Upper Airways Obstruction
Assess Look / Listen / Feel (Anytime) Degree of obstruction Site of ObstructionGuidel Airway
TracheostomyTracheostomy aids respiration by: 1. Reducing the 'dead space' (lips to tracheostome) by about 50%. 2. By-passing resistance to airflow in nose, mouth and glottis. 3. Allowing easy bronchial 'toilet‘. 4. Use of mechanically assisted respiration.
Criteria for intervention Inspiratory stridor, recession of the suprasternal notch and intercostal spaces, and with anxious, pale. Sweaty face, operation must not be delayed. Cyanosis indicates a late and grave stage. *-With paralyzing disease and normal lungs; if the vital capacity falls to a quarter of normal or if with deep breath, the patient can count only to 20 and not to 60. * With pulmonary disease; if patient loses consciousness or PCO exceeds 70 mmHg.(35-45mmhg) * With crushed chest; clinical judgment is usually sufficient, but PC02 measurement is valuable. In real urgency Without proper facilities and training, a laryngotomy must be performed. With well trained & skilled staff of RCU , endotracheal tube may be a best solution .
Postoperative management Nursing is essential for the first 24 h at least including chart of follow up. 2. Position sitting upright in bed. 3. Suction regularly, with aseptic technique, passing a sterile catheter into trachea and main bronchi. 4. Humidification is essential, using humidifier or moistened gauze over the tracheostomy tube. 5. Prevention of crusting by irrigation with N/S & suction 6. Prevention of apnea In cases of long-standing obstruction, apnea may occur immediately after opening of trachea, caused by sudden cleaning of the C02. Carbon dioxide (5-7% in oxygen) is given via flow-meter through the tracheostome if this occurs.
7. Care of tube Metal type . The inner tube is taken out and cleaned hourly at first day . the outer tube must be held firmly while withdrawing the inner one. Cuffed plastic tubes ; The cuff should be of adequate length and not inflated too much, to avoid pressure necrosis of tracheal mucosa, necessity of periodic deflation of cuff : 5/60 minutes Low-pressure high volume cuffed tubes or double-cuffed type must always be employed, to minimize the risk of tracheal stenosis.
8. Decannulation The tube is removed when the patient is comfortable with its corked off tube. -Difficulty occurs especially with children if the tracheostomy has been present for a long time. -Gradual reduction in the size of tube, then sealing off .
Complications A.Early 1.Apnoea / co2 gush >>resp.alk.>hypokalaemia>arrythmia 2. Haemorrhage May occur if haemostasis is not secured at operation or ulceration by the tip of the tube if of the wrong shape.
3. Displacement of tube If complete it must be reinserted at once after the wound and tracheal opening are adequately dilated. Partial dislodgement may pass unobserved for a time, with the tube lying just in front of the tracheal opening.
4. Surgical emphysema and pneumothorax A- More common in children. B- If tracheostomy is too low. C- If wound closed tightly. D- If tissue planes are dissected too much. E- Under L.A more than G.A . F- Adminstration of high pressure O2 5. Syncope &Cardiac arrest Manipulation of sucker catheter
B. Late 1. Local sepsis or septicemia. 2. Perichondritis and stenosis a. May develop in the subglottic region if the tracheostome is too high a smaller tube, of non-irritating Portex, may help . b. A stricture above a well-placed trache-ostome may result from trauma by an ill-fitting tube or a small opening . c. A low tracheal stricture may be a late sequel of prolonged over-inflation of a cuffed tube.
3.Tracheo-oesphageal fistula Due to pressure of an ill-fitting tube against the posterior wall.