Tracheostomy and Cricothyroidotomy

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1. Tracheostomy and Cricothyroidotomy Prepared by- Aalok thakur Intern,7 th batch jmcth

2. tracheostomy Making an opening in anterior wall of trachea and converting it into stoma on the skin surface

3. Functions of Tracheostomy Alternative pathway for breathing Improves alveolar ventilation Protects the airway Permits removal of tracheobronchial secretions Intermittent positive pressure ventilation To administrate anaesthesia

4. Indication of tracheostomy Respiratory obstruction Retained secretion Respiratory insufficiency

5. Types of tracheostomy Emergency tracheostomy Elective tracheostomy Percutaneous dilatational tracheostomy Mini tracheostomy

6. technique Position Supine position with pillow under shoulder Anaesthesia No anaesthesia in unconciouss or emergency patient 1-2%lignocaine with epinephrine GA

7. Steps of operation A vertical incision is made in the midline of neck,extending from cricoid cartilage to just above the sternal notch After incision tissues are dissected in midline. dilated veins are either ligated or displaced Strap muscles are seperated in midline and retracted laterally Thyroid isthmus is displaced upward or divided between the clamps and suture ligated A few drops of 4% lignocaine are injected into the trachea to suppress the cough when trachea is incised Trachea is fixed with a hook and opened with a vertical incision in the region of 3 rd and 4 th or 3 rd and 2 nd ring. this is then converted into circular opening

8. Contd.. Tracheostomy tube is inserted and secured by tapes Skin incision should not sutured or packed Gauze dressing is placed between skin and flange of the tube around the stoma

9. Post operative care Constant supervision Suction Care of tracheostomy tube

10. Complication Immidiate Haemorrhage Apnoea Pneumothorax due to injury to apical pleura Injury to recurrent laryngeal nerve Aspiration of blood Injury to esophagus Intermitant Bleeding,reactionary or secondary Displacement of tube Blocking of stube Subcutaneous emphysema Local wound infection and granulation

11. Contd.. Late Haemorrhage due to erosion of major vessel Laryngeal stenosis Tracheal stenosis Tracheo-oesophageal fistula Problem of tracheostomy scar

12. Cricothyroidotomy emergency procedure performed on patients with severe respiratory distress in whom attempts at orotracheal or nasotracheal intubation either have failed or were deemed to have an unacceptable level of risk

13. indication Inability to intubate Inability to ventilate Severe facial or nasal injuries (that do not allow oral or nasal tracheal intubation) Massive midfacial trauma Possible cervical spine trauma preventing adequate ventilation Anaphylaxis

14. procedure Using IV cannula 14 gauge iv cannula introduced into the lumen of trachea with patent neck in extended position Cannula is then directed and advanced aaudally and the needle removed Using a scalpel Thyroid is steadied with thumb and middle finger of the left hand and cricothyroid space identified with index finger of right hand Scalpel is used to cut the skin, subcutaneous tissue, and cricothyroid membrane horizontally to enter the subglottic area and then turned vertically to admit a thin endotracheal tube

15. Contd.. Using a cricothyrotome or mini-tracheostomy set mini-tracheostomy set is used

16. contrindication Inability to identify landmarks (cricothyroid membrane) Underlying anatomical abnormality (tumor) Tracheal transection Acute laryngeal disease due to infection or trauma Small children under 10 years old (a 12–14 gauge catheter over the needle may be safer)

17. complication esophageal perforation occurs when the blade penetrates too deeply subcutaneous emphysema may occur if the horizontal incision is too wide, allowing air to become trapped in the subcutaneous tissue hemorrhage may occur if a vessel is ruptured

18. Postoperative care chest x-ray film to confirm placement of the tracheostomy tube respiratory therapy so the patient can be mechanically ventilated Tracheostomy tube placed during an emergency cricothyroidotomy can be left in place for up to 72 hours.