Tracheostomy

Tracheostomy

1. Tracheostomy

2. •Definition:
−Surgical procedure to create an opening through the neck
into the trachea
−Synonymous with tracheotomy
•History of Tracheostomy
–Period of legend (2000 BC –1546 AD )
–Period of fear (1546 –1833): operation performed by few braves, often at the risk of their
reputation
–Period of dramatization (1833 –1932): surgery performed in acutely obstructed airways
–Period of enthusiasm (1932 –1965) : Do tracheostomy if you think so
–Period of rationalization (1965 …) : Merits of tracheostomy versus intubtation

3. Indications
1.Upperairwayobstruction
−Congenital:laryngealweb,cyst,choanalatresia
−Infection/inflammation:epiglottitis,croup,deepneck
spaceabscess,edemaduetoirritation,irradiation,allergy
−Traumatoairway:external,endoscopic
−Neoplasm:laryngo-tracheal,pharyngeal
−Foreignbodyinairway
−Paralysisoflarynx:B/Labductorpalsy

4. 2. Respiratory insufficiency
–Chronic bronchitis, bronchiectasis, atelectasis,
retained airway secretions
3. Retained secretions in the airway
–Inability to cough out the sputum : coma,
respiratory muscle palsy or spasm, laryngectomy
–Painful cough :chest injuries, pneumonia
–Excessive secretions :pulmonary edema

5. 4. Anesthesia administration in:
–Laryngo-pharyngeal growths
–Maxillofacial trauma
–Trismus
–Severe Ludwig’s angina
–Positive pressure ventilation for > 72 hrs

6. Types of Tracheostomy
•Emergency /Elective
•Temporary / Permanent
•Therapeutic /Prophylactic
–High : (1
st
ring -above thyroid isthmus)
–Mid : (2
nd
–4
th
ring -behind thyroid isthmus)
–Low : (below 4
th
ring -below thyroid isthmus )

7. •Mid tracheostomy is commonly preferred because
–High tracheostomy leads to subglottic stenosis
–Low tracheostomy is avoided as
•Trachea is deeper
•Displacement of tracheostomy tube is common
•Proximity to great vessels
•Surgical emphysema is common
•Tracheostomy stoma is close to tracheal bifurcation

8. Commonly used Tracheostomy
tubes

9. Jackson’s metallic tube
•Made of German silver
•Has obturator , inner tube and outer tube
•Inner tube is longer than outer tube for its removal and
cleaning
•Outer tube maintains patency
•Pilot is inserted into outer tube for smooth & non-traumatic
insertion of tube
•Outer tube has a lock mechanism for the inner tube and used
for protection of the inner tube during coughing

10. Jackson’s metallic tube

11. Fuller’s bivalved metallic tube
•Outertubeisbivalved.The2blades
whenpressedtogether,helpin
smoothentryoftube
•Innertubeislongerandhasavent
forphonation
•Patientphonatesbyclosingmain
tubeopening
•Ventalsohelpsindecannulationof
tube

12. Portex cuffed tube
•Made of siliconized Poly Vinyl Chloride
•Thermolabile and prevents crusting
•Low-pressure high-volume cuff maintains an air-tight
seal required for
–Prevention of aspiration of secretions
–Positive pressure ventilation

13. Portex cuffed tube

14. Cuffed double lumen tube

15. Cuffed fenestrated tube

16. Portex uncuffed tube
For tracheostomy patient receiving radiation and in children

17. Uncuffed double lumen fenestrated tube

18. Hands free speaking valve

19. Tube with adjustable flange
Used in obese neck, edematous neck

20. Salpekar double cuff tube
Prevents ischemic necrosis of tracheal cartilage

21. Metallic Tubes Plastic Tubes
Easily cleaned without suctionCleaning requires suction
Cuff is absent Cuff is present
Cannot be connected to
ventilator
Can be connected
Rigid , less comfortable to
patient
Soft, more comfortable
Concomitant radiotherapy is to
be avoided
Can be given

22. Age of pt Tracheostomy tube size
Portex (I.D. in
mm)
Metallic (Fg)
1 –3 yrs 4.0 –4.5 16
4 –6 yrs 5.0 18
7 –9 yrs 5.5 20, 22
10 –12 yrs 6.0 24, 26
13 –18 yrs 7.0 –7.5 28, 30
Adult 8.0 –9.0 32, 34, 36

23. Steps of Tracheostomy

24. 1. Positioning
•Supine position with
extension of neck
•Antiseptic dressingand
draping
•Local or General anesthesia
with endotracheal intubation

25. 2. Infiltration
•Cricoidpalpatedand5cm
horizontalincision line
marked2cmbelowit
•2%lignocainewith1:200000
adrenalineinjectedinincision
line

26. 3. Incision
•A 5 cm horizontal incision made with
# 15 blade and deepened below
subcutaneous tissue
•A 5 cm midline vertical incision
made below cricoid in emergency to
avoid injury to blood vessels

27. 4. Exposure of strap muscles
•Investinglayerofdeep
cervicalfasciaopened
verticallywitharteryforceps
•Palpationfortrachealrings
doneregularlyduringthe
dissection

28. 5. Exposure of thyroid isthmus
Strapmusclesretracted
laterallywithLangenbeck
retractorstoexposethe
trachea&thyroidisthmus

29. 6. Isthmus separation from trachea
Thyroid isthmus detached from tracheal surface and
retracted with blunt tracheal hook

30. 7. Division of thyroid isthmus
•Ifrequired,thyroidisthmus
isdividedbetweenclamps
andtransfixionsutures
appliedattheends

31. 8. Confirmation of trachea
•5mlsyringecontaining4%Lignocainetaken,its
needleinsertedintotracheaandaspirated
–Airbubblesconfirmpresenceofneedleintrachea
•2mlofsolutioninjectedintotracheaandneedle
removedquicklytoavoidbreakingofneedleduring
violentcoughmovements

32. 9. Creation of tracheal window
•Cricoid hook inserted below the cricoid to steady
trachea
•Tracheal window created by excising anterior 1/3rd
of 2
nd
& 3
rd
tracheal ring
with No. 11 blade and
held with Allis tissue forceps

33. Bjork flap
Alternatelyaninferiorlybasedtrachealflapismade
andsuturedtolowerskinedge

34. 10. Insertion of tracheostomy tube
•Endotrachealtubewithdrawninto
larynx
•Lubricatedtracheostomytube
insertedintotrachea
•Confirmpresenceoftubein
tracheawithhelpofambubag
andauscultation

35. 11. Suturing of flanges
•Cuffinflatedwith5mlofair
and anestheticcircuit
connectedtothetube
•Neckextensionreleasedand
flangesoftubesuturedto
skintoavoidtubemovement

36. Tying the tapes
•Tapesoftracheostomy
tubetiedaroundtheneck
keepingaspacefor1
fingerandneckkept
flexed
•Skinincisionclosed
looselytoavoidsurgical
emphysema.

37. Insertion of medicated gauze
Betadine soaked gauze or Sofratulle put around the
tracheostomy opening

38. Complications of Tracheostomy
•Immediate Complications (occur during operation)
–Primary Haemorrhage
–Air embolism
–Cardiac arrest
–Aspiration of blood
–CO2withdrawal apnoea
–Injury to apical pleura (pneumothorax), recurrent
laryngeal nerve, esophagus

39. IntermediateComplications
•Occurs within first few days
–Reactionary & secondary hemorrhage
–Blocking or displacement of tube
–Subcutaneous emphysema, pneumothorax
–Tracheitis and crusting
–Atelectasis & lung abscess
–Wound infection

40. LateComplications
Occur after weeks / months
–Subglottic stenosis, tracheal stenosis
–Tracheo-arterial or Tracheo-venous fistula
–Tracheo-esophageal fistula
–Persistent tracheo-cutaneous fistula
–Decannulation difficulty
–Tracheostomy wound scar / keloid
–Metallic tube corrosion and fragment aspiration

41. Surgical emphysema

42. Tracheostomy suction
•Ptgiven100%oxygenandcuffdeflated
•Suctioncatheterwiththediameter<1/3rdofinternal
diameteroftracheostomytubetobeused
•Catheterintroducedbeyondtheinnertubeandnotmoreinside
toavoidtracheal/bronchialirritation(Multiple-eyedcatheters
preferredastheyproducelesstraumathanwhistletipcatheters)
•Lubricatedcathetertipinsertedwithsuctionoff
•Attheendofinspiration,suctionputonandcatheter
withdrawninrotatingmotion

43. Tracheostomy suction contd…
•Eachsuctionprocedureshouldlastfor10-15seconds.Instill
0.5mlNaHCO3toliquefycrusts
•Chest auscultated for confirmation of adequate suctioning
•Cuff re-inflated to a pressure of 25 mmHg and patient
oxygenated again
•Tracheostomy wound dressing done BID, a Moist gauze piece
placed over tracheostomy stoma
•Steam inhalation TID
•Chest physiotherapy, expectorants and mucolytics continued

45. Changing of tracheostomy tube
•Inner tube is removed and cleaned when blocked
•Outer tube not 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 and dilatation of
trachea

46. Decannulation
•Adult: plug or seal tube opening and if tolerated for 24 hrs,
remove tube
•Children : Sequentially reduce the size of tube
•After tube removal close wound
−Healing occurs within 1 week
−Secondary closure after freshening the wound margin is
required rarely

47. Difficulty in Decannulation
Organic causes:
•Persistence of cause
requiring tracheostomy
•Obstructing tracheal
granulations
•Tracheal edema
•Subglottic stenosis
•Collapse of tracheal
wall (tracheomalacia)
Non-organic causes:
•Emotionaldependence in
children
•Inability to tolerate upper airway
resistance
•In-coordination of laryngeal
opening reflex
•Long-standing tube leads to
impaired laryngeal development

48. Tracheostomy Intubation
Invasive Non-invasive
Complications are more Less
Can be kept for > 7 daysShould not be kept
Pt can speak Cannot speak
Tracheo-bronchial toilet is easyDifficult
Decreases dead space by 30-50% Does not

49. Disadvantages of Tracheostomy
•Anosmia : no nasal air entry
•Aphonia : avoided by phonatory vent
•Aspiration: avoided by cuffed tube
•Inability to lift heavy weight
•Inability to perform strenuous exercise
•Inability to swim

50. Percutaneous Tracheostomy
•Trachea punctured with needle and cannula
•Needle removed and a guide wire passed into trachea
via cannula
•Cannula removed and graded dilators passed over
the guide wire till the opening can admit a
tracheostomy tube

51. Percutaneous Tracheostomy

52. Cricothyroidotomy
1.Midline vertical skin incision made to identify cricothyroid
notch
2. Cricothyroid membrane incised horizontally, with # 11 blade,
close to cricoid
3. Knife handle inserted and rotated by 90
0
, to widen the
horizontal opening and tracheostomy tube is inserted
4. Elective tracheostomy done as soon as possible to avoid
subglottic stenosis

55. Cricothyroidotomy

56. PG Question : Describe the anatomical considerations
between pediatric and adult tracheostomy. Why is
decannulation difficult in children?