TRACHEOSTOMY

Definition

Greek
Trachea and tome (cut)

Tracheostomy :
surgical procedure to bypass the airway in the patient with
upper airway obstruction
Anatomy of the Neck
SURGICAL ANATOMY
Indications

A. Respiratory obstruction.
B. Retained secretions.
C. Respiratory insufficiency.
A. Respiratory obstruction
1. Infections
Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria, Ludwig's angina,
peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess
2. Trauma
External injury of larynx and trachea ,Trauma due to endoscopies, especially in
infants and children,Fractures of mandible or maxillofacial injuries
3. Neoplasms
Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and
thyroid
4. Foreign body larynx
5. Oedema larynx
due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity),
radiation
6. Bilateral abductor paralysis
7. Congenital anomalies
– Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia
B. Retained secretions

1. Inability to cough
– Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic overdose
– Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre syndrome,
myasthenia gravis
– Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning
2. Painful cough
– Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
– Bulbar polio, polyneuritis, bilateral laryngeal paralysis
Pre Operative

■ Informed consent  explain about:

– Operating procedures
– Loss of voices when tracheostomy canule still in the trachea
– Complication of operation
■ Should be done in the operating theatre as much as possible
■ Adequate lightning
■ One assistant required
■ Tracheostomy set
Pre Op
■ Plastic or metal canule preparation
■ Prophylactic antibiotic: Cefazolin or combination of Clindamycin and
Garamycin
■ Anaesthetic preparation:
– Local or general anasthesia  local anasthesia with lidocain (max
dose 7 mg/kgBW)
■ Patient’s position is supine with hyperextension of the head  give a
cushion below the shoulder  trachea will be exposed to the anterior
■ Give the head a “doughnut” cushion
 Types of Tracheostomy Tubes

Cuffed Tube with Cuffed Tube with Cuffless Tube with

Disposable Inner Reusable Inner Disposable Inner
Cannula Cannula Cannula
Used for patients with
Used to obtain a closed Used to obtain a closed tracheal problems
circuit for ventilation circuit for ventilation

Used for patients who are

ready for decannulation
 Types of Tracheostomy Tubes

Cuffed Tube with Fenestrated Cuffed Fenestrated Cuffless

Reusable Inner Tracheostomy Tube Tracheostomy Tube
Cannula
Used for patients who are on the Used for patients who have difficulty
Used for patients with tracheal ventilator but are not able to tolerate using a speaking valve
problems
a speaking valve to speak

Used for patients who are ready for

decannulation
Cuff size
 Steps Of Operation
1. A vertical incision in the midline of
neck, extending from cricoid cartilage
to just above the sternal notch.
A transverse incision, 5 cm long, made 2
fingers' breadth above the sternal notch can
be used in elective procedures. It has the
advantage of a cosmetically better scar .
2. After incision, tissues are dissected in the midline. Dilated veins are
either displaced or ligated.
3. Strap muscles are separated in the midline and
retracted laterally.
4. Thyroid isthmus is displaced upwards or divided
between the clamps, and suture-ligated.
Tapes of tracheostomy tube tied around the neck keeping a space
for 1 finger. Neck kept flexed
Insertion of medicated gauze

Betadine soaked gauze or Sofratulle

put around the tracheostomy
opening.
Post Operative Management

■ Observation for the first 24 hours

■ Treatment for primary disease
■ Tracheostomy cannula management:
– Suction of the secrete / hour
– Cleanse the smaller cannula / 6 hours
– Nebulizer with warm air for 15 minutes /6 hours
– Treat tracheostomy wound with gauze replacement every treatment
Post Operative Care
1.Constant Supervision
■ For bleeding, displacement, blocking of tubes, removing
secretions
■ Patient is given a bell or paper pad to communicate
■ Pt given 100 % oxygen. Deflate the tube cuff.
2.Suction

■ Suction catheter with negative suction pressure (10 -15

mmHg) used.

■ Catheter diameter should be < 1/3rd of internal diameter

of tracheostomy tube

■ Catheter length introduced just enough to go beyond inner

tube (10 cm)
 3.Tracheostomy tube care

■ Inner tube is removed & cleaned when blocked

■ Outer tube never removed before 72 hrs to allow formation of

tracheo-cutaneous tract

■ Cuff of Portex tube deflated for 10 minutes every 2 hours to

prevent pressure necrosis & dilatation of trachea

Complications of tracheostomy

1. Immediate Complications (During tracheostomy)

2. Intermediate Complications (Few hours or days later)
3. Late Complications (Due to prolonged use of tube for weeks-months)
Immediate complications
■ Haemorrhage
■ Aspiration of blood
■ Injury to recurrent laryngeal nerve
■ Injury to apical pleura (Pneumothorax)
■ Injury to oesophagus (May cause
tracheoesophageal fistula)
■ Apnoea (Due to Carbondioxide wash out)
Intermediate Complications
■ Haemorrhage
■ Displacement of tube (Due to use of improper size tube)
■ Blocking of tube (Due to excessive crusting/poor humidification)
■ Subcutaneous emphysema
■ Tracheitis/Tracheobronchitis with crusting in trachea
■ Pulmonary infections (Due to compromised airway defense
mechanism)
■ Wound infection & granulation
Late Complications
■ Haemorrhage (Due to erosion of major vessels esp
innominate/bracheocephalic art)
■ Laryngeal stenosis (Due to perichondritis of cricoid cartilage)
■ Tracheal stenosis (Due to tracheal ulceration & infection)
■ Tracheoesophageal fistula (Due to erosion of trachea by tip of the tube)
■ Persistent tracheocutaneous fistula
■ Keloid/Unsighty scar at tracheostomy site
■ Difficult decannulation
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