SLP 10420: SLP MANAGEMENT IN A.Y.

2022-2023

HEAD AND NECK PATHOLOGIES TERM 2

LECTURE/LAB

[TRANS] 3RD SHIFTING UNIT 1: Introduction to Tracheostomy

Date: March 30, 2023

○ Discuss the functions of the different

parts of the tracheostomy tube.
OUTLINE
○ Describe the effects of tracheostomy on
I. Tracheostomy
A. Introduction speech and swallowing
B. Relevant Anatomy ○ Identify the key-steps of tracheostomy
C. Indications for Tracheostomy procedure and its implications
II. The Tracheostomy Tube
A. Outer Cannula
B. Cuff TRACHEOSTOMY
C. Neck Plate/Neck Flange ● One of the oldest surgical procedures recorded
D. Inner Cannula in human history
E. Obturator
● Born from the impending death of airway
F. Caps and Decannulation Plugs
III. Pediatric and Neonatal Tracheostomy obstruction
IV. Tracheostomy Tubes for Special Intention/Use
V. Selecting the Appropriate Tracheostomy Tube As Professionals
VI. Cuff ● Ear-Nose-Throat surgeons, require knowledge
A. Uncuffed or Deflated Cuff and surgical skills in airway management
B. Fenestrated including tracheostomy
C. Talking Tracheostomy Tubes
● SLPs should have knowledge on tracheostomy
D. Tracheostomy Tubes w/ addt’l Suction
Channels to able to effectively handle the speech and
VII. Effects on Swallowing swallowing issues concerning tracheostomy
A. Risks of Aspiration w/ Tracheostomy
Tube
VIII. Effects on Voicing INTRODUCTION
A. Requiring Cuff Inflation
B. Not Requiring Cuff Inflation
C. Digital Occlusion DEFINITION OF TERMS
IX. Other Methods of Communication
X. Surgical Procedure TRACHEOTOMY Is the creation of an
A. Skin Incisions opening in the
B. Tracheal Window anterior tracheal wall
C. Intraoperative Complications
D. Early Post-Op Complications
E. Late Post-Op Complications
XI. Tracheostomy Care
XII. Conclusion
TRACHEOSTOMY Is the creation of
permanent stoma by
SESSION OBJECTIVES suturing the edges of
● At the end of the session the students should be the trachea to the
able to: skin
○ Describe the different types of
tracheostomy.
○ Discuss the indications for TYPES OF TRACHEOSTOMY
tracheostomy.

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LECTURE/LAB

OPEN SURGICAL May be done under general or

local anesthesia

Anterior tracheal wall is opened

under direct vision

Performed and more familiar to

ENTs, General & Neurosurgeons

PERCUTANEOUS Minimally invasive procedure

DILATATIONAL ● Done by
(PDT) anesthesiologists and
Figure 1. Cricoid cartilage and its reference points
physicians in the ICU
LARYNX
Involves the placement of the
● Organ for phonation and is located in the
tracheostomy tube without direct
anterior portion of the neck
visualization of the trachea
● Bulges posteriorly into the hypopharynx during
swallowing
Uses the guide wire technique
● Elevates and moves anteriorly with the
now known as Sledinger
contraction of the strap muscles
Technique
● Epiglottic fold folds downward over the glottis to
prevent aspiration, allowing the bolus to pass
Picture A
midline into the esophagus
the tracheostomy tube is
threaded through the guide wire
for its placement within the
trachea

RELEVANT ANATOMY
● The sternal notch, thyroid cartilage, and cricoid
cartilage are easily palpable through the skin
Figure 2. The structure of the trachea and larynx

CRICOID CARTILAGE
TRACHEA
● The key surface landmark during tracheostomy
● Situated below the larynx, specifically below the
● It is usually found by using the thyroid cartilage
cricoid as a continuation of the upper airway
above and the sternal notch below as reference
● Bounded medially/on each side by the medial
points
border of the sternocleidomastoid muscles
● Proceeds more posteriorly and is covered by the
manubrium of the sternum
● Lies posterior to the strap muscles and isthmus
of the thyroid
● During surgical tracheostomy, the strap muscles
have to be divided at the midline and lateralized
● The thyroid isthmus can be retracted superiorly
or divided at the midline and ligated

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● Retraction and ligation of the thyroid isthmus will
expose the first four tracheal rings
○ To be able to identify the first tracheal
ring, the cricoid cartilage has to be
identified first, and so the tracheal ring
below it must be the first.
● Tubular structure
● 12-15 cm in length
● 25mm outer diameter
● 16-20 C-shaped cartilages
● Closed posteriorly by trachealis muscle
● At the level of the 5th TV bifurcates into right
and left bronchi
○ Right main bronchi → more direct
continuation of the trachea and is
angled more acutely compared to the
left; shorter and has wider diameter
Figure 3. The structure of the trachea and primary
bronchi
INFANT AIRWAY ANATOMY
Figure 4. Trachea
● We should not think that infants are just small
adults
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● In proportion to the rest of the body, infant head
is much larger than adults
○ Makes infants assume a more neck
flexion position and thus are more prone
to airway obstruction
● Tongue is proportionately larger than adults
○ When the tongue of an infant relaxes
during sleep, it also has the tendency to
obstruct more frequently than that of an
adult
● Larynx is situated at higher level in relation to
the cervical spine
● At birth, the opening of the rima glottidis is at the
level of intervertebral space 3rd and 4th of the
CV, while the adult’s is one vertebra lower
● The narrowest portion of infant airway is at the
level of the cricoid cartilage, while in the adult’s,
it is at the level of the rima glottidis
● Overall diameter of adult’s airway is 10-12 mm
wider than that of a newborn
● Major conducting airways are narrower and
shorter in infants compared to adults
○ Since they have a smaller airway, an
inflammation or swelling in the airway on
a small diameter airway can cause an
early onset of airway obstruction in
infants compared to adults
● Bifurcation at the carina is more acute, right
mainstem bronchus is less vertical compared to
that of adult
○ The carina marks the bifurcation of the
trachea into right and left main bronchi
when you visualize the trachea
endoscopically, and so the right and left
bronchi are angled more acutely from
the trachea compared to the adult’s
○ Foreign bodies are launched into either
left or right main bronchi in infants or
young children
INDICATIONS FOR TRACHEOSTOMY
SLP 10420: SLP MANAGEMENT IN
HEAD AND NECK PATHOLOGIES
LECTURE/LAB
Figure 5. Upper Airway
1. Need for assisted ventilation over a prolonged
period of time
a. Meaning these are patients who require
respirators
b. If the clinician assessed the patient to
be needing mechanical ventilation for
more than 21 days in adult patients
c. Tracheostomy has to be performed in 1
or 2 weeks of ventilation
d. Individualized basis when it comes to
pediatric population
e. The intention of tracheostomy is to
decrease the risk of laryngeal trauma
from translaryngeal intubation
i. When the patient is intubated,
you have the endotracheal tube
placed between the glottis; it is
usually located posteriorly, and
so, especially if the
endotracheal tube is too large
that it intinges (?) on the blood
supply of the mucosa of the
posterior part of the larynx, then
there will be soft tissue swelling
and then there can also be
ulceration, and then as a
healing process, there can be
fibrosis, and eventually, stenosis
or narrowing of the airway
ii. That is what we want to prevent
when we want to convert
endotracheal tube to
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tracheostomy in patients who
will be on prolonged mechanical
ventilation
2. Acute upper airway obstruction
a. Secondary to congenital problems
i. Can be due to laryngomalacia,
which is severe; bilateral vocal
fold paralysis, or laryngeal webs
b. Trauma
i. Trauma to the anterior neck
(blunt/penetrating)
c. Toxic
i. Due to ingestion or inhalation of
corrosive substances
d. Foreign body aspiration
e. Neoplastic
i. Tumor
f. Infection
i. Swelling s/t infection
g. Anaphylaxis
i. Swelling s/t severe allergic
reaction
h. Sleep disorders
● The goal of tracheostomy for px’s with
acute upper airway obstruction is to
bypass the obstruction and to
re-establish the airway of the patient
● (refer to figure 5. upper airway) As you
can see in the photo, there is blockage
at the level of the glottis. Thus, the px is
tracheostomized to bypass the foreign
body causing airway obstruction.
3. Deficit of lower airway protection of oral and
gastric secretions
a. Meaning patients are aspirating oral and
gastric secretions
4. Pulmonary toilet or clearance of lower
respiratory tract secretions
● Tracheostomy is done for (3) and (4)
especially when:
○ Px is aspirating food and oral
secretions
○ Absence of cough reflex; thus
unable to clear secretions
○ Coma or altered sensorium
● Tracheostomy is performed because we
would like to prevent the patient from
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HEAD AND NECK PATHOLOGIES TERM 2

LECTURE/LAB

developing lower respiratory tract Figure 6.1 The Outer Cannula

infections (aspiration pneumonia) ● The one within the rainbox*
● The tracheostomy tube itself
● Fits entirely within the trachea
THE TRACHEOSTOMY TUBE
● The diameter of the outer cannula: widest
diameter of the tube itself (not including the cuff)
● Curvature of the shaft of the tracheostomy tube
are angled differently from one tracheostomy
tube to another

Figure x.x angulation variations of tracheostomy tubes

Figure 6.0 The Tracheostomy Tube parts ○ Angulation could be subtle or acute or
sharp
Four categories:
1. Dual-cannula cuffed tube CUFF
2. Single-cannula, cuffed tubes
3. Dual-cannula, cuffless tubes
4. Single-cannula, cuffless tubes

● Tracheostomy tubes are constructed of a variety

of materials, including polyvinyl chloride,
silicone, nylon, stainless steel, and silver.
● Most tracheostomy tubes are composed only of
a few parts; it is important to be familiar with the
names of the major parts of the tubes and it’s
function.
Figure 6.2 The Cuff
OUTER CANNULA
● The cuff, if present, is connected to the pilot
balloon by means of the inflation line
● Inflation port or valve at the distal end of the
balloon allows for attachment of a syringe to
inflate the cuff
○ The decision about when and why to
place a cuff/uncuffed and when to
deflate/inflate a cuff will be discussed
later
● Different brands of tracheostomy tubes may
have different shapes, sizes, and types of cuff
○ It can be teardrop, barrel-shaped,
foam-type, or round
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○ Each would have different reasons for

its design, which we will not cover in this
lecture

Figure 6.5 Inner Cannula

Figure 6.3 Types of Cuff
NECK PLATE OR NECK FLANGE
Figure 6.4 Neck Flange
● Fits directly against the skin of the neck and
allows the tracheostomy tube to be anchored to
the neck to stabilize it
● It can be anchored by means of a cloth tape
placed around the neck of the patient or a soft
collar or the flange can be sutured to the skin
○ There are holes on each end of the neck
flange and these areas can be sutured
to the neck to stabilize the tracheostomy
tube
● Also is an important source of clinical
information
○ The specifications of each tube are
usually imprinted or embossed on the
neck flange
● The inner cannula, when present, nests within
the outer cannula and is secured to it
● The primary purpose of the inner cannula is to
clear secretions through cleaning or
replacement at regular intervals
● The inner cannula has a 15 millimeter connector
at its proximal end
○ This is the standard connection for
manual resuscitation band, ventilation
tubing, and other respiratory and airway
appliances
● If the outer cannula has fenestra or opening on
the shaft, there would be an accompanying
fenestrated inner cannula
● Also, inner cannulas would have different locking
mechanisms and locking the inner cannula to
the main tube is important to avoid inadvertent
dislodgement as this may easily be coughed out
by the patient
OBTURATOR

INNER CANNULA

Figure 6.6 Obturator

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● The sole purpose of the obturator, sometimes

TRACHEOSTOMY TUBES FOR SPECIAL
called the pilot, is to assist with the insertion of INTENTION/USE
the tracheostomy tube
● The blunted tip of the obturator cushions the
EXTRA-LONG TRACHEOSTOMY TUBES (XLT)
distal tip of the tube as it is inserted, thus
avoiding potential tissue damage as it is
advance into the trachea

CAPS AND DECANNULATION PLUGS

Figure 7. XLT vs. a regular tracheostomy tube

Figure 6.7 Cap (top) and Decannulation Plug (bottom)

● Other accessories for the tracheostomy tube
● A tracheostomy cap and decannulation plug are
used to prevent air from entering the
tracheostomy tube, and these forces the patient
to breathe through the mouth and nose,
simulating a normal breathing
● The decannulation plug is differentiated from the
cap because it is applied by removing first the Figure 8. XLT in Tracheomalacia
inner cannula and twisting or screwing the ● If you compare the XLT to the regular
decannulation plug to the proximal end of the tracheostomy to the regular tracheostomy tube
outer cannula you can see that the shaft is longer.
● The use of caps and plugs allow the patient to ● Fixed or adjusted neck flange
phonate easily without digital occlusion ● Useful in cases of tracheomalacia, unusual
○ In preparation for possible anatomy, or morbid obesity
decannulation of a patient ○ Tracheomalacia → so as to place the
cuff of the tracheostomy tube more
PEDIATRIC AND NEONATAL TRACHEOSTOMY distally and freeing this area (Figure 8)
● Due to the small tracheal diameter, pediatric and where the original tracheostomy tube
neonatal tracheostomy tubes are generally cuff used to rest to allow it to heal.
uncuffed and don’t have inner tube
○ This is to avoid reducing the internal METAL TRACHEOSTOMY TUBES
diameter of the tracheostomy tube
further
● No inner cannula
● Neonatal tubes are shorter than pediatric tubes
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LECTURE/LAB
Figure 9. Metal Tracheostomy Tube
● Can be constructed of stainless steel or silver
● This has become uncommon nowadays
because there are a lot of Polyvinyl chloride and
silicone tracheostomy tubes that are more
available
● Heavier than plastic
● Reflects ambient temperature
● Walls are thinner
● Silver has an additional benefit of having
bactericidal properties
● Can last a lifetime with regular cleaning
● Has value in places where plastic tubes are
difficult to obtain
SELECTING THE APPROPRIATE
TRACHEOSTOMY TUBE
● When selecting the appropriate tracheostomy
tube both the diameter and length should be
considered.
CHOOSE OPTIMAL TUBE DIAMETER
● If diameter is too big
○ Injures the tracheal mucosa >
compromising its vascular supply >
ulceration > fibrous stenosis
○ Overinflation of a cuffed tracheostomy
tube for a prolonged period may
produce a similar injury
● Tube should be large enough
○ To allow adequate air exchange, easy
suctioning, and clearance of secretions
● But should not be too small
○ That it can be dislodged or produces
high airway resistance
CHOOSE OPTIMAL TUBE LENGTH
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● Length is important especially in the neonatal
and infant population
Figure 10. Accidental Decannulation or Formation of
False Passage
● A tube that is too short may result in accidental
decannulation or formation of a false passage.
○ Tracheostomy tube is not inserted
through the lumen but in an area
anterior to the lumen, especially if the
tube is short
● If the tube is too long, the end may abrade the
carina or rest within the right mainstem
bronchus, thereby occluding the left
● The size of the tracheostomy tube usually refers
to the inner diameter of the inner cannula
HOW DO WE IDENTIFY THE SIZING OF THE
TRACHEOSTOMY TUBE?
● The tubes are usually sized according to:
○ If inner cannula is present → the inner
diameter of the inner cannula
○ If there is no inner cannula → the inner
diameter of the outer cannula
● Shiley
○ The most popular brand of
Tracheostomy Tube
○ This brand and all other metal
tracheostomy tube uses the Jackson
Sizing System, not metric
■ It is based on the French sizing
● All other tracheostomy tubes, aside from Shiley
and the tracheostomy metal tracheostomy trube,
uses the metric or the ISO system
CUFF
● The primary purpose of cuff is to seal the airway
● Especially when there is a need for positive
pressure ventilation
SLP 10420: SLP MANAGEMENT IN
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LECTURE/LAB
● When the cuff is inflated there is no admixture of
room air with the inspired gasses and the patient
breathes entirely through tracheostomy tube
● When there is tight seal between trachea and
the cuff, it prevents seepage of secretions, fluids
or even food from entering the lungs
UNCUFFED OR DEFLATED CUFF
● Allows for laminar airflow around the tube,
lessening the resistance
● Allows for the admixture of room air as part of
the inspired tidal volume
● Expired air reaches the vocal folds for phonation
FENESTRATED (CUFFED OR UNCUFFED)
● The shaft of the tube has an opening on the
dorsal aspect that allows for an added boost of
air to the vocal folds
○ It’s main purpose is for phonation
TALKING TRACHEOSTOMY TUBES
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● Designed for ventilator dependent patients who
are awake who desired to speak regardless of
cuff inflation
● For Blom Speech Cannula, there is fenestration
just 1mm above the cuff and there are two
valves, the flap valve and the bubble valve
● During inspiration the flap valve and the bubble
valve expands into the fenestra to seal it
● This allows the air to be delivered into the
patient’s lungs and prevent air from escaping the
upper airway
● During exhalation, the mechanism is reverse
where the flap valve closes and the bubble valve
collapses to unblock the fenestra and allow the
air to go up to the vocal folds
TRACHEOSTOMY TUBES WITH ADDITIONAL
SUCTION CHANNELS
● Another type of tracheostomy for special use
● There is a suction channel where the tip is
above the cuff
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● Prevents accumulation of the secretions above If the patient is not requiring cuff inflation, whether it is
cuff which has been implicated in the uncuffed or fenestrated. There are methods of allowing
development of ventilator-associated pneumonia the patient to speak:
● Digital occlusion
● Capping (and cannulation plugs)
EFFECTS ON SWALLOWING
● Speaking valve

RISKS OF ASPIRATION WITH TRACHEOSTOMY DIGITAL OCCLUSION

TUBE
● Thereotically, decreased elevation and anterior
rotation of the larynx because the trachea is
anchored to the strap muscles
● Inflated cuff impinges against the esophageal
wall causing esophageal compression
● Attenuation of the reflex of the vocal folds
○ Meaning we do have what we call a
laryngeal adapter reflex in our vocal
folds closes whenever there is a
stimulation of a possible foreign body
● Reduction in subglottic pressure
○ If we have reduction in the subglottic Figure 11. Digital occlusion
pressure, we have reduced ability to
cough out or expectorate secretions ● Digital occlusion is basically covering the
such as saliva or oral and gastric proximal end of the tracheostomy tube and this
secretions, as well as pulmonary allows the air from the lungs to reach the vocal
secretions folds consequently allowing the patient to speak

EFFECTS ON VOICING

TRACHEOSTOMY REQUIRING CUFF INFLATION

● Aphonia
○ If the px has tracheostomy tube, then he
would have aphonia
○ If the tracheostomy is requiring cuff
inflation because of its connection to
positive pressure ventilation, there is a Figure 12. Capping
way for a patient to have voice by ● Cap is placed over the 15-millimeter connector
means of using a talking tracheostomy of the inner cannula so that when it is covered,
tube then the patient will be able to breathe through
the nose and mouth and speak because the air
from the lungs as the patient exhales or as the
TRACHEOSTOMY NOT REQUIRING CUFF patient attempts to talk reaches the vocal folds.
INFLATION (Uncuffed and Fenestrated)

METHODS OF PHONATION

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● Electronic devices
○ Some patients prefer to use electronic
devices, tablets, iPads, and cellular
phones

SURGICAL PROCEDURE

Figure 15. Procedure for Tracheostomy

● For most patients, it is ideal that before doing
the tracheostomy the airway is secured by
translaryngeal intubation:
○ Place the patient supine on the
Figure 13. Speaking valve
operating table or other firm surface with
a rolled towel or sheet under the
● Speaking valve is a one-way valve that allows
shoulders to extend the neck and a
air to enter the tracheostomy tube but prevents it
doughnut pillow under the head
from being exhaled through the valve
■ Allows the trachea to be brought
● Speaking valves are attached to the
more anteriorly and exposed
15-millimeter connector at the proximal end of
○ If the patient cannot tolerate lying supine
the inner cannula, just like placing the cap
(e.g. in cases of acute airway
● The exhaled air during expiration is directed
obstruction), tracheostomy will be
around the tracheostomy tube. Or if the
performed under local anesthesia with
tracheostomy tube is fenestrated then through
patient in a sitting or semi-sitting
the finestra to the upper airway, thus allowing
position
the patient to phonate then talk

SKIN INCISIONS
OTHER METHODS OF COMMUNICATION
Specially for patients who are unable to have talking
tracheostomy tube
● Communication boards
○ You can also use the magic slate
(rightmost pic)

Figure 14. Communication boards

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Figure 16. Types of skin incisions for tracheostomy
TRANSVERSE SKIN INCISION
● For planned trach, a transverse skin incision
approximately 1cm below the inferior border of
the cricoid cartilage within the medial aspects of
the sternocleidomastoid muscle is created
● Produces an acceptable cosmetic appearance
after the granulation
VERTICAL SKIN INCISION
● Begins from the anterior aspect of the cricoid
cartilage extending 2-3 cm inferiorly
● Employed during emergency tracheostomy to
avoid transecting the veins that run parallel to
the trachea and to prevent bleeding
● Usually results in scars
TRACHEAL WINDOW
● Tracheal window – the opening through tracheal
rings 2-3 or 3-4
● There are several types of tracheal wall incisions
when creating a window and is dependent on
surgeons’ preference
● In terms of location, the tracheal window is
created between rings 2-3 or 3-4
● As much as possible, we want to keep tracheal
ring 1 intact to avoid injury to the cricoid
cartilage to prevent subglottic stenosis
● We also avoid creating a window below rings 3
and 4 to avoid the blood vessels and prevent
bleeding
● Types of tracheostomy window:
○ T-shape
○ Box
○ H
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○ Cross
○ A superior base flap / u-shape flap
○ Vertical incision
○ Transverse incision
○ Puncture
○ Inferiorly based flap / inverted u
SURGICAL PRODECURE FOR TRACHEAL WINDOW
● Once the tracheal window is created, the
endotracheal tube is retracted superiorly just
above the trachestoma
● The tracheostomy tube with no obturator is
inserted initially at a right angle into the trachea
● As the cannula is inserted, it is rotated so that
the axis is parallel to the trachea
● The obturator is removed and the cannula is
placed
● Lastly, the oxygen source is connected to the
15mm connector of the inner cannula
INTRAOPERATIVE COMPLICATION
● Hemorrhage
○ Laceration of major blood vessels
● Pneumothorax
○ Due to traumatic puncture of the pleura
especially in pediatric age groups
because their pleura or tip of the lungs
protrude beyond the level of the clavicle
over the shoulders so it is near the
trachea
○ Due to rupture of bled in a patient
struggling to breathe and damage to the
posterior tracheal wall
○ Due to excessive positive pressure
ventilation using ventilating bag
● Intraoperative fire
○ Related to the use of electrocautery or
high concentration of oxygen that’s why
when we have entered the trachea as
much as possible we avoid using the
electrocautery
■ If there is a need to use
electrocautery then we should
tell the anesthesiologist to stop
the oxygen
● Air embolism
○ Results from aspiration of volume of air
through a rent in the venous circulation
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then the air is transported to the
pulmonary arteries where it may cause
interference in the gas exchange which
may also lead to cardiac arrest
Figure 17. Laceration of membranous tracheal wall after
surgical tracheostomy
EARLY POST-OP COMPLICATION
● Tracheostomy tube displacement
○ Results in decannulation and loss of
airway
● Tube obstruction
○ Secondary to mucus plug, blood clots,
or tube displacement
○ Mucus plug is the most frequent
complication of tracheostomy
■ There is also loss of airway
● Stomal erosion
○ Excessive traction forces created by the
weight of the ventilator tubings against
the trachea
● Hemorrhage
○ Due to erosion to the nearby blood
vessels
○ Due to a bleeding granulation tissue
around the stoma
○ Due to aggressive suctioning thus
creating erosion to the tracheal mucosa
● Infection
○ Peristomal area or region around the
opening of the tracheostomy tube is
quickly colonized by bacteria
○ If there is foul smelling discharge from
the tracheostomy tube then there might
be tracheitis and this has to be
addressed with antibiotics
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● Subcutaneous emphysema
○ Air is forced into the subcutaneous
tissue plane during the placement of the
tracheostomy tube especially if the
patient was coughing excessively during
the time of placement or in the
immediate postoperative period
■ This air may thoracic cavity and
cause pneumomediastinum
● Pneumomediastinum
● Post obstructive pulmonary edema
○ Although the cause is unclear, negative
pressure obstructive pulmonary edema
happens when there is negative
intrapleural pressure – which promotes
the transfer of blood from the system to
the pulmonary circulation
○ And the further increase in pulmonary
microvascular pressure causes the
edema after tracheostomy
Figure 18. Mucus Plug
LATE POST-OP COMPLICATION
● Tracheoinnominate fistula hemorrhage
○ A communication between the trachea
and the innominate artery. This is due to
the erosion of the tube on the blood
vessel.
○ The risk factor for the development of
tracheoinnominate fistula is the low
placement of the tracheostomy tube;
SLP 10420: SLP MANAGEMENT IN
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that is why we would like to place our
tracheostomy tube up to the fourth
tracheal ring
■ If we place the tracheostomy
tube below the tracheal ring
then there is a possibility of
eroding the innominate artery
■ Also if the innominate artery is
high riding then even if the
tracheostomy tube is placed at
the proper level, it can still erode
the innominate artery
○ The hallmark of a tracheoinnominate
fistula is a sentinel bleed, a mild bleed
which may be followed by a massive
bleeding
● Tracheoesophageal fistula
○ A communication between the trachea
and esophagus. This may be due to a
malpositioned tracheostomy tube which
exerts pressure on the posterior wall of
the trachea and into the esophagus.
○ Patients with this condition may present
with recurrent aspiration, persistent
coughing, severe stomach distention,
and gastric contents presenting through
the tracheostomy
● Tracheocutaneous fistula
○ Represents failure of the tracheostoma
to close after the granulation
○ This happens when the peristomal skin
in the tracheal mucosa heals to one
another creating an uninterrupted tract
○ To be able to correct this, the tract has
to be removed and the skin has to be
closed primarily
● Stomal granulation tissue
○ Due to high rate of bacterial colonization
on the stoma in the constant mechanical
irritation associated with the movement
of the tube
○ Granulation tissue formation can be
removed or resected surgically; or if it is
in its early phase, then the patient would
benefit from an intralesional injection of
corticosteroid
● Tracheomalacia
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A.Y. 2022-2023
TERM 2
○ Due to the weakening of the tracheal
cartilage due to ischemic injury and
destruction of the tracheal cartilage
○ We already mentioned that if we place
an extra long tracheostomy tube, this
places the cuff of the tracheostomy tube
more distal/away from the area of the
tracheomalacia thus allowing the
tracheomalacia to heal
● Tracheal stenosis
○ Has the same etiology in that it’s an
ischemic injury to the mucosa causing
inflammation of the cartilage, eventually
fibrosis and stenosis or collapse of the
area
○ If the tracheal stenosis is severe, then
there would be a need to resect the
segment of the trachea that is stenosed,
and the proximal and the distal end of
the remaining trachea will have to be
anastomosed or connected to each
other
TRACHEOSTOMY CARE
After the tracheostomy, and let’s say for example the
patient has recovered, and there is a plan for
decannulation after the trial of capping or the use of the
cannulation plug, or even downsizing the tracheostomy:
DECANNULATION
● Before attempting decannulation, upper airway
should be examined by performing direct
laryngoscopy and bronchoscopy
○ We also advocate that before
decannulation, the larynx and the
trachea is directly visualized
● However, not all patients are amenable for
decannulation. There are several patient factors
that would prevent them from being
decannulated, and so they will have to be sent
home with a tracheostomy tube in place.
TRACHEOSTOMY CARE
● If the patient cannot be decannulated, then the
caregiver and if possible the patient, must be
trained to do tracheostomy care
 SLP 10420: SLP MANAGEMENT IN
HEAD AND NECK PATHOLOGIES
LECTURE/LAB
○ This has to be done prior to discharge
from the hospital
○ We tell our patient that before sending
them home, the following equipment
and materials must be available and
tested
○ The caregiver and the patient must be
taught to:
■ Clean
■ Change the tracheostomy tube
■ Irrigate the trachea
■ Provide suction
■ Perform percussion
○ They should also be educated on how to
detect complications and given
instructions in cases of emergencies
MATERIALS NEEDED FOR TRACHEAL IRRIGATION
AND SUCTIONING
While you might not be obligated to instruct patients on
how to perform tracheostomy care, it's also important
that you are aware of the steps and the materials that
are needed to perform tracheostomy care.
● During tracheostomy care, the trachea has to be
suctioned so as to remove secretions. The
materials needed are:
○ Suction machine
○ Suction tubing
○ Clean gloves
○ Bowl of water
● When suctioning the trachea, it is advisable to
not insert the tubing too deeply so as to prevent
erosion or abrasion of the tracheal mucosa and
the carina
○ We often tell our patients that we try to
estimate the depth of the insertion of the
suction tubing would be just a
little/slightly/a few mm below the distal
tip tracheostomy tube
● When it comes to irrigation, we would like to
irrigate the trachea so as to thin the secretion
before and after suctioning
○ We can use about 2-3mL of normal
saline and it is
irrigated/infiltrated/injected through the
tracheostoma
○ We can perform percussion or chest
flapping after that
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A.Y. 2022-2023
TERM 2
○ And then we can suction again
MATERIALS NEEDED FOR INNER CANNULA
The following are the materials needed to clean the inner
cannula → removable and is the one that has to be
cleaned in order to prevent blood clots and mucus from
obstructing the airway
● Once the inner cannula is removed, it has to be
soaked in half strength hydrogen peroxide
○ Prepare an equal amount of hydrogen
peroxide and an equal amount of your
sterile saline and place it in a basin
○ You can soak the inner cannula there in
a few minutes (5-10 mins)
● After that you can use the tracheostomy brush to
clean the inside of the inner cannula
● After that you can air dry the inner cannula and
return or replace it into the tracheostomy (outer
cannula)
● For cleaning the skin, you can use hydrogen
peroxide to remove the mucus around the stoma
○ If it is in the early period of tracheostomy
some of the blood clots, then you can
apply antiseptic solutions such as
betadine or antiseptic sprays and then
place dressing underneath the neck
lounge
CONCLUSION
● Tracheostomy is a common life-saving
procedure to secure airway
● Knowledge of anatomy of both adult and infant
airway is key to prevent complications of the
tracheostomy procedure and maintenance or
care
● Most common indication for tracheostomy is
prolonged intubation followed by airway
obstruction, pulmonary toilet, and protection
from aspiration of secretions
● There are different types of tracheostomy tube
and it is important to be familiar with this to know
its effect on the voicing and swallowing of a
patient with tracheostomy