Tracheotomy is one of the commonly used techniques, not only for upper and lower airway obstruction, but also for respiratory obstruction caused by lower airway secretions and alveolar hyperventilation, many neurocritical patients are in coma, some need ventilator-assisted breathing and require tracheotomy treatment. In fact, the percutaneous tracheotomy carried out in our department is relatively mature, easy to operate, less damage, relatively low risk, and great benefit to patients.
1, the purpose of tracheotomy
(1) Reduce the resistance of the airway: 1/3 – 1/2 of the resistance of the normal airway comes from the upper airway, and tracheotomy reduces the resistance of the airway, which is beneficial to ventilation.
(2) Reduce the dead space of the airway: about 100 ml of dead space of the airway is in the upper airway, and tracheotomy increases the effective ventilation volume.
(3) Tracheotomy facilitates sputum aspiration and airway humidification, and prevents lung infection caused by aspiration of throat secretions and vomitus.
(4) It facilitates the use of ventilator for intermittent positive pressure breathing.
(5) To buy time to treat the primary disease.
2.Indications for tracheotomy
(1) Difficulty in breathing, blue lips and finger (toe) nails, labored breathing, trigeminal signs, adult respiratory rate > 35 times/min, lung volume < 500 ml, tidal volume < 250 ml.
(2) The patient is irritable, sweating profusely, heart rate >120 beats/min, blood pressure is elevated, cough is weak, and respiratory secretions are numerous and sticky.
(3) partial pressure of oxygen <8 kPa (60 ml Hg), partial pressure of carbon dioxide >6.67 kPa (50 mm Hg), PH <7.35.
3.Care of tracheotomy
Post-tracheotomy care is very important, improper care can produce many complications, and even make the patient’s life in danger. Care should start from the following aspects.
(1) Keep the room temperature and humidity appropriate: place the patient in a single patient room with fresh air, quiet, clean and dust-free, keep the room temperature at 21 degrees Celsius and the relative humidity at 60%. Cover the tracheal tube orifice with 2-4 layers of wet gauze, sprinkle water on the floor frequently, or use a humidifier, and disinfect the room air with UV light regularly.
(2) Prevent blockage of the tracheal tube: blockage of the tube due to air sac slippage is a common emergency, and patients often have sudden respiratory distress, cyanosis, and irritability. In this case, the trocar balloon should be removed immediately for examination. Blockage of the catheter by secretions is also a common cause. Due to the adhesion of secretion, it accumulates into a lump and causes blockage of the tracheal tube, resulting in breathing difficulty for the patient, so it should be cleared in time. In addition, when replacing the catheter for cleaning and disinfection, the gauze should be prevented from being left in the catheter.
(3) Timely aspiration: In tracheotomy patients, due to the loss of epiglottis and the weakened cough reflex, it is difficult to cough and excrete sputum. If sputum is not aspirated in time, it will block the catheter. When aspirating sputum, pay attention to the rotation of the suction tube from the deep left and right and raise it upward, and the suction tube must be changed every time the sputum is aspirated.
(4) Adequate humidification: Under normal circumstances, the air inhaled into the respiratory tract is humidified by the mucous membrane of the nasal cavity, oral cavity and upper respiratory tract. Tracheotomy patients lose the above wetting function, which makes it easy for secretions to dry up and produce tracheal blockage, pulmonary atelectasis and secondary infection, etc. Therefore, the following methods of wetting should be used.
①Intermittent wetting: 500 ml of saline plus 160,000 units of gentamicin and 5 mg of chymotrypsin should be injected into the trachea after each sputum aspiration for a total of 2-5 ml per day, and ultrasonic nebulized inhalation can also be used intermittently.
②Continuous wetting method: slowly drip the wetting solution into the trachea via scalp needle with a drip rate of 4-6 drops/minute by an infusion set. Not less than 200 ml per day and night, antibiotics or other drugs can be added to the humidified solution as needed.
(5) Prevention of local infection: strict aseptic operation to prevent infection. The tracheal cannula is cleaned and disinfected 2-3 times a day, and the gauze pad of the tracheal tube is kept dry and changed daily. The catheter is soaked with 0.5% Neosporin, then boiled and disinfected, then rinsed with water and boiled and disinfected again to be reused.
4.Common complications after tracheotomy
Tracheotomy complications are related to the operator’s proficiency, the condition of the primary disease and the quality of care. The following complications often occur.
(1) Detubation: Detubation is mainly caused by poor fixation. Detubation is a serious and urgent situation, and asphyxia will occur if not treated in time. If the catheter is completely dislodged, the patient can stop breathing instantly.
(2) Bleeding: It can be caused by incomplete hemostasis during tracheotomy or damage to the tracheal wall due to catheter compression, irritation, rough suction action, etc. The patient feels pain in the sternal stalk or blood in the sputum, and once hemorrhage occurs, tracheal intubation should be performed immediately to stop the bleeding by pressure. The percutaneous tracheotomy currently taken for bleeding is rare.
(3) Subcutaneous emphysema: It is a relatively common complication after tracheotomy, which mostly occurs in the neck and may occasionally extend to the chest and head. There is a twisting sensation or grip of snow when the emphysema is palpated by hand, and there is violent bubble sound on auscultation.
(4) Mediastinal emphysema and pneumothorax: it is easy to occur in those with subcutaneous emphysema, and the patient may have chest pain. The presence of mediastinal emphysema and pneumothorax can be detected on examination and chest X-ray, and should be treated quickly.
(5) Infection: It is the most common complication of tracheotomy. It is related to indoor air pollution, aseptic operation and the original condition. After infection, the airway sputum volume increases dyspnea and fever, which can aggravate the original disease.
(6) Tracheal wall ulceration and perforation: Ischemic necrosis of the tracheal mucosa due to inappropriate selection of cannula or too long placement time, deflation of the air sac when it is not set, etc. In mild cases, ulcers are formed, and in severe cases, perforation can be caused, and tracheoesophageal fistula can also be caused.
(7) Subsonic granuloma, scarring and stenosis: local irritation with tracheal cannula has a tube, which is a late complication after tracheotomy.
5.Aspiration operation after tracheotomy
Sucking sputum for tracheotomy patients is a technical operation frequently performed, and whether the operation is correct or not will directly affect the effect of sucking sputum and the condition. Therefore, the following matters should be noted.
(1) The suctioning action should be gentle to reduce the damage to the tracheal wall. Choose 12-14 rubber or silicone tubes with moderate hardness, smooth surface and relatively large inner diameter, or special suction tubes.
(2) Strictly aseptic operation: wash hands before operation, use one tube at a time, and aspirate endotracheal secretions first and then nasal and oral secretions according to the principle of first inside and then outside.
(3) Take 3-5 deep breaths before aspiration, and for those using ventilators, hyperventilation for 2-3 minutes is required to increase the partial pressure of oxygen in the alveoli, and then aspirate the secretions quickly, accurately and gently. It should be rotated from deep left to right and raised upwards avoiding lifting and inserting up and down. A suction time should not exceed 15 seconds, especially in patients with respiratory failure, longer suction can cause hypoxia, respiratory distress, and even asphyxia. If the secretion is too much and cannot be sucked at one time, it can be re-attracted after hyperventilation.
(4) When suctioning sputum, open the suction device again after reaching the depth of trachea, or fold the suction tube by hand so that it does not leak, and open it again after the suction tube is deep into the trachea.
(5) The negative suction pressure should not exceed 6.7 kPa.
6.Care for tracheotomy patients before extubation
Once the cause of tracheotomy is removed and the patient’s condition is relatively stable, extubation should be considered. In this stage, all resuscitation items and instruments should be prepared, and the patient’s respiratory changes and pronunciation should be closely observed. If the patient is found to have difficulty in breathing, cyanosis and irritability, the blockage should be removed immediately, extubation should be suspended, and laryngeal lesions should be examined and treated. After 24-48 hours of full blockage, if the patient has no respiratory difficulty, good pronunciation and normal sputum discharge, the tube can be removed. The wound is tightened with butterfly tape and covered with sterile gauze.