CONTENTS

 Tracheostomy
 Indications for a tracheostomy
 Types of Tracheostomy Tubes
 Tracheostomy Procedure
 contraindication

 Equipment

 Preparation for Tracheostomy

 Positioning
 Incision
 Introduction of Guide Wire, Stylet and Initial Tract Dilatation
 Placement of the Tracheostomy Tube
 Confirmation of Placement
 Securing the Tube
 Complications and Risks of Tracheostomy
 Summary
 Tracheostomy

A tracheotomy or a tracheostomy is an opening surgically created through the neck into

the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an
operating room under general anesthesia. A tube is usually placed through this opening to
provide an airway and to remove secretions from the lungs.  Breathing is done through the
tracheostomy tube rather than through the nose and mouth. The term “tracheotomy” refers to the
incision into the trachea (windpipe) that forms a temporary or permanent opening, which is
called a “tracheostomy,” however; the terms are sometimes used interchangeably.

Indications for a tracheostomy

A tracheostomy is usually done for one of three reasons:

1. to bypass an obstructed upper airway;

2. to clean and remove secretions from the airway;

3. to more easily, and usually more safely, deliver oxygen to the lungs.

All tracheostomies are performed due to a lack of air getting to the lungs. There are many
reasons why sufficient air cannot get to the lungs.

Airway Problems That May Require a Tracheostomy

 Tumors, such as cystic hygroma

 Laryngectomy
 Infection, such as epiglottitis or croup
 Subglottic Stenosis
 Subglottic Web
 Tracheomalacia
 Vocal cord paralysis (VCP)
 Laryngeal injury or spasms
 Congenital abnormalities of the airway
 Large tongue or small jaw that blocks airway
 Treacher Collins and Pierre Robin Syndromes
 Severe neck or mouth injuries
 Airway burns from inhalation of corrosive material, smoke or steam
 Obstructive sleep apnea
 Foreign body obstruction
 Lung Problems That May Require a Tracheostomy

 Need for prolonged respiratory support, such as Bronchopulmonary Dysplasia (BPD)

 Chronic pulmonary disease to reduce anatomic dead space
 Chest wall injury
 Diaphragm dysfunction
Other Reasons for a Tracheostomy

 Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm

 Aspiration related to muscle or sensory problems in the throat
 Fracture of cervical vertebrae with spinal cord injury
 Long-term unconsciousness or coma
 Disorders of respiratory control such as congenital central hypoventilation or central
apnea
 Facial surgery and facial burns
 Anaphylaxis (severe allergic reaction)

Types of Tracheostomy Tubes

A tracheostomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma (the hole

made in the neck and windpipe (Trachea)). There are different types of tracheostomy tubes that
vary in certain features for different purposes.  These are manufactured by different companies. 
However, a specific type of tracheostomy tube will be the same no matter which company
manufactures them.
A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck
plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the
tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach
cloth ties or velcro strap around the neck. The inner cannula fits inside the outer cannula. It has a
lock to keep it from being coughed out, and it is removed for cleaning. The obturator is used to
insert a tracheostomy tube.  It fits inside the tube to provide a smooth surface that guides
the tracheostomy tube when it is being inserted.
There are different types of tracheostomy tubes available and the patient should be given the tube
that best suits his/her needs. The frequency of these tube changes will depend on the type of tube
and may possibly alter during the winter or summer months. Practitioners should refer to
specialist practitioners and/or the manufacturers for advice. 
Tube Indication Recommendations

Cuffed Tube with Disposable Inner Cannula

Used to obtain a closed circuit for Cuff should be inflated when using with
ventilation ventilators. 

Cuff should be inflated just enough to

  allow minimal airleak.

  Cuff should be deflated if patient uses a

speaking valve.
Click picture  to enlarge
Cuff pressure should be checked twice a
day.

Inner cannula is disposable.

Cuffed Tube with Reusable Inner Cannula

Used to obtain a closed circuit for Cuff should be inflated when using with
ventilation ventilators. 

Cuff should be inflated just enough to

allow minimal airleak.
Click picture  to enlarge

Cuff should be deflated if patient uses a

speaking valve.

Cuff pressure should be checked twice a

day.

Inner cannula is not disposable.  You can

reuse it after cleaning it thoroughly.
Cuffless Tube with Disposable Inner Cannula
Used for patients with tracheal
problems
Used for patients who are ready
 Click for decannulation
picture  to enlarge
Cuffed Tube with Reusable Inner Cannula
Used for patients with tracheal
problems
Used for patients who are ready
for decannulation
Click picture  to enlarge
Fenestrated Cuffed Tracheostomy Tube
Used for patients who are on the
ventilator but are not able to
tolerate a speaking valve to speak
 Click
picture  to enlarge
Save the decannulation plug if the
patient is close to getting decannulated.
Patient may be able to eat and may be
able to talk without a speaking valve.
Inner cannula is disposable.
Save the decannulation plug if the
patient is close to getting decannulated.
Patient may be able to eat and may be
able to speak without a speaking valve.
Inner cannula is not disposable. You can
reuse it after cleaning it thoroughly.
There is a high risk for granuloma
formation at the site of the fenestration
(hole).
There is a higher risk for aspirating
secretions.
It may be difficult to ventilate the patient
adequately.
 Fenestrated Cuffless Tracheostomy Tube

Used for patients who have There is a high risk for granuloma
difficulty using a speaking valve formation at the site of the fenestration
(hole).
 Click
picture  to enlarge

Metal Tracheostomy Tube

Not used as frequently anymore.  Patients cannot get a MRI.

Many of the patients who received
a tracheostomy years ago still One needs to notify the security
 Click choose to continue using the metal personnel at the airport prior to metal
picture  to enlarge tracheostomy tubes. detection screening.

Tracheostomy Procedure

The superior thyroid notch, cricoid and suprasternal notch usually can be easily palpated through
the skin. The cricothyroid space can be identified by palpating a slight indentation immediately
below the inferior edge of the thyroid cartilage. Cricothyroid arteries traverse the superior aspect
of this space on each side and anastomose near the midline.

The innominate artery crosses from left to right anterior to the trachea at the superior thoracic
inlet. Its pulsations can be palpated and occasionally seen in the suprasternal notch especially in
 case of a high riding vessel, representing a contraindication for a bedside percutaneous or open
tracheostomy.
The isthmus of the thyroid gland lies across the 2nd to 4th tracheal rings and must be dealt with
in any procedure at or around the upper trachea.
 
Indications for PDT

They are the same as a routine open operative tracheostomy with particular attention to
contraindications.1

Contraindications for PDT

Absolute:

Emergent tracheostomy ( i.e., securing emergent airway) in any patient population, infants and
children (<15 years)

Relative Surgical Contraindications:

Poor neck landmarks, neck mass (e.g. goiter), high innominate or pulsating vessels, previous
neck surgery, limited neck extension, severe coagulopathy (uncorrected)
Relative Anesthetic Contraindications:

High PEEP (>18 cm), high airway pressure (>45 cm),  high FiO2 (80%), retrognathic mandible
with a limited view of the larynx on laryngoscopy
Preparation for Tracheostomy

Once the decision to perform a tracheostomy has been made, the surgeon must determine if the
patient is a good candidate for the surgery and obtain written informed consent. In addition, the
range of motion of the neck needs to be assessed. The tracheostomy team, including the surgeons
and anesthesiologists need to discuss the entire sequence and alternatives to the procedure. All
equipment must be available and functioning properly.

Equipment

A regimented approach to preparation and performance of the procedure has been shown to
significantly reduce the incidence of procedural complications4.
Our approach includes the following equipment and protocols:

 We routinely use Cook Blue Rhino single dilator kit and videobronchoscopy to perform
the procedure.
 The following must be available:
 An attending anesthesiologist must be present for maintenance of airway,
provision of intravenous sedation and performance of bronchoscopy.
 An intubation roll and a cricoid hook.
 Open tracheostomy set.

Positioning

1. The patient’s neck is extended over a shoulder roll (unless there is a contraindication).

2. The anesthesiologist stands at the head end of the bed and under direct laryngoscopy
positions the endotracheal tube (ETT) so that the cuff is midway at the vocal cord level.

Incision

1. We routinely inject the skin with 1% lidocaine with 1:100,000 epinephrine solution.

2. A horizontal or vertical incision centered on the inferior border of the cricoid cartilage
may be used. We routinely use a 3-4 cm vertical incision.

Placement of Introducer Needle

1. A minimal dissection is performed onto the pretracheal tissue in order to push the thyroid
isthmus downward.

2. The larynx is stabilized and pulled cephalad with the operator’s left hand.

3. A bronchoscopy is then performed and the light reflex is used to select the best site for
the introducer needle.

4. Placing the needle at the inferior edge of the light reflex, the tip of the needle is directed
caudad into the tracheal lumen avoiding the posterior tracheal wall at all cost.

Introduction of Guide Wire, Stylet and Initial Tract Dilatation

The needle is withdrawn while keeping the cannula in the tracheal lumen. A J-tipped guide wire
is then place under vision. The stylet is then placed with the safety ridge directed towards the tip
of the wire. The tract is then dilated with the 8 FR dilator.
Dilatation with the Blue Rhino Dilator
The Blue Rhino dilator is loaded on the stylet with the tip resting on the safety ridge. The dilator
is moved in and out to optimally dilate the tissue between the skin and the tracheal lumen. The
Blue Rhino dilator is never advanced beyond the point where 40 FR mark disappears below the
skin level.

Placement of the Tracheostomy Tube

1. A tracheostomy tube is loaded onto the dilator
- Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to the 26 FR dilator
- Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the 28 FR dilator

2. The dilator is then loaded on the safety ridge of the stylet and placed into the tracheal
lumen under direct visualization.

Confirmation of Placement 
The bronchoscope is withdrawn from the ETT and introduced via the tracheostomy tube. The
placement is confirmed by visualizing the carina.

Securing the Tube

We routinely secure the tube with 2 sutures of 2-0 nylon on each side of the flange. In addition, a
tracheostomy tape is used to hold the tube in place. A flexible extension tube is used to connect
the tube to the ventilator circuit to avoid undue movement of the tube in the immediate
postoperative period.
Postoperative Consideration

A chest X-ray is not routinely required as long as the entire procedure was done under direct
visualization and there were no adverse events intraoperatively6. The postoperative care is same
as for the open procedure.
The tract between the skin and the tracheal lumen takes a little longer (10-14 days) to mature as
there is no formal layer by layer dissection involved. We, therefore, perform the first tube change
on Day 10-12 postoperatively.

Complications and Risks of Tracheostomy

As with any surgery, there are some risks associated with tracheotomies. However, serious
infections are rare.

Early Complications that may arise during the tracheostomy procedure or soon thereafter

include:
 Bleeding
 Air trapped around the lungs (pneumothorax)
 Air trapped in the deeper layers of the chest(pneumomediastinum)
 Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)
 Damage to the swallowing tube (esophagus)
 Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)
 Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway
walls.  Blockages can be prevented by suctioning, humidifying the air, and selecting the
appropriate tracheostomy tube.
 Many of these early complications can be avoided or dealt with appropriately with our
experienced surgeons in a hospital setting.

Over time, other complications may arise from the surgery.

Later Complications that may occur while the tracheostomy tube is in place include:
 Accidental removal of the tracheostomy tube (accidental decannulation)
 Infection in the trachea and around the tracheostomy tube
 Windpipe itself may become damaged for a number of reasons, including pressure from
the tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves
too much
These complications can usually be prevented or quickly dealt with if the caregiver has proper
knowledge of how to care for the tracheostomy site.

Delayed Complications that may result after longer-term presence of a tracheostomy include:

 Thinning (erosion) of the trachea from the tube rubbing against it (tracheomalacia)
 Development of a small connection from the trachea (windpipe) to the esophagus
(swallowing tube) which is called a tracheo-esophageal fistula
 Development of bumps (granulation tissue) that may need to be surgically removed
before decannulation (removal of trach tube) can occur
 Narrowing or collapse of the airway above the site of the tracheostomy, possibly
requiring an additional surgical procedure to repair it
 Once the tracheostomy tube is removed, the opening may not close on its own.  Tubes
remaining in place for 16 weeks or longer are more at risk for needing surgical closure
 SUMMARY

A tracheostomy is a surgical procedure to cut an opening into the trachea (windpipe) so that a
tube can be inserted into the opening to assist breathing. ... A person with permanent damage or
loss of function around the larynx or swallowing area may need a permanent tracheostomy tube
to help them breathe at night.
 BIBLIOGRAPHY
1. Goldenberg D, Bhatti .N. Management of the Impaired Airway in the Adult, in
Otolaryngology: Head & Neck Surgery, Cummings CW, Editor. 2005, Mosby

2. Seldinger, S.I., Catheter replacement of the needle in percutaneous arteriography; a new

technique. Acta Radiol, 1953. 39(5): p. 368-76.

3. Ciaglia, P., R. Firsching, and C. Syniec, Elective percutaneous dilatational tracheostomy.

A new simple bedside procedure; preliminary report. Chest, 1985. 87(6): p. 715-9.

4. Bhatti N, Mirski M, Tatlipinar A, Koch WM, Goldenberg D. Reduction of complication

rate in percutaneous dilation tracheostomies. Laryngoscope, 2007. 117(1):172-5.

5. Marelli D, Paul A, Monilidis S, Walsh G et al. Endoscopic guided percutaneous

tracheostomy: early results of a consecutive trial. J Trauma. 1990. 30(4):433-5.

6. Hoehne F, Ozaeta M, Chung R. Routine chest X-ray after percutaneous tracheostomy is

unnecessary. Am Surg, 2005. 71(1):51-3.