MD

TYPES OF TRACHEOSTOMY TUBE

  • A tracheostomy tube may be metallic or nonmetallic

Metallic Tracheostomy Tube

  • Metallic tubes are formed from the alloy of silver, copper and phosphorus
  • Example Jackson’s Tracheostomy tube.
  • Has an inner and an outer tube.The inner tube is longer than the outer one so that secretions and crusts formed in it can be removed and the tube reinserted after cleaning without difficulty. However, they do not have a cuff and cannot produce an airtight seal.
  • Advantages of a double lumen tracheostomy tube are easy to remove,clean and replace inner cannula.
  • Inner cannula should be removed and cleaned as and when indicated for the first 3 days. Outer tube, unless blocked or displaced, should not be removed for 3-4 days to allow a track to be formed when tube placement will be easy.

Nonmetallic Tracheostomy Tube

  • Can be of cuffed or noncuffed variety, e.g. rubber and PVC tubes.

Cuffed Tracheostomy Tubes

  • Pediatric tubes do not have a cuff.
  • Cuffed tubes are used in situation where positive pressure ventilation is required, or when the airway is at risk from aspiration. (In unconscious patient or when patient is on respiration).
  • The cuff should be deflated every 2 hours for 5 mins to present pressure damage to the trachea.

Uncuffed Tracheostomy Tubes

  • It is suitable for a patient who has returned to the ward from a prolonged stay in intensive care and requires physiotherapy and suction via trachea.
  • This type of tube is not suitable for patients who are unable to swallow due to incompetent laryngeal reflexes, and aspiration of oral or gastric con­tents is likely to occur.
  • An uncuffed tube is advantageous in that it allows the patient to breathe around it in the event of the tube becoming blocked. Patients can also speak with an uncuffed tube.

Important

Nonmetallic Tracheostomy Tube - Cuffed tubes are used in situation where positive pressure ventilation is required, or when the airway is at risk from aspiration. (In unconscious patient or when patient is on respiration).

Metallic Tracheostomy Tube -Metallic tubes are formed from the alloy of silver, copper and phosphorus .

  • Example Jackson’s Tracheostomy tube.
  • Advantages of a double lumen tracheostomy tube are easy to remove,clean and replace inner cannula.

Thalassemia

Thalassemias are a heterogeneous group of hereditary blood disorders characterized by faulty globin chain synthesis resulting in defective hemoglobin, which can lead to anemia

Thalassemia provides partial resistance against malaria.

Beta thalassemia

Clinical features

Minor variant (heterozygous): unremarkable symptoms (low risk of hemolysis, rarely splenomegaly)

Major variant (homozygous) Severe hemolytic anemia, Hepatosplenomegaly ,Growth retardation ,Skeletal deformities (high forehead, prominent zygomatic bones, and maxilla)

Alpha thalassemia

most commonly seen in people of Asian and African descent

Clinical features

Silent carrier: asymptomatic

Alpha thalassemia trait: mild hemolytic anemia with normal RBC and RDW

Hemoglobin H disease

Jaundice and anemia at birth

Chronic hemolytic anemia which may require transfusions

Hb-Bart's hydrops fetalis syndrome (most severe variant of alpha thalassemia)

Intrauterine ascites and hydrops fetalis, severe hepatosplenomegaly, and often cardiac and skeletal anomalies

Incompatible with life (death in utero or shortly after birth)

Diagnostics

Microcytic hypochromic anemia

Blood smear: target cells , teardrop cells

Bone marrow biopsy: reactive hyperplasia

Confirmatory tests

Hb-electrophoresis Alpha thalassemia can usually only be detected if ≥ 3 alleles are defective.

DNA analysis: to test for alpha thalassemia minor and minima (< 3 alleles defective)

Skeletal deformities -high forehead, prominent zygomatic bones and maxilla can be seen on all imaging modalities.

X-ray: hair-on-end (“crew cut”) sign

ENDOMETRIOSIS

The proliferation and functioning of endometrial tissue outside of the uterine cavity

Incidence: - 15-30% of all premenopausal women, -mean age at presentation: 25-30 years
 
Etiology - unknown

theories

- retrograde menstruation theory of Sampson
- Mullerian metaplasia theory of Meyer
- endometriosis results from the metaplastic transformation of peritoneal mesothelium under the influence of certain unidentified stimuli
- lymphatic spread theory of Halban
- surgical transplantation
- deficiency of immune surveillance


Predisposing Factors

- nulliparity
- age > 25 years
- family history
- obstructive anomalies of genital tract

Sites of Occurrence

ovaries  most common location, 60% of patients have ovarian involvement
broad ligament
peritoneal surface of the cul-de-sac (uterosacral ligaments)
rectosigmoid colon
appendix


Symptoms

there may be little correlation between the extent of disease and symptomatology

pelvic pain - due to swelling and bleeding of ectopic endometrium, unilateral if due to endometrioma

dysmenorrhea (secondary) - worsens with age, suprapubic and back pain often precede menstrual flow (24-48 hours) and continue throughout and after flow

infertility - 30-40% of patients with endometriosis will be infertile, 15-30% of those who are infertile will have endometriosis

dyspareunia  on deep penetration

premenstrual and postmenstrual spotting
bladder symptoms - frequency, dysuria, hematuria

bowel symptoms - direct and indirect involvement diarrhea, constipation, pain and hematochezia

Diagnosis

truly a surgical diagnosis

history - cyclic symptoms - pelvic pain, dysmenorrhea, dyschezia

physical examination

- tender nodularity of uterine ligaments and cul-de-sac
- fixed retroversion of uterus
- firm, fixed adnexal mass (endometrioma)

laparoscopy

- dark blue or brownish-black implants (mulberry spots) on the uterosacral ligaments, cul-de-sac, or anywhere in the pelvis
- chocolate cysts in the ovaries (endometrioma)
- powder-burn lesions
- early white lesions and blebs


Treatment

pseudopregnancy - cyclic estrogen-progesterone (OCP) or medroxyprogesterone (Provera)

pseudomenopause - danazol (Danocrine) = weak androgen, s/e:  weight gain, fluid retention, acne, or hirsutism, leuprolide (Lupron) = GnRH agonist (suppresses pituitary GnRH)

s/e: hot flashes, vaginal dryness, reduced libido, and osteoporosis with prolonged use .these can only be used short term because of osteoporotic potential

surgical

- laparoscopic resection and lasering of implants
- lysis of adhesions
- use of electrocautery
- unilateral salpingo-oophorectomy
- uterine suspension
- rarely total pelvic clean-out
- follow-up with 3 months of medical treatment