TRACHEOSTOMY

NOMENCLATURE

1. Formation of a surgical opening in the

trachea
2. Creation of a permanent stoma between
the trachea and the cervical skin
 HISTORY

• In 1620 Habicot published the first book on

tracheostomies.
• In the 1800s tracheostomy as a way of
treating patients with Diphtheria
• Chevelier Jackson in 1923 published his
work on tracheostomies
 INDICATIONS

1. Mechanical obstruction of the upper airways.

2. Protection of tracheobronchial tree in patients at
risk of aspiration.
3. Respiratory failure.
4. Retention of bronchial secretions.
5. Elective tracheostomy, e.g. during major head
and neck surgery a tracheostomy can
provide/improve surgical access and facilitate
ventilation.
 Advantage
- they reduce the upper airway dead space
by up to 150 ml (50%) :
- reduced effort in breathing compared to
the naso- or oropharyngeal route
- tracheostomy tubes are more comfortable
than endotracheal tubesbetter tolerated
- better tolerated
- potential to eat and talk with the tube in
situ
 Disadvantage
• Warming, humidification and filtering of air do
not take place drying out of the tracheal and
bronchial epithelium
• Epithelium responds increased production
of mucus mucus plugs or crusts
blockage of the airways
- Mucociliary clearance mechanism is disrupted
- Effectiveness of the patients swallow may be
significantly reduced
- Normal cough reflex and the positive
intralaryngeal pressure on expiration, is lost
MECHANICAL UPPER AIRWAY
OBSTRUCTION
 PROTECTION OF THE TRACHEOBRONCHIAL
TREE FROM ASPIRATION
- Neurological diseases [polyneuritis (e.g. Guillain
–Barre syndrome), motor neurone disease,
bulbar poliomyelitis, multiple sclerosis,
myasthenia gravis, tetanus, brain-stem stroke
and bulbar palsy].
- Coma (Glascow Coma Scale score is less than
8, the patient is at risk of aspiration as the
protective reflexes are lost. That includes head
injury, overdose, poisoning, stroke, and brain
tumour).
- Trauma (severe facial fractures, may result in the
aspiration of blood from the upper airways).
 RESPIRATORY FAILURE

• Pulmonary diseases (exacerbation of

chronic bronchitis and emphysema,
severe asthma, severe pneumonia).
• Neurological diseases (multiple sclerosis,
motor neurone disease).
• Severe chest injury (flail chest).
 RETENTION OF BRONCHIAL
SECRETIONS
Including :
- chronic pulmonary disease,
- acute respiratory infection,
- decreased level of consciousness, and
- Trauma to the thoracic cage or musculature
with in-effective cough and retention of
secretions.
 ALTERNATIVE METHODS OF SECURING
A SAFE AIRWAY

• Non-invasive positive pressure

ventilation (NPPV)
• Laryngeal mask airway (LMA)
• Endotracheal intubation
• Transtracheal needle ventilation
• Cricothyroidotomy (minitracheostomy,
laryngotomy)
• Tracheostomy
 PERI-OPERATIVE CARE
• patient should be positioned on the
operating table with the neck extended.
• trachea and laryngeal cartilages should be
palpated in order to establish where to
make the incision
• marked with a marking pen and the skin
and beeper structures should be infiltrated
with 0.5% Marcaine containing 1 : 200,000
adrenaline
The horizontal skin incision held open by a self
retaining forcep.
The strap muscles are clearly seen with the
bloodless plane visible in the midline.
With the strap muscles retracted, the thyroid
isthmus is clearly seen.
The thyroid isthmus is divided between two
haemostats.
The tracheal rings are clearly seen with the
cricoid cartilage superiorly.
 The tracheal dilator is used to open the
trachea after incising vertically through the
tracheal rings.
The loop in the tracheostomy tape is passed
through the flange.
 The ends of the tracheostomy tape
have been pulled through the loop and tied
firmly around the patient’s neck.
COMPLICATIONS OF SURGICAL
TRACHEOSTOMIES