FIG. 236-2. Creation of a tracheal flap.
There are many tracheostomy tubes available, including those made of plastic, silicone, nylon, and metal. They vary in luminal diameter, length, angle of the curvature, presence of an inner cannula, obturators, locking mechanisms at the hub, cuffs, valves, and fenestrations ( Fig 236-3). The size of the tracheostomy tube is defined by the size of the inner diameter. Adult tracheostomy tubes range from 4.0 to 10.0 mm, and pediatric tracheostomy tubes range from 0.0 to 4.0 mm. Some tubes are designed to work with an artificial voice through an airport above the tracheostomy, with a tracheoesophageal prosthesis, and with other voice devices. Obturators fit through the tracheal tube to create a smooth surface during insertion. Inner cannulas provide a mechanism for clearing the artificial airway without losing patency. It should be noted that pediatric tracheostomy tubes never have an inner cannula due to the small size of the inner diameter. Most pediatric and adult tracheostomy tubes have a 15-mm standard respiratory connection that may be used with ventilator tubing and a bag-valve device. Tracheostomy tubes with balloon cuffs are used in the first postoperative week to prevent aspiration of blood or secretions. To prevent tracheomalacia and stenosis, cuffless tracheostomy tubes are used after 1 week if the patient is not ventilator dependent.
The most common complications of tracheostomy tubes include accidental decannulation, tube obstruction, infection, development of a bleeding tracheoinnominate fistula, and tracheal stenosis ( Fig, 2.36.-4). Accidental decannulation can occur in the early or late period after tracheostomy tube placement, particularly when patients cough or extend their neck. To replace the tube, hyperextend the patient's neck and, using the curve of the tube, gently direct the tube into the opening ( Fig.236-5). Hyperextension of the neck places the larynx and trachea in a very anterior position, thereby facilitating placement of the tube. If a tracheostomy tube is not readily available, an endotracheal tube may be quickly inserted into the stoma in order to maintain airway security. In cases of extreme airway compromise, the patient may be endotracheally intubated from above in order to secure the airway and allow time to assess the tracheostomy site. The only time the patient may not be endotracheally intubated orally is in the case of a laryngectomy. Patients who have had a laryngectomy will have a tracheal stoma and sometimes a tracheostomy tube in place but will not have an accessible airway passage from their mouth. The only access to the tracheal bronchial tree in laryngectomy patients is through the neck.
Tracheostomy tube obstruction with mucous plugging is a common complication of this airway device. Secretions may act by a ball-valve mechanism, allowing air in but restricting outward ventilation. Dried crusts and secretions and other obstructing lesions should be manually removed. The inner cannula of the tracheostomy tube must be removed, and often the entire tracheostomy tube must be removed and cleaned with sterile saline water. If profuse, thick secretions are seen in the trachea, they should be suctioned after preoxygenation and placement of sterile saline solution to aid in loosening the secretions. Prolonged use of large suction catheters without preoxygenation will cause hypoxemia.
All indwelling tracheostomy tubes are contaminated with normal and sometimes pathogenic flora. Stomal skin infection, tracheitis, and bronchitis can be a recurring problem.6 Staphylococcus aureus, Pseudomonas, and Candida are often identified.6 Broad-spectrum antibiotics are indicated in the setting of clinical disease.
Bleeding is one of the most common complications in the early period after tracheostomy tube placement. Hemorrhage most commonly occurs between the first and third week postoperatively.7 Sources of hemorrhage include granulation tissue, thyroid arteries, the thyroid gland, the tracheal wall, or the innominate artery. 7 If bleeding is slow, the tube may be removed, and the stoma and tracheal wall should be examined. Local bleeding can be controlled with silver nitrate or electrocautery. With more brisk bleeding, the tracheostomy tube should be kept in place until an airway is placed below the bleeding site. Maneuvers to control bleeding include local digital pressure, hyperinflation of the cuff, and mild traction of the tube with manual pressure. These maneuvers are particularly essential in cases of tracheoinnominate fistula. Tracheoinnominate artery fistula is a rare but life-threatening complication occurring in approximately less than 1 percent of all tracheostomies.8 Bleeding results from direct pressure of the tip of the tracheal cannula against the innominate artery ( Fig 2.3§.-6). Some patients may present with premonitory tracheal stomal bleeding (a sentinel bleed) or hemoptysis. Such bleeding may be mild to severe and should not be taken lightly, since the potential exists for sudden massive hemorrhage. Immediate otolaryngologic consultation is required, and operative intervention is lifesaving.
FIG. 236-6. Ihe arrow points to the position of the tracheostomy tube in relation to the innominate artery. Ihis close approximation facilitates creation of a tracheoinnominate fistula.
Less commonly seen is the presentation of tracheal or stomal stenosis. Iracheal stenosis results from necrosis at the pressure points of the cuff that become scar and result in airway narrowing. Signs and symptoms include dyspnea, wheezing, stridor, or inability to clear secretions. Ireatment includes humidified oxygen, nebulized racemic epinephrine, and early administration of steroids. Radiographs may be helpful in demonstrating narrowing of the trachea, but flexible bronchoscopy is the diagnostic modality of choice. Immediate otolaryngologic consultation is warranted.
The surgical management of laryngotracheal stenosis often employs techniques that utilize tracheal stents for various periods of time. Placement of an endolaryngeal stent renders a patient tracheostomy dependent until the stent is removed, due to blockage of the airway at the laryngeal level by the solid stent ( Fig 236-7). There are many different endolaryngeal stent designs and materials, including silastic endolaryngeal molds secured by cutaneous buttons, a stent secured by a strap that comes out the tracheal stoma and is attached to the skin, the Abouker stent complex (used in pediatric airway surgery), and the Montgomery T-tube stent. Although endolaryngeal stents are secured by buttons or straps, a known complication of these devices is dislodgement. If a stent becomes dislodged but the tracheostomy tube remains in position, airway security is not an issue. The operating surgeon should be notified when extrusion or dislodgment of any stent occurs.
FIG. 236-7. Relation of the tracheostomy tube to the laryngeal stent. The stent lies superior within the lumen of the trachea.
The Abouker stent, which is commonly used in pediatric laryngotracheal reconstruction, consists of a metal tracheostomy tube wired to a silastic stent that remains in the tracheal lumen (Fig.^^^-B).9 Removing the inner cannula of the trachesotomy tube should relieve airway obstruction in patients with Abouker stents. Only the inner cannula can be removed. The tracheostomy tube cannot be removed because it is wired to the stent.
FIG. 236-8. The Abouker stent, which is commonly used in pediatric laryngotracheal reconstruction, involves a metal tracheostomy tube that is wired to a silastic stent that remains in the tracheal lumen.
Ihe Montgomery I-tube configuration is commonly used in adult laryngotracheal reconstruction.10 It is a modification of a tracheostomy tube that does not have an inner cannula. Humidification and suctioning of the I tube is essential to prevent mucous plugging. Airway obstruction should be addressed by first suctioning both the upper and lower limbs of the I tube ( Fig .236.-9). If suctioning both limbs of the I tube does not relieve the obstruction, the I tube should be removed and the trachea should be cannulated with an appropriately sized tracheostomy tube or an endotracheal tube.
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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.