Tracheostomy

A tracheotomy is a procedure consisting of a surgical or percutaneous incision made in the anterior aspect of the neck, with the intention of opening a direct airway into the cervical trachea into which a tube is inserted to assist the patient with breathing. The procedure may be carried out to treat either acute respiratory impairment or chronic breathing difficulty. Common acute indications for the tracheostomy include blockages caused by angioedema, inflammation, foreign objects, severe facial trauma or burns to the airway, cancers and congenital tumours, insufficiency of the throat muscles and patients in allergic or anaphylactic emergencies. A tracheostomy is also performed after failed intubation or to remove fluid accumulated in the upper airway and throat. Respiratory failure is a frequent indication for the tracheostomy, patients that are unable to breathe normally and unassisted require assisted breathing apparatus to supply the lungs with sufficient oxygen. This can occur in unconscious patients or those in a coma due to trauma or drug interactions, patients suffering from brain damage, fully or partially paralysed patients and patients suffering from nervous system syndromes. A tracheostomy maybe be performed either surgically or percutaneously, a percutaneous tracheostomy can be used in emergency medicine, the trachea cannot be directly visualised in this procedure. Local anaesthesia may be administered but time constraints may prevent this. The patients neck is extended and an incision is made beginning at the cricoids cartilage and continuing for two centimetres in the midline. Dilators can be used to dilate the skin and the layers beneath to accommodate the tracheostomy tube. Surgical tracheostomies are conducted in an operating theatre by surgeons, the patient may be under general or local anaesthesia. The patients neck is extended by placing their neck over a shoulder roll. An vertical incision is made on the inferior border of the cricoid cartilage and extended up to 4 centimetres. The larynx is stabilised and a bronchoscope introduced endotrachealy to select a good site for the introducer needle. The introducer needle is inserted into the tracheal lumen, and then detached, leaving the

cannula in place. A guide wire, along with stylet is placed and the tissue is dilated. A tracheostomy tube is then loaded onto the dilator and inserted into the tracheal lumen, it is secured with sutures and tape. There are many complications associated with tracheostomies, early complications include excessive bleeding, pneumothorax, pneumomediastinum, subcutaneous emphysema, damage to the oesophagus, recurrent laryngeal nerve trauma, blockages of the tracheostomy tube by blood clots or mucus. Subsequent complications include damage to the trachea caused by pressure or chafing of the tube and scar tissue formation, infection and inflammation of the area around the tube, and accidental removal of the tube. Further risks include development of granulation tissue within the trachea, development of tracheo-esophageal fistulas and poor healing after tube removal.