suggested using a curved cannula to fit the anatomy of the throat. By the 19th century, successful operations had been reported for trauma, foreign bodies, Tracheostomy tube circa 1860–1865. 1-800-258-5361 SIMS Portex Inc. 3 or inflammation to the airway causing acute obstruction of the upper airway. During the diphtheria epidemic in France in 1825, tracheostomies gained further recognition. Improvements followed: In 1852 Bourdillat developed a primitive pilot tube; in 1869 Durham introduced the famous lobster-tail tube; and in 1880 the first pediatric tracheostomy tube was introduced by Parker. Tracheostomies were performed for patients with severe burns and scalds of the face and neck and for other operative procedures, but diphtheria remained the most important indication until 1936, when Davidson described this procedure for poliomyelitis. With early recognition of respiratory failure, improved surgical technique, modern tracheostomy tubes, ventilators, and improved nursing care in state-of-the-art intensive care units, this procedure has become commonplace. In the mid-1980s, the first significant advancement in the surgical management of the airway in 90 years was introduced. This procedure, percutaneous tracheostomy, had been described in 1957 by Sheldon, and it has just recently gained in popularity and may soon become the preferred technique for managing the airway. Percutaneous tracheostomy has all but eliminated the complications that are common with the surgical tracheostomy. This relatively new procedure has been shown to have many advantages over translaryngeal intubation and the surgical approach to tracheostomy. 4 SIMS Portex Inc. 1-800-258-5361 Anatomy and Physiology A knowledge of the anatomy and physiology of the respiratory system is necessary to the health care provider who is involved in the care of the tracheostomized patient. The Upper Airway The nose plays a very important role in the upper airway. As air enters the nostrils large particles of dust and dirt are filtered. The mucus membranes of the nasopharynx further filter this air, warm or cool the inspired air, and humidify it. The column of inspired air travels down through the oral pharynx to the laryngopharynx. Here it passes through the larynx where the vocal cords are located. The larynx is located at the top of the trachea. When a person breathes in, the vocal cords open, allowing air to pass freely into the trachea. Nasopharynx Oral Pharynx Laryngopharynx Larynx Vocal Cords Cricoid Cartilage Esophagus Trachea Normal anatomy of the upper airway. 1-800-258-5361 SIMS Portex Inc. 5 The larynx is composed of nine cartilage structures: three large single cartilages and three paired cartilages. The three large single cartilages are the epiglottis, the thyroid, and the cricoid. The three paired cartilages are the smaller arytenoids, cuneiforms, and the corniculates. The cricoid cartilage is the only circumferential cartilage of the trachea, and is an important landmark used during tracheostomy. The trachea is a tubular structure 10–14 cm in length in an adult. It extends from the larynx through the neck to the thorax, where it terminates at the carina, dividing into the right and left main stem bronchi. The trachea joins with the larynx at the level of the 6th cervical vertebra; it bifurcates at the carina at about the level of the 5th thoracic vertebra. Within the thorax the trachea lies in the mediastinum, its lower position being directly behind the heart and its large vessels. It is constructed of 15 to 20 C-shaped cartilaginous rings separated by fibrous muscular tissue which form the supporting framework. Each cartilage is incomplete dorsally where it is adjacent to the esophagus. A fibro-elastic membrane containing smooth transverse fibers of muscle extends across the open portion of the trachea where the cartilages are incomplete dorsally. The anterior cartilage provides the rigidity necessary to maintain patency of the tube. The tracheal structure consist of four layers: mucosa, submucosa, cartilage, and adventitia. The inner layer, the mucosa, has ciliated pseudo-stratified columnar epithelium with goblet cells. Mucus excreted from the goblet cells helps trap inhaled particles of dust and the cilia sweep it upward into the laryngopharynx where it can be swallowed or coughed out. The submucosa is loose connective tissue containing glands that secrete mucus. The trachea ends by dividing into the right and left main stem bronchi which extend to the lungs. Each bronchus enters its own respective lung through the hilus (an opening through which nerves, vessels, etc. enter or exit an organ). The right main stem bronchus is shorter, wider, and more vertical than the left. Consequently, this 6 SIMS Portex Inc. 1-800-258-5361 bronchus is more easily intubated, suctioned, and foreign bodies more frequently end up in the right bronchus. The Lower Airway As soon as the bronchi enter each lung they branch to form smaller or secondary bronchi, one for each lobe of the lung (three lobes on the right and two on the left). The secondary bronchi continue to branch to form still smaller tubes or bronchioles. Structurally, the bronchi are very similar to the trachea. Their walls have cartilaginous rings and are lined with ciliated mucus membrane. However, as they become smaller and smaller, less and less cartilage is present in their walls, and more and more smooth muscle appears. The lungs are truly the organs of respiration where exchange of gases between blood and air takes place. Trachea Carina Left Main Stem Bronchus Secondary Bronchi Bronchioles Normal anatomy of the lower airway. 1-800-258-5361 SIMS Portex Inc. 7 The lungs are made up of light spongy tissue. Within this spongy tissue lie the secondary bronchi and bronchioles, which conduct air to and from the respiratory units (alveoli) of the lung. Fissures divide each lobe of the lung. The right lung has three lobes and the left lung has two. Each lobe is further divided into lobules. Lobules are irregular in size and shape, but each is supplied with air by a bronchiole. As the bronchioles enter the lobules they divide repeatedly to form very small airways called terminal bronchioles and then the smallest airways, the respiratory bronchioles. These smallest of airways finally reach the functional unit of the lung, the alveoli. It is here within the alveoli that the exchange of oxygen and carbon dioxide takes place. Alveolus Capillary Alveolus Capillary Alveola/capillary exchange. 8 SIMS Portex Inc. 1-800-258-5361 Tracheostomy The Operative Procedure General Indications There are four main indications or goals for a tracheostomy. The procedure may be required to achieve any one or combination of these four. Heading the list is the assurance of a patent airway. As long as the tracheostomy tube itself is not blocked and it extends below the level of any site of blockage, the upper airway is virtually assured of being open. Obstruction in the upper airway caused by edema of the glottis or by carcinoma of the larynx are just two of many indications for tracheostomy. Another important goal is protection of the lungs from potential threats such as obstruction or aspiration. Tracheostomy may be indicated for more effective removal of secretions from the trachea and lower airways. Patients with sputum retention may be candidates for standard or mini-tracheostomy. A final and very common indication for tracheostomy is to permit long-term ventilatory support. There are several advantages: the anatomical dead space is reduced, the ventilator may be easily attached directly to the tracheostomy tube, the airway is protected, a convenient access to the airway for suctioning is available, ventilatory support or tracheostomy tube dependency can be reduced, improved communication and nutritional support is also provided. The Procedure Tracheostomy should rarely be considered for emergency access and control of the airway. It is best performed with access gained to the trachea with an endotracheal tube in place. Rapid access to the airway is possible in less than one minute via oral or nasal intubation of the trachea, or cricothyrotomy. Little equipment is required for these routes; most emergency cricothyrotomy need only a large bore needle or scalpel. 1-800-258-5361 SIMS Portex Inc. 9 Tracheostomy, on the other hand, is a procedure that requires more sophisticated skills and equipment. Tracheostomy is used infrequently as the initial route to gain access to the airway. Surgical tracheostomy is usually performed in the operating room or less commonly in an intensive care unit under general or local anesthesia. Thyroid Cartilage Cricoid Cartilage Trachea Incision Surgical tracheostomy. With the patient positioned with the neck hyperextended, the skin area is prepared and an incision is made below the cricoid cartilage. The trachea is located with blunt dissection, bleeding is controlled if necessary, and an incision (one of many types) is made through the 2nd, 3rd, or 4th tracheal cartilage. A cuffed tracheostomy tube of proper size and length is inserted through the anterior wall of the trachea as the endotracheal tube is slid above the ostomy site. The tracheostomy tube is gently positioned and ventilation is confirmed 10 SIMS Portex Inc. 1-800-258-5361