TRACHEOSTOMY

BY VERONICA ROBERT, MD 4
MODERATOR DR.SAMSON
 OUTLINE
Definition
Anatomy of larynx and trachea
Indications
Types of tracheostomy
Procedure
Types of tracheostomy tubes
Tracheostomy care
Complications
 Definition
• Tracheostomy is making an opening in the
anterior wall of trachea & converting it into a
stoma on the skin surface .
• The term tracheotomy has been interchangeably
used but actually it means opening the trachea,
which is a step in tracheostomy operation.
 Anatomy of larynx
• It is the musculocartilaginous structure, lined
with mucous membrane. Functions to
maintain flow of passing air and phonation.
• connected to the superior part of trachea and
to the pharynx.
• It begins at level of vertebrae c4 and ends at
level of vertebrae c7.
 Cont…
• Blood supplied by superior laryngeal artery
from superior thyroid artery and the inferior
laryngeal artery from inferior thyroid artery.
• Nerve innervation superior and recurrent
laryngeal nerve branches of vagus nerve.
 Anatomy of trachea
•The trachea is a fibromuscular tube supported by 16-20 c
shaped rings of hyaline cartilages which are opened
posteriorly.
•The soft tissue posterior wall is in contact with the
oesophagus.
•Trachea lies in midline of the neck extending from cricoid
cartilage at lower border of C6 vertebra to the lower
border of T4 vetebra where it branches to form the main
bronchi.
•In adults it is 12-16 cm long, and 13-16 mm wide in women
and 16-20 mm wide in men.
 Cont…
• The blood supply is primarily supported by the
bracheocephalic artery and through the inferior
thyroid and bronchial arteries.
• The nerve supply is by parasympathetic and
sympathetic fibres.
• The parasympathetic supply to the trachea is by
the recurrent laryngeal nerve – a branch of the
vagus nerve.
Tracheal blood supply. A, Left anterior view. B,
Right anterior view. Note
 indications
• Four basic indication for tracheostomy;
– To bypass upper airway obstruction
– To assist respiration over prolonged intubation
– Respiratory insufficiency
– Major head and neck surgery
 Airway obstructions
• Congenital anomalies
Laryngeal web or stenosis,bilateral choanal atresia, tracheo-
oesophageal fistula.
• Traumatic causes
external-gunshot,blow injuries,strangulation or cut throat
injuries of larynx,fractures of mandile or maxillofacial
internal-ihalation of hot fumes,foreign body.

• Infectious causes
Acute epiglotitis,acute laryngotracheobronchitis,diphtheria
•
ludwing’s»angina,parapharyngeal and retropharyngial abscess
•  Neoplastic
Benign and malignant tumours of tongue,pharynx
larynx,upper trachea and thyroid.

• Neurologic
Tetanus,myasthenia gravis,bilateral laryngeal
paralysis,bulbar poliomyelitis.
 Respiratory insufficiency

• In chronic lung conditions such asemphysema, chronic

bronchitis,bronchiectasis, atelectasis .
• unconscious people,coma - head injuries, secretions
accumulate in the lower respiratory tract, gas diffusion within
the alveoli deteriorates, resulting in respiratory failure.
Once a tracheostomy has been carried out secretions can be
aspirated with minimal upset to the patient.
In addition, the reduction in respiratory dead space (up to 30-
40%) makes it easier for the patient to breathe.
 Pronged intubation
In cases where prolonged, continuous or more
intermittent positive pressure required,
tracheostomy provides the safest means of
assisting ventilation. The tracheostomy tube is
more secure than a nasotracheal or
orotracheal tube & the reduction of
respiratory dead space facilitates the process
of weaning the patient off the ventilator.
 Major surgeries
Tracheostomy is an integral part of many head &
neck procedures.
The tracheostomy is not only to guard against
airway obstruction due to swelling, but also
against aspiration of blood in the event of post
op haemorrhage, and facilitates the
administration of any further anaesthetic if
required in event of major complications.
Types of tracheostomy
subclasses

• High level
Level • mid level
• low level

• Emergency
Timing
• elective

• Temporary
Indication
• permanent
 High Tracheostomy-
It is done above the level of thyroid isthmus( i.e,
II, III, IV tracheal rings).
Tracheostomy at this site can cause perichondritis
of the cricoid cartilage & subglottic stenosis so
its generally avoided.
Only indication is Ca larynx because in such cases,
total larynx anyway would ultimately be
removed & a fresh tracheostome made in a
clear area lower down.
 Mid Tracheostomy-
Is the most preferred one & is done through the
II & III rings & would entail division of the
thyroid isthmus or its retraction upwards or
downwards to expose this part of trachea.
 Low Tracheostomy-
• It is done below the level of isthmus. Trachea is
deep at this level & close to several large vessels,
also there are difficulties with tracheostomy tube
impringes on suprasternal notch.
• Elective low tracheostomy is done in patients
with laryngeal trauma to prevent aggravation of
the laryngeal injury and in laryngeal
papillomatoses to avoid implantation.
 Emergency tracheostomy
• Its employed when airway obstruction is
complete or almost complete and
• There is an urgent need to establish the
airway.
• Intubation or laryngotomy are either not
possible in such cases.
 Elective tracheostomy

• Planned procedure, prepared with all operative

procedures are available, the tube can be putted under
local/general anaesthesia
• Its of to types
• (a) therapeutic, to relieve respiratory obstruction,
remove secretions or give assisted ventilation.
• (b)prophylactic, to guard against anticipated respiratory
obstruction or aspiration of blood/pharyngeal
secretions such as in extensive surgeries of tongue,
floor of mouth, mandibular resection or laryngofissure.
 Temporary Tracheostomy
Tracheostomy is to be used for shorter duration for;
therapeutic, to relieve respiratory obstruction, remove
tracheobronchial secretions or give assisted ventilation.
prophylactic, to guard against anticipated respiratory
obstruction or aspiration of blood or pharyngeal
secretions such as in extensive surgery of tongue, floor of
mouth, mandibular resection or laryngofissure.
Mainly done in major head & neck operations, following
which postoperative swelling might result in upper airways
obstruction and for respiratory support in a ventilated
patient.
 Permanent Tracheostomy
 It is an elective procedure in which trachea is
permanently disconnected from the pharynx &
the proximal end of the trachea is sutured to
the skin.
It is carried out as a part of an operation
involving removal of the larynx, such as a
laryngectomy or laryngopharyngectomy or as a
part of a diversion procedure for aspiration
problems.
 Procedure
• Informed consent;
procedure,complications,care
• Endotracheal intubation especially in infants
children
• Position
supine with a pillow under the shoulders to that
neck is extended.
 Anaesthesia
• not used in unconscious pts/ emergency
procedure
• Conscious pts, 1-2% lignocaine with
epinephrine
• GA with intubation +/-
 Steps of procedure
1. Vertical incision in the midline of the neck,
extending from cricoid cartilage to just above
sternal notch.
2. 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, suture – ligated.
5. Trachea is fixed with a hook and opened with vertical
incision in the region of 3rd and 4th or 3rd and 2nd rings.
6. Tracheostomy tube of appropriate size is inserted
and secured by tapes
7. Skin incision should not be sutured or packed tightly
as may lead to development of subcutaneous
emphysema
8. Gauze dressing is placed between the skin and
flange of the tube around the stoma
 Types of tracheostomy tubes
• Cuffed tubes with disposable and re usable
inner cannula
– Both are used to obtain a closed circuit for
ventilation
• Cuff less tube with disposable and usable
inner cannula
– Used for patients who are ready for decannulation
• Fenestrated cuffed tracheostomy tube
– Used for patients who are on the ventilator but
are not able to tolerate a speaking valve to speak
• Fenestrated cuff less tracheostomy tube
• Used for patients who have difficulty using a speaking
valve
• Metal tracheostomy tube
• Not used as frequently anymore.  Many of the patients
who received a tracheostomy years ago still choose to
continue using the metal tracheostomy tubes.
 Tracheostomy care
• Suctioning
Depending on the amount of secretions, suction may be required every half
an hour or so.
• Humidification by use of humidifier, steam tent, ultrasonic nebuliser or
keeping a boiling kettle in the room.To avoid tracheitis and crusting.
• Cuffed tube
The tube should be deflated for at least 5 minutes every hour during first 24
hrs to prevent necrosis.
• Tube changes
After the tract is formed (3-5 days) the tube should be changed at least
weekly to minimize formation of granulation tissues.
• Skin and stoma care
Dressing should be sterile,daily
 Decannulation(weaning)
Tracheostomy tube should not be kept longer than necessary.
Prolonged use of tube leads to tracheobronchial
infections, tracheal ulceration, granulations,stenosis and
unsightly scars.
• To decannulate a patient,
tracheostomy tube is plugged and the patient closely
observed. If the patient can tolerate it for 24 h, tube can be
safely removed.
In children, the above procedure is done using a smaller tube.
After tube removal, wound is taped and patient again closely
observed.
 complications
• Classified as
A. Immediate
B. Intermediate
C. late
 Immediate
• At the time of op
• 1. primary haemorrhage
• 2. apnoea due to opening of the trachea in a pt who
had prolonged respiratory obstruction
• 3. pneumothorax due to injury to apical pleura.
• 4. injury to recurrent laryngeal nerves.
• 5. aspiration of blood
• 6. injury to oesophagus, may lead to tracheo-
oesophageal fistula
 Intermediate
• During first few hours or days
• 1. bleeding
• 2. displacement of tube
• 3. blocking of tube
• 4. subq emphysema
• 5. tracheitis and tracheobronchitis with crusting in
trachea
• 6. atelectasis and lung abscess
• 7.local wound infection and granulation
 Late
• With prolonged use of tube for weeks and months
• 1. haemorrhage, due to erosion of major vessel
• 2. laryngeal stenosis due to perichondritis of cricoid
cartilage
• 3. tracheal stenosis, due to tracheal ulceration and
infection
• 4.tracheo-oesophagus fistula, due to prolonged use of
cuffed tube/erosion of trachea
• 5. persistent tracheocutaneous fistula.
• 6.problems tracheostomy scar, keloid or unsightly scar
 Cricothyrotomy-mini
tracheostomy/laryngotomy
• This is a procedure for opening the airway through the
cricothyroid membrane.
• Patient's head and neck is extended, lower border of thyroid
cartilage and cricoid ring are identified. Skin in this area is incised
vertically and then cricothyroid membrane cut with a transverse
incision.
The space can be kept open with a small tracheostomy tube or by
inserting the handle of knife and turning it at right angles if tube is
not available.
It is essential to perform an orderly tracheostomy as soon as
possible because perichondritis subglottic oedema and laryngeal
stenosis can follow prolonged laryngotomy.