Laryngectomy and Tracheostomy

Tracheostomy
+ Laryngectomy
Dr Andrew crofton
Ed registrar
Information you need to know now
Has the patient had a laryngectomy or tracheostomy?
Is the upper airway difficult or impossible to manage?
How old is the tracheostomy?
Surgical or percutaneous tracheostomy?
4 main types of incisions to create tracheostomy
Horizontal slit
Typically between 2/3 or 3/4th tracheal rings
Silk stay suture can be placed through tracheal wall on each side and tapes to neck skin to facilitate tube replacement by pulling trachea forwards and widening the opening should the tube become dislodged
Sutures removed after first tube change at day 5-7 post-op
Window
More permanent option
Vertical slit
Semi-permanent option
Absorbable sutures often placed in tracheal flaps and tacked to skin edges to facilitate replacement of dislodged tube
Bjork flap
Ramp of trachea is sutured to the skin allowing easier replacement of tubes
The sutures act to hold the flap in place NOT to elevate the trachea for tracheostomy change
If these sutures are pulled, may tear the ramp and occlude the stoma
Surgical vs. Percutaneous
Surgical tracheostomies
Established tracts wthin 2-3 days
Percutaneous tracheostomies
Skin and tissues will spring back if tube removed
Should ideally not be changed for 7-10 days
Immediate complications
Haemorrhage
Misplacement of tube
Pneumothorax
Tube occlusion
Surgical emphysema
Loss of upper airway
10% complication rate of percutaneous vs. 8.7% for surgical tracheostomies
Delayed complications (<7 days) Tube blockage (sudden or gradual; blood or secretions) Partial or complete tube displacement Infection of stoma site Infection of bronchial tree (pneumonia) Ulceration and/or necrosis of trachea by tube migration Risk of occlusion of tracheostomy tube if fatigued/obese and difficulty extending the neck Tracheo-oesophageal fistula formation Haemorrhage (erosion through blood vessels) Tracheostomy site infection Surgical site infection more common post-surgical tracheostomy (7%) than percutaneous (3.4%) May be polymicrobial with most common organisms being S. aureus, Pseudomonas and Candida Stable patients can be treated with Augmentin BD Unstable patients should receive PipTaz + Vancomycin Use a fluoroquinolone for Pseudomonas Dressing changes with gauze soaked in 0.25% acetic acid are effective for local wound infections Tracheostomy site bleeding Slow bleeding can be controlled with packing of site with gauze Local bleeding may be controlled with silver nitrate If bleeding is brisk, replace the tracheostomy tube with a cuffed ET with cuff BELOW bleeding site Tracheo-innominate arterial fistula is a rare but life-threatening complication Cuff pressure >25mmHg, tube below 3rd tracheal ring and deformed neck/chest are all risk factors
Usually present within 3 weeks (peaks between week 1 and 2)
Some patients may have sentinel arterial bleed or haemoptysis
Bleeding may be mild or severe but needs to be thoroughly investigated as subsequent haemorrhage can be fatal
Immediate ENT and cardiothoracic surgical consultation is required
Tracheostomy site bleeding
If massive bleeding
Hyperinflate the cuff to control brisk bleeding while planning operative intervention
IF bleeding persists, slowly withdraw tube while exerting pressure on anterior trachea
If this fails, place a cuffed ET from above past the site of bleeding to prevent pulmonary aspiration of blood and remove tracheostomy as ET passes using fibreoptic bronchoscopy
Stomal haemorrhage is then controlled by digital pressure through stoma of the innominate artery against the manubrium (Utley maneuver)
Maintain tamponade until operating theatre
Tracheal stenosis
Treat with oxygen, nebulised adrenaline and steroids
Late complications (>7 days)
Granulomata of the trachea may cause respiratory difficulty when tube removed
Tracheal dilation, stenosis, persistent sinus or collapse
Risk factors for tracheal stenosis are >1 week duration and tube >7.5mm
Scar formation
Blocked tubes can occur at any time
Especially if not suctioned/humidified regularly
Haemorrhage
Physiological changes
Upper airway anatomical deadspace reduced by 50%
Can help facilitate weaning off ventilator
Loss of natural warming, humidification of air by upper airway
Risk of thick and dried secretions – blockage
Loss of ability to speak
Distress, anxiety and complications of speaking valves
Ability to swallow is adversely effected
Cuff limits laryngeal function and laryngeal musculature can become wasted with prolonged disuse
Sense of taste and smell can be lost
Altered body image
Uncuffed tubes
With patent upper airway, can breath around tracheostomy tube
No airway protection
Cannot provide PPV via tube
Minitrach
4mm internal diameter without cuff
Primarily for airway suction but can facilitate O2 delivery
Too small to provide ventilation
Sometimes used prior to decannulation to facilitate suctioning and keep tract open in case tracheostomy tube needs re-insertion
Cuffed tube
Seals off upper airway preventing breathing around the tube if inflated
Airway protected
PPV can be applied
If tube becomes blocked, patient has no other way to ventilate
Fenestrated tubes
Have opening on outer cannula to allow air to pass from oropharynx as well as via the tracheostomy
Air movement allows speech and more effective cough
Different inner cannulae allow outer hole to be kept patent or blocked
Increases risk of aspiration
Suctioning with a fenestrated tube should ONLY be performed with non-fenestrated inner cannula to prevent suction tube rising up into larynx
Can help train the larynx after prolonged tracheostomy use
Airway red flags
If cuffed tube
Talking, audible air leaks, bubbles of saliva at mouth/nose means cuff is not effective (damaged) or tube tip not correctly sited
Grunting
Snoring
Stridor
Breathing red flags
Apnoea
Accessory muscle use
Tachypnoea
Higher airway pressures on ventilator
Lower tidal volumes on ventilator
Hypoxia
Whistling noises or noisy breathing
Tracheostomy-specific red flags
Visibly dislodged tracheostomy tube
If adjustable flange, check to see where it was last positioned in notes
Blood or blood-stained secretions around tube
Increasing discomfort or pain
Repeated cuff inflations
Damaged or malpositioned requiring hyperinflation to seal off
General red flags
Anxiety
Sweating
Tachycardia
Hypotension
Loss of consciousness
Agitation
Restless
Confusion
Tracheostomy management protocol
Call for help
Look, listen and feel at mouth and tracheostomy
Waveform capnography
High-flow O2 to mouth and tracheostomy
Remove speaking valve/cap/inner cannula
Attempt to pass suction catheter
Deflate the cuff
Remove the tracheostomy tube (stitch cutters may be required)
Standard oral airway manoeuvres
Cover stoma
BVM, oral or nasal airway adjuncts, LMA
Tracheostomy STOMA ventilation via paediatric face mask or LMA
Advanced airway manoevres
Attempt oral intubation preparing for difficult airway
Attempt intubation of stoma (6.0) with consideration of Aintree/Bougie/fibreoptic scope

Laryngectomy algorithm
Call for help
High-flow O2 to laryngectomy stoma
Most stomas will not have a tube in situ
Remove stoma cover/inner tube if present
Attempt to pass suction catheter
Deflate the cuff if present
Remove tube from stoma if present
Laryngectomy stoma ventilation via paeds face mask or LMA
Attempt intubation of laryngectomy stoma 6.0 tube with consideration of fibreoptic scope/Aintree/bougie

Changing a tracheostomy tube
If <7 days old: Tract will not be mature and may easily create false passage Tract may easily collapse if obese or swollen neck Should only be performed by surgeon familiar with procedure If >7 days old
Patient can breathe through stoma so don’t rush
Check cuff if using cuffed tube
Cricoid hook can be used to lift and stabilise trachea
Use obturator within new tube to prevent hollow tube damaging structures
If encounter resistance, can try smaller tube or ET 6.0 but smaller diameter tubes will also be shorter (could be too short for patients neck)
Laryngeal stents
Solid stents block the airway at the level of the larynx
Entirely dependent on tracheostomy
Dislodgement can occur
T-tubes may require suctioning of both upper and lower limbs
If fails to resolve obstruction, may have to remove T-tube and replace with traditional tracheostomy or ET tube
Speech valves
Passy-Muir valves
One-way valves that close during forced exhalation to allow air to pass around uncuffed tube and through vocal cords
Should NEVER be used with a cuffed tube as patient will NOT be able to exhale
Tracheo-oesophageal prosthesis
Used for laryngectomy patients to allow air to pass
Do NOT remove these in the case of airway obstruction in laryngectomy patients
One-way valve surgically placed between posterior tracheal wall and anterior wall of cervical oesophagus
Placement of finger over stoma while exhaling forces exhaled air into oesophagus, which vibrates to create sound
Complications
Leakage due to enlargement of tracheo-oesophageal fistula
Increases risk of aspiration pneumonia
Temporary solution to this is replacement with Foley catheter
Valve aspiration
Valve extrusion