Tracheostomy by Abhinav Srivastava Associate professor of ENT.ppt

Tracheostomy

1. Dr. Abhinav Srivastava
Associate Professor
Department of ENT

2. Tracheostomy
Surgical procedure
wherein a stoma
(window) is created
connecting anterior wall
of trachea to the exterior
Tracheotomy: Opening
the trachea
Laryngotomy:
(Cricothyroidotomy/
coniotomy) Opening the
larynx at the cricothyroid
membrane

3. History
Rig Veda: 2000BC
Sushruta: 600 AD
First successful tracheostomy was reportedly
done by Brasovala in the 15
th
century
1799: George Washington died of an upper
airway blockage on which a tracheostomy
could have been performed. Though his
physician knew of the procedure, he was not
willing to perform his first on his first
president.

4. Functions of tracheostomy
Relief from upper airway obstruction “By-
pass”
Prolonged assisted ventilation
< airway resistance
< dead space
Tracheo-bronchial toilet,
insufflation
Aspiration
Anesthesia

5. Indications for tracheostomy
Obstructive
All causes of stridor
Oral, pharyngeal, laryngeal,
tracheobronchial
Intraluminal/ extraluminal
Congenital/ inflammatory/ traumatic/
neoplastic/ neurological
Non-obstructive

6. Oral
Cong.
Inflam.
Trauma
Neoplasm
Neuro
Macroglossia, micrognathia,
congenital tumours
Ludwigs angina
#mandible, odema tongue,
hematoma, corrosive poisoning
Ca. tongue
Unconscious

7. Oropharynx/ Hypopharynx
Cong.
Inflam.
Trauma
Neoplasm
Neuro
Misc
Macroglossia, Micrognathia,
congenital tumors, lingual thyroid
Acute tonsillitis, quinsy, OSAS
Hematoma, corrosive poisoning, FB
Ca. base tongue, tonsils, hypopharynx
Cricopharyngeal spasm-aspiration
Pharyngeal pouch

8. Larynx
Cong.
Inflam.
Trauma
Neoplasm
Neuro
Laryngomalacia, stenosis, web,
cyst, cong. Tumors
Acute epiglottitis, ALTBS,
diphtheria, laryngeal odema
FB, LTT, LTS, corrosive poisoning
Ca. larynx, juvenile laryngeal
papillomatosis
Bilateral abductor palsy- post
thyroidectomy, CTS, aspiration-
secretional obstruction

9. Tracheo-bronchial
Cong.
Inflam.
Trauma
Neoplasm
Neuro
Atresia, tracheo-esophagial fistula
ALTBS
FB
Ca. trachea, bronchus
-

10. Neck-Mediastinum (Extraluminal)
Cong.
Inflam.
Trauma
Neoplasm
Neuro
Abnormal vessels, mediastinal
tumors
Mediastinitis, pneumomediastinum,
retro/ parapharyngeal abscess
Hematoma, pneumomediastinum
Thyroid malignancy,
Mediastinal tumors,
lymphoma
-

11. Non-obstructive indications
Assisted ventilation
Assist tracheo-bronchial toilet
Aspiration
Anesthesia
Alaryngeal

12. Assisted ventilation
Higher centre, comatosed: Head injury, CVA,
encephalitis, etc.
Resp. centre: Bulbar paralysis, barbiturate poisoning,
OP poisoning, drug intoxications
Anterior horn cells/ nerves: Polio, polyneuritis, cervical
spine injury
Myo-neural junction: Tetanus
Resp. muscles: Myasthenia gravis
Chest wall: # ribs, pain
Lungs: COPD, status asthmaticus, collapse,
emphysema, pneumothorax, etc.

13. Types of tracheostomy
Timing
Elective
Emergency
Duration
Temporary
Permanent
–Tracheal fenestration
–Post-laryngectomy
Site
High
Mid
Low
Technique
Anterior wall-skin
–Slit/ window/ ‘U’ or
‘H’ flap
End-skin
Age
Adult
Pediatric

15. Tracheostomy tubes
Metalic
Jackson’s
Fuller’s
Plastic (Portex)
Cuffed
Non-cuffed
Single cannula
Double cannula

20. Technique
Position
Place a sand bag under
the shoulders
Extension of neck and
extension of head at
the atlanto-occipetal
joint

21. Technique: anesthesia
LA/ GA
LA: Area of infiltration- ‘Rhomboid’

24. Incision
Emergency- Vertical
in midline from
cricoid to suprasternal
notch
Elective: Horizontal-
midpoint between
cricoid and
suprasternal notch
(2 fingers)

25. Deeper layers
Dissected vertically in the midline
Layers encountered
Superficial fascia- fatty and membranous
layers (anterior communicating vein)
Investing layer of deep cervical fascia
Strap muscles- retractor
Pre-tracheal layer covering isthmus of
thyroid

26. Isthmus of thyroid
May be dealt in 3 ways
1.Retract upwards using blunt single hook
(Isthmus hook)
2.Divide between clamps and later suture
the stumps
3.Expose trachea either below or above
isthmus
Inferior thyroid veins

27. Technique- continued
Pretracheal layer covering trachea
Expose trachea
Palpate for cricoid cartilage, stabilize- ‘cricoid hook’
Inject 4% lignocaine- confirm airway and suppress
cough
Slit (Vertical/ horizontal) or create window between 3-5
th

tracheal rings
Insert tube- Preferably cuffed- inflate
Straps after flexing neck/ suture tube to skin
Wound closure- NOT TIGHT
Assist ventilation with O2

35. Post-operative care
‘Aseptic precautions’ ‘Barrier nursing’
Tube position and patency- Ventilator tubes
‘pull’/ restless patients
Cuff management
Wound dressed to prevent maceration from secretions
and skin erosion from tube straps
Tracheo-bronchial toilet- Suction with ‘Y’ connector
Change of tubes- after 72 hrs- track formation
–In emergency situations (<72hrs.)- extend neck, keep tube
ready, use tracheal dilator and quickly change the tube
Antibiotics, mucolytics, analgesics, supportive

36. Complications- Immediate
Apnoea, aspiration
Bleeding
Collapse of the lungs
Damage to adjacent structures- larynx,
esophagus, thyroid, vessels, recurrent
laryngeal nerves, etc.
Embolism- ‘air’

37. Complications- Intermediate
Tube obstruction
Tube displacement
Tracheal erosion
Surgical emphysema
Wound infection
Tracheitis, tracheobronchitis, lung
infections
Granulation tissue, bleeding
Dysphagia- Subglottic pressure, pain, cuff

39. Complications- Late
Difficult decannulation
Tracheomalacia
Tracheo-cutaneous fistula
Tracheo-esophageal
fistula (cuff+nasogastric
tube)
Tracheo-arterial/venous
fistula
Laryngotracheal stenosis
Scar
FB

40. Decannulation
Rule-out proximal obstruction
Corking the Fuller’s tube/ small
size Jackson’s tube/ fenestrated
plastic tube
Observe for 48 hours
If able to tolerate corking-
remove the tube
Strap plaster/ suture the wound