TRACHEOSTOMY AND

MANAGEMENT OF
TRACHEOSTIMIZED
PATIENTS
DR BILAWAL KHAN HOUSE OFFICER
ENT B WARD.
Khyber Teaching Hospital Peshawar.
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TRACHEOSTOMY
The term tracheotomy is used to refer to
the creation of a surgical opening into the
trachea. Tracheostomy is used when a
formal opening or stoma is made.In
common use the terms are
interchangeable.

HISTORY OF
TRACHEOSTOMY.
Tracheostomy was performed in ancient
times and the recordings of such events
have been documented by Asclepades,
the Greek Physician in 100 BC.It was
only towards the end of 19th Century that
peroral intubation was re introduced and
became an increasingly more possible
with the invention and subsequent
modification of laryngoscope.
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History of Tracheostomy.
The development of tracheostomy has been divided into
five periods.
1. Period of Legend. 200BC to AD1546.
2. Period of Fear. 1546 to 1833. during which
operation was performed only by brave, few often at
the risk of their reputation.
3. Period of Drama. 1833 to 1932. during which
procedure was generally performed only in
emergency situations on acutely obstructed patients.
4. Period of Enthusiasm. 1932 to 1965. during which
the adage if you think tracheostomy..do it
became popular.
5. Period of Rationalization.
1965 to the present
during which the relative merits of intubation were 4
tracheostomy were debated.

INDICATIONS OF
TRACHEOSTOMY.
Upper airway
obstruction.
Mechanical
respiratory
insufficency.
Respiratory
difficulties due to
secretions.
Elective.

Respiratory
obstruction.
Respiratory failure.
Respiratory
paralysis.
Removal of retained
secretions.
Reduction of dead
space.
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CRICOTHYROTOMY.
In the emergency situations any medical or
paramedical worker may on occasion find
themselves confronted with the need to
alleviate acute upper airway obstruction, either
in hospital or out in the community.
If there is
Suspicion of acute airway problem.
Worsening stridor.
Reducing self ventilation.
Then perform Cricothyrotomy.
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Cricothyrotomy.
(Procedure).

Extend the Neck.

Palpate the cricoid arch;Enter just above it.
Enter larynx just above the cricoid.
Midline incision using either blade or I.V
cannula.
Knife may be rotated through 900 to keep the
incision open.
Convert to formal tracheostomy as soon as
possible.
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Complications of
Cricothyrotomy.
PERICHONDRITIS.
SUBGLOTTIC OEDEMA.
STENOSIS.

OPEN TRACHEOSTOMY.
Local Anesthesia.
Avoid injecting the trachea (cough reflex)
Avoid paratracheal gutter ( recurrent laryngeal
nerve RLN may exacerbate obstruction.
General Anesthesia.
Gas induction.
Never give any muscle relaxant until airway is
secured.
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TRACHEOSTOMY.(STEPS).
1. Collar incision 2cm>suprasternal
notch.
2. Elevate platysma, divide strap
muscles in midline.
3. Thyroid isthmus may be avoidable,
otherwise divide.
4. Palpate and expose the trachea.
5. Alert Anesthesist, suction ready.

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TRACHEOSTOMY.(Steps).
6. Child-

insert two stay sutures, vertical

incision.
7. Adult- horizontal incision, third tracheal
space-may need to exise part of one
tracheal ring.
8. Insert tube connect to anesthetic circuit.
9. Tape stay sutures to the chest in a child.
10. Loose sutures on skin.
11. Suture and tape tube.
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STEPS OF
TRACHEOSTOMY.

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STEPS OF
TRACHEOSTOMY.

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TRACHEOSTOMY TUBES.
CUFFED/ UNCUFFED.
FENESTRATED/ UNFENESTRATED.
SPEAKING VALVE.

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TRACHOSTOMY TUBES.

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TRACHEOSTOMY TUBES.

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TRACHEOSTOMY TUBES.

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TRACHESTOMY TUBES.

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TRACHEOSTOMY TUBES.

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TRACHEOSTOMY CARE.
1.
2.
3.
4.
5.
6.
7.

Nursing care.
Fixation of the tracheostomy tube.
Removal of secretions.
Humidifications.
Changing of tracheostomy tube.
Care of inflatable cuff.
Breathing exersices.

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COMPLICATIONS OF
TRACHESTOMY.
IMMEDIATE.
Haemorrhage.
Thyroid veins.
Jugular veins.
Arteries.

Air embolism.
Apnoea.
Cardiac arrest.
Local damage.
Cricoidcartilage.
Tracheal cartilage.
Recurrent laryngeal nerves.

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COMPLICATIONS OF
TRACHEOSTOMY.
INTERMEDIATE.

Dislodgement / displacement of tube.

Surgical emphysema of the neck.
Pneumothorax/Pneumomediastinum.
Scabs and crusts.
Infection.
Tracheal necrosis.
Tracheoarterial fistula.
Tracheo-oesophageal fistula.
Dysphagia.
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COMPLICATIONS OF
TRACHEOSTOMY.
LATE.
Stenosis of the trachea.
Difficulty with decannulation.
Tracheocutaneous fistula/scars.

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DECANNULATION.
PRINCIPLES

Tube size reduced before decannulation.

Tube is corked off for increasing periods.
Self ventilating for at least one full night.
No further need for tracheal suction.
Remove tube, plug tracheostomy site.
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CASE REPORT(1).

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CASE REPORT (1).

Saleem Ullah 50 years of age from Bannu
Presented in June 2005 with.
Hoarseness of voice
Shortness of Breath
Noisy Breathing
Mild Cough
Indirect and Direct Laryngoscopy Showed
Mass on right vocal cord, which was mobile, there was no cervical
lymphadenopathy.
Biopsy of the leison confirms squamous cell carcinoma of the glottis
and the patient was staged as T1 N0M0. Patient was referred for
radiotherapy where he had completed 35 doses of radiation. Few
weeks ago he again presented with Hoarseness of voice and
Stridor.This time when Direct Laryngoscopy was performed,there
was a fungating growth of right vocal cord , anterior commissure
and anterior end of left vocal cord.Biopsy was taken and to relieve
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the air way TRACHEOSTOMY was performed.

CASE REPORT (2)

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CASE REPORT (2).

Ghulam Qadir 50 years male from D.I.Khan presented to our unit on
15-1-06, with
Difficulty in Swallowing for solids and liqiuds.
Shortness of Breath.
Stridor.
Weight loss.
Generalized weakness.
On examination patient was anaemic and wasted because of
dysphagia.His x-rays neck showed increased prevertebral soft
tissue shadow,Indirect laryngoscopy showed pooling of saliva with
restricted vocal cords movement. On direct laryngoscopy ,and
oesophagoscopy there was a huge mass in the post cricoid region
involving left half of the larynx and extending to the upper end of
the oesophagus. Biopsy of the mass confirmed squamous cell
carcinoma of the hypopharynx.Due to involvement of the larynx
TRACHESTOMY was perfomed, and For feeding purposes
Nasogastric Tube was passed.
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CASE REPORT (3).

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CASE REPORT (3).

Tawnga 60 years of age from Board Peshawar presented to our unit
on
5-1-06 with.
Swelling in front of neck.
Shortness of breath off/on.
Dysphagia off/on.
On clinical examination it was a mulitnodular goitre causing pressure
on the trachea. Blood investgations and thyroid scan showed
multinodular euthyroid.
Subtotal thyroidectomy was performed on 8-1-06 , the recovery was
uneventful. On third post operative day she developed stridor,
Indirect laryngoscopy showed left vocal cord palsy with sluggish
movements in right vocal cord. Patient was restricted to the bed to
avoid any shortness of breath. But gradually the condion of patient
worsened and she was unable to do some stressful activity
because of stridor and shortness of breath. Direct laryngoscopy
showed bilateral abductor paralysis of vocal cords, and the cords
were in median position with a chink of airway. To relieve her
airway TRACHEOSTOMYwas performed and a tracheostomy 30
tube with speaking valve was placed.

CASE REPORT (4).

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CASE REPORT (4).

AbdulMalik 50years male from south waziristan presented
to our unit on
20-12-05 with
Difficulty in breathing.
Difficulty in swallowing.
Previously 06 months ago he was diagnosed as a case of
carcinoma larynx of T1N0M0. Patient was referred to
IRNUM for radiotherapy. He completed the full course
of radiations. At this time there was recurrence of the
tumour involving whole of the left side of larynx with
invasion of the laryngeal framework . Now the tumour
classified as T4N0M0. Total laryngectomy was
performed in our unit on 26-12-05. and permanent
TRACHEOSTOMY was done.
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THANKS

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