2. Contraindications
2
.1 Absolute Contraindications
T
he following count as absolute contraindications:
- positioning the tracheostomy tube in emergencies,
- application in paediatrics,
- existing infections in the area of the tracheostomy,
-
existing malignancy in the area of the tracheostomy,
- unstable fracture of the cervical spine and
- uncertainty about the identification of the anatomi-
cal orientation points.
2
.2 Relative Contraindications
The following count as relative contraindications in
which the risks have to be considered alongside the
benefits of the procedure:
- an enlarged thyroid gland,
- previous surgical interventions in the neck region
(e.g. thyroidectomy),
- increased tendency to bleed, e.g. in the case of
treatment with anticoagulants,
- unusually deep-seated trachea, e.g. in the case
of obesity, where if necessary an extra-long tub has
to be inserted.
3. Special Instructions and
Precautionary Measures
Attention must be paid to the following instructions
and precautionary measures:
- A tracheostoma which has been created by means
of dilative tracheotomy has the special advantage
that it normally heals independently leaving only
minor scarring.
On the other hand it must be considered that using
the dilative technique in most cases the insertion of
the tracheostomy tube is more difficult; therefore, this
method bears a higher risk, e.g. that the insertion of
the tube might not be carried out quick enough, that
the trachea might be damaged or that bleedings
might occur. Furthermore there is the risk that the
trachestomy tube might erroneously be inserted via
the wrong way (via falsa). Due to these reasons the
insertion of a trachestomy tube should always be
carried out by trained staff only and under the obser-
vance of adequate precautionary measures.
In case of long term users the creation of an epithe-
lial stoma is therefore recommended.
- The first placement of a tracheostomy tube must be
carried out under aseptic conditions.
- It is recommended to carry out the percutaneous
tracheotomy under bronchoscopic control, in order to
monitor the intratracheal position of the puncture can-
nula, the guide wire, the dilators and the tracheosto-
my tube and to avoid the danger of paratracheal
insertion or injury to the trachea. For this purpose it is
highly recommended to use the tracheostomy endo-
scope for dilation tracheostomy according to Klemm
(
details see the relevant instructions for use).
-
It is recommended, for instance by means of ultra-
sound, to identify tracheal and pretracheal condi-
tions like the thyroid gland isthmus, large vessels as
well as cricoid cartilages to ascertain the optimal
s
pot for puncture and to avoid bleeding.
ATTENTION: With every percutaneous tracheosto-
my there is a risk of bleeding, hypoxia, subcuta-
neous emphysema and/or pneumothorax.
- During surgery the patient’s breathing must be
guaranteed with an endotracheal tube and constant
oximetric monitoring.
- If there are anomalous vessels present, which can
be identified by ultrasound examination, this can
cause significant bleeding.
- In the event of haemorrhages this can cause air-
way obstructions if the blood is not immediately suc-
tioned off.
- Puncture of the trachea must be checked by the
aspiration of air.
- Following puncture, the tip of the puncture cannu-
la should be angled at approx. 60º vis à vis the ante-
rior wall of the trachea in order to avoid injuries to the
posterior wall of the trachea. This also applies to the
subsequent insertion of the guide wire and dilators.
- To avoid injuries to the posterior wall of the trachea
the distal tip of the guiding catheter must never jut
out over the tip of the guide wire. Therefore the prox-
imal guide wire marking must always be at the prox-
imal end of the guiding catheter.
- The safety stop of the guiding catheter should
always be placed immediately in front of the tip of
the experc dilator or the atraumatic inserter. For con-
trol/checking purposes the guiding catheter has
appropriate markings.
- The experc dilator should not be inserted beyond
the “MAXIMUM INSERTION” mark (skin level) in or-
der to avoid injuries to the trachea at the level of the
carina. This is particularly critical with small patients
(height approx. 150 cm or smaller; body weight 50 kg
or less).
- When inserting the experc dilator or the tracheosto-
my tube with atraumatic inserter or atraumatic inser-
tion system, excessive rotating movements must be
avoided as this can damage the trachea.
- Dilation should be carried out in line with the tube
size so that insertion of the tracheostomy tube is pos-
sible without exerting pressure.
- The atraumatic inserter or the atraumatic insertion
system must be positioned in the tracheostomy tube
such that the collapsible silicone sleeve balances the
sudden change in diameter between the inserter and
7
TRACOE percutan
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