TRACHEOSTOMY

TRACHEOSTOMY
MAKING AN OPENING IN THE ANTERIOR WALL OF TRACHEA &
CONVERTING IT IN TO A STOMA ON THE SKIN THE SURFACE
Functions of Tracheostomy
1. Alternative pathway for breathing
2. Improves alveolar ventilation In cases of respiratory insufficiency :
(a) Decreasing the dead space by 30-50% (normal dead space is 150 ml).
(b) Reducing the resistance to airflow.
3. Protects the airways By using cuffed tube, tracheobronchial tree is protected against aspiration of:
(a) Pharyngeal secretions, as in case of bulbar paralysis or coma.
(b) Blood, as in haemorrhage from pharynx, larynx or maxillofacial injuries. With tracheostomy, pharynx and larynx can also be
packed to control bleeding.
4. Permits removal of tracheobronchial secretions
When patient is unable to cough as in coma, head injuries, respiratory paralysis; or
when cough is painful, as in chest injuries or upper abdominal operations, the tracheobronchial airway can be kept clean of secretions by
repeated suction through the tracheostomy, thus avoiding need for repeated bronchoscopy or intubation which is not only traumatic but
requires expertise.
5. Intermittent positive pressure respiration (IPPR) If IPPR is required beyond 72 hours, tracheostomy is superior to intubation.
6. To administer anaesthesia } laryngopharyngeal growths or trismus.
Indications of Tracheostomy

There are three main indications
A. Respiratory obstruction.
B. Retained secretions.
C. Respiratory insufficiency.
A. Respiratory obstruction

1. Infections
Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria Ludwig's angina, peritonsillar,
retropharyngeal or parapharyngeal abscess, tongue abscess
2. Trauma
External injury of larynx and trachea ,Trauma due to endoscopies, especially in infants and
children,Fractures of mandible or maxillofacial injuries
3. Neoplasms
Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and thyroid
4. Foreign body larynx
5. Oedema larynx
due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), radiation
6. Bilateral abductor paralysis
7. Congenital anomalies
Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia
B. Retained secretions

1. Inability to cough
Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic
overdose
Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre
syndrome, myasthenia gravis
Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning
2. Painful cough
Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
Bulbar polio, polyneuritis, bilateral laryngeal paralysis
C. Respiratory insufficiency

Chronic lung conditions, viz. emphysema, chronic bronchitis,
bronchiectasis, atelectasis
Types of Tracheostomy

Emergency tracheostomy
Elective or tranquil tracheostomy
Permanent tracheostomy
Percutaneous dilatational tracheostomy
Mini tracheostomy (cricothyroidotomy)
1. Emergency tracheostomy

It is 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 or feasible in such
cases.

2. Elective tracheostomy
(syn. tranquil, orderly or routine
tracheostomy)

This is a planned, unhurried procedure. Almost all operative surgical
facilities are available, endotracheal tube can be put and local or
general anaesthesia can be given.
It is of two types:
(a) Therapeutic, to relieve respiratory obstruction, remove
tracheobronchial secretions or give assisted ventilation.
(b) 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.
3. Permanent tracheostomy

bilateral abductor paralysis & laryngeal stenosis.
BASED ON LEVEL
T
R
A
C
H
E
O
S
T
O
M
Y

HIGH
MID
LOW
above the level of thyroid isthmus
perichondritis of the cricoid cartilage and subglottic
stenosis and is always avoided.
Only indication } carcinoma of larynx because in such
cases, total larynx anyway would ultimately be removed
and a fresh tracheostome made in a clean area lower
down
(
T
H
Y
R
O
I
D

i
s
t
h
m
u
s

l
i
e
s

a
g
a
i
n
s
t

I
I
,

I
I
I

a
n
d

I
V

t
r
a
c
h
e
a
l

r
i
n
g
s
)
.

preferred one
Through the II or III rings and would entail division of the thyroid
isthmus or its retraction upwards or downwards to expose this
part of trachea.
below the level of isthmus.
Trachea is deep at this level and close to several large vessels;
also there are difficulties with
tracheostomy tube which impinges on suprasternal notch.
Technique
Whenever possible, endotracheal intubation should be done before
tracheostomy. This is specially important in infants and children.

Position
supine with a pillow under the shoulders so that neck is extended.

Anaesthesia
No anaesthesia }unconscious patients/ emergency procedure.
conscious patients, 1-2% lignocaine with epinephrine
GA with intubation+/-
1. A vertical incision
in the midline of neck, extending from
cricoid cartilage to just above the sternal
notch.
This is the most favoured incision and can be
used in emergency and elective procedures.
It gives rapid access with minimum of
bleeding and tissue dissection.

A transverse incision, 5 cm long, made 2 fingers' breadth above
the sternal notch can be used in elective procedures. It has the
advantage of a cosmetically better scar .
2. After incision, 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, and suture-ligated.

6. Trachea is fixed with a hook and opened with a vertical incision in the
region of 3rd and 4th or 3rd and 2nd rings. This is then converted
into a circular opening. The first tracheal ring is never divided as
perichondritis of cricoid cartilage with stenosis can result (Fig. 63.2).
7. Tracheostomy tube of appropriate size is inserted and secured by tapes
8. Skin incision should not be sutured or packed tightly as it may lead to
development of subcutaneous emphysema.
9. Gauze dressing is placed between the skin and flange of the tube
around the stoma.
Compli cati ons
A. Immediate
(at the time of operation):
1. Haemorrhage.
2. Apnoea. This follows opening of trachea in a patient who had prolonged respiratory
obstruction. This is due to sudden washing out of CO2 which was acting as a respiratory
stimulus. Treatment is to administer 5% CO in oxygen or assisted ventilation.
3. Pneumothorax due to injury to apical pleura.
4. Injury to recurrent laryngeal nerves.
5. Aspiration of blood.
6. Injury to oesophagus. This can occur with tip of knife while incising the trachea and
may result in tracheo-oesophageal fistula.
B. Intermediate
(during first few hours or days):
1. Bleeding, reactionary or secondary.
2. Displacement of tube.
3. Blocking of tube.
4. Subcutaneous emphysema.
5. Tracheitis and tracheobronchitis with crusting in trachea.
6. Atelectasis and lung abscess.
7. Local wound infection and granulations.
C. 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-oesophageal fistula, due to prolonged use of cuffed tube or erosion
of trachea by the tip of tracheostomy tube.
5. Problems of decannulation. Seen commonly in infants and children.
6. Persistent tracheocutaneous fistula.
7. Problems of tracheostomy scar. Keloid or unsightly scar.
8. Corrosion of tracheostomy tube and aspiration of its fragments into the
tracheobronchial tree.
1. J aw thrust

Lifting the jaw forward and extending the
neck improves the airway by displacing the
soft tissues. Neck extension should be
avoided in spinal
injuries.
2. Oropharyngeal
airway

It displaces the tongue anteriorly and
relieves soft tissue obstruction. Ventilation
can be carried out by face mask placed
snugly over the face and
covering both nose and mouth. Ambu bag
can be used for inflation of air or oxygen.

3. Nasopharyngeal
airway (trumpet)

It is inserted transnasally into the posterior
hypopharynx and relieves soft tissue
obstruction caused by the tongue and
pharynx. It is better tolerated
than oropharyngeal airway in awake
patients.
4. Laryngeal mask
airway
It is a device with a tube and a triangular
distal end which fits over the laryngeal inlet .
Oxygen can be delivered directly into the
trachea.
Though most commonly used for non-
emergent airway control, it can be used as an
alternative if standard mask ventilation is
inadequate and
intubation unsuccessful
6. Endotracheal
intubation

This is the most rapid method. Larynx is
visualised with a laryngoscope and
endotracheal tube or a bronchoscope
inserted. No anaesthesia is
required. This helps to avoid a hurried
tracheostomy in which complication rate is
higher. After intubation, an orderly
tracheostomy can be
performed.
7. Cricothyrotomy or
laryngotomy or mini
tracheostomy

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. This
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.
8. Emergency
tracheostomy

Technique of emergency tracheostomy is as follows:
Patient's neck is extended, trachea identified and fixed
between surgeon's left thumb and
index finger. A vertical incision is made from lower border of
thyroid to suprasternal notch cutting through skin and
subcutaneous tissues. Lower
border of cricoid cartilage is identified and a transverse
incision made in pretracheal fascia. The thyroid isthmus
dissected down to expose upper
three tracheal rings. Vertical tracheal incision is made in 2nd
and 3rd rings, opened with a haemostat and the tube
inserted. Bleeding can be
controlled by packing with gauze.
Emergency tracheostomy on a struggling patient with
inadequate lighting, suction and instruments is fraught with
many complications. If possible,
an endotracheal tube should be put for a more orderly
procedure to be carried out.
page 340
page 341