CHAPTER 7: Tracheotomy

Question 1

The earliest accounts of a procedure resembling tracheotomy are found in Egyptian tablets dating back to

Answer 1

3600 BCE

Question 2

Opposed the procedure, citing potential risk to the carotid

Answer 2

Hippocrates

Question 3

Regaled the court with stories of Alexander the Great, who saved a fellow warrior choking on a bone by opening the soldier’s airway with his sword

Answer 3

Poet of Homerus of Byzantium

Question 4

A firsthand account of the surgery was recorded

Answer 4

340 CE

Question 5

Described making an incision at tracheal rings 3 to 4 and pulling the cartilage apart with hooks to allow a patient to breathe more easily

Answer 5

Antyllus of Rome

Question 6

Placed a reed into the trachea of a pig and demonstrated lung ventilation by blowing into the cannula intermittently

Answer 6

Andreas Vesalius (1543), De Humani Corporis Fabrica

Question 7

Is credited with providing the first documented successful tracheotomy. He performed the procedure on a patient in 1546 to relieve airway obstruction resulting from a peritonsillar abscess

Answer 7

Antonio Musa Brassavola

Question 8

Physicians who attended George Washington, who awoke one morning in 1799 with a severe sore throat

Answer 8

James Craik, Gustavus Brown, Elisha Dick

Question 9

The junior member ;of the group suggested that Washington should have a tracheotomy to relieve the obstruction

Answer 9

Elisha Dick

Question 10

Advocated for a more aggressive use of tracheotomy for airway management

Answer 10

Pierre Bretonneau and Armand Trousseau

Question 11

Published his experience in 1869, noting that he had “performed the operation in more than 200 cases of diphtheria

Answer 11

Armand Trousseau

Question 12

Presented a paper in 1871, in which he described using tracheotomy to provide general anesthesia

Answer 12

Friedrich Trendelenburg

Question 13

Helped to standardize techniques for performing tracheotomy and published protocols for the care of these patients

Answer 13

Chevalier Jackson

Question 14

Published their work on endotracheal intubation based on their experience with patients who sustained facial injuries during WWI

Answer 14

Rowbotham and Magill

Question 15

Indications for tracheostomy

Answer 15

1. Prolonged mechanical ventilation
2. Pulmonary toilet
3. Surgical access
4. Airway obstruction

Question 16

TRUE or FALSE

Translaryngeal intubation was recommended if fewer than 10 days of ventilation were anticipated

Answer 16

TRUE

Question 17

TRUE or FALSE

If the need for mechanical ventilation was expected to exceed 21 days, tracheotomy was recommended

Answer 17

TRUE

Question 18

Creation of an opening in the anterior tracheal wall

Answer 18

Tracheotomy

Question 19

Formalization of a permanent stoma by suturing the edges of the trachea to the skin

Answer 19

Tracheostomy

Question 20

Inferiorly based tracheal flap, help to prevent false passage when replacing a dislodged tube

Answer 20

Bjork flap

Question 21

A curved metal tube was introduced by

Answer 21

Julius Casserius

Question 22

Selection of the proper tube depends on

Answer 22

1. Lung mechanics
2. Patient anatomy
3. Communication needs

Question 23

Composed of silver or steel offer the benefit of a low profile but lack a 15-mm connector and cuff and therefore not suitable in patients who require mechanical ventilator

Answer 23

Metal tubes

Question 24

Tube configurations are defined by

Answer 24

1. Inner diameter
2. Outer diameter
3. Length
4. Curvature of the appliance

Question 25

Refers to the diameter of the inner cannula (dual-cannula systems)

Answer 25

Inner diameter

Question 26

Determined by the ID of the tube itself (single-cannula tube system)

Answer 26

Inner diameter

Question 27

TRUE or FALSE | If the ID is too small, resistance through the tube increases and impacts the work of breathing

Answer 27

TRUE

Question 28

True or False Tubes with extra proximal length (horizontal) are designed to accommodate the obese neck or neck masses that displace the trachea posteriorly

Answer 28

True

Question 29

True or False | Tubes with extra distal (vertical) length can be used to bypass areas of stenosis or malacia distal to the stoma

Answer 29

True

Question 30

Are ideal for patients who do not require mechanical ventilation

Answer 30

Uncuffed tubes

Question 31

True or False | Uncuffed tubes can bypass upper airway obstruction, allow for pulmonary toilet, and accommodate speech

Answer 31

True

Question 32

Designed to facilitate positive pressure ventilation

Answer 32

Cuffed tubes

Question 33

True or False | Most cuffs are designed to be high-volume/low-pressure cuffs to help mitigate the risk of tracheal stenosis

Answer 33

True

Question 34

Tracheal mucosa capillary perfusion pressure

Answer 34

25-30mmHg

Question 35

Cuff pressure greater than 25-30mmHg can result in

Answer 35

Ischemic necrosis—>stenosis

Question 36

Ideal for patients who need only intermittent postive pressure

Answer 36

Low -volume/high pressure (tight-to-shaft)

Question 37

Classifications of tracheotomy can be classified as

Answer 37

1. Intraprocedural 2. Early (<7 days) 3. Late (>7 days)

Question 38

Intraprocedural complications:

Answer 38

1. Airway fire 2. Bleeding 3. Pneumothorax/Pneumomediastinum

Question 39

The initiation and propagation of fire requires 3 things:

Answer 39

1. Fuel source 2. Energy source 3. Oxidizing agent

Question 40

True or False | Intraoperatively, most bleeding is secondary to anterior vein injury or from the bleeding edge of the thyroid

Answer 40

True

Question 41

Potential mechanism (pneumothorax/pneumomediastinum)

Answer 41

1. Direct injury to the pleura 2. Dissection of air along the trachea 3. Rupture of an alveolar bleb

Question 42

Early complications of tracheotomy

Answer 42

1. Infection 2. Tube obstruction 3. Pressure ulcers 4. Accidental decannulation

Question 43

True or False | Tracheotomy bypasses the natural warming and humidification provided by the nasal passages

Answer 43

True

Question 44

True or False | If the tube cannot be successfully placed through the tracheotomy, translaryngeal intubation should be attempted

Answer 44

True

Question 45

Late complications of tracheotomy

Answer 45

1. Tracheal stenosis 2. Tracheoinnominate fistula 3. Tracheoesophageal fistula 4. Tracheocutaneous fistula

Question 46

True or False When cuff pressure exceeds capillary perfusion pressure, the result is ischemic necrosis and chondritis of the underlying tracheal cartilages

Answer 46

True

Question 47

True or False | High-volume, low-pressure cuffs have been designed to mitigate tracheal stenosis

Answer 47

True

Question 48

Characterized by a corkscrew pattern (disruption and fracture of the tracheal rings)

Answer 48

Stenoses from PDT

Question 49

True or false | Tracheoinnominate fistula occurs in approximately 0.7% of patients in both acute (<2 weeks) and chronic (>2 weeks)

Answer 49

True

Question 50

A sentinel bleeding event often, but not always, precedes massive hemorrhage

Answer 50

Tracheoinnominate fistula

Question 51

In 78% tracheoinnominate fistula, the event occurs between

Answer 51

3-4 weeks after tracheostomy

Question 52

Risk factors in treacheoinnominate fistula/bleeding

Answer 52

1. Low placement of the tracheostomy 2. Malnutrition 3. Radiation 4. Steroid usage 5. Hyperextension of the head

Question 53

First priority in tracheoinnominate fistula/bleeding

Answer 53

Immediate attention to establishing an airway with an ETT that bypasses or tamponades the fistula

Question 54

Definitive treatment of tracheoinnominate fistula/bleeding

Answer 54

Median sternotomy with ligation of the innominate artery

Question 55

True or False | The risk of fistula formation through the “party wall” is increased when large-bore NGT is also in place

Answer 55

True

Question 56

Tracheoesophageal fistula is best managed by

Answer 56

Interposition of viable tissue between the membranous trachea and the esophagus

Question 57

True or False Of patients who have a tracheotomy tube in place for more than 4 months, 70% will have a persistent tracheocutaneous fistula as a result of epithelialization of the tract

Answer 57

True

Question 58

True or False | A history of radiation exposure or the use of a Bjork flap increases the risk of a persistent tract after decannulation

Answer 58

True

Question 59

True or False Patient who had had an open tracheostomy could have the first tracheostomy tube change by physicians between days 3 and 5

Answer 59

True

Question 60

True or False Percutaneous tracheostomy appliances should not be removed or changed until day 10 because of the increased risk of false passage

Answer 60

True

Question 61

Candidates for decannulation should be assessed for

Answer 61

1. Level of consciousness 2. Respiratory status 3. Ability to cough and swallow

Question 62

True or False | The length of the capping trial is patient dependent and can range from overnight to several weeks

Answer 62

True