TRACHEOSTOMY

DR.AYESHA FAYYAZ
Tracheotomy Vs Tracheostomy

Tracheotomy is Tracheostomy is
surgical opening of creation of a stoma
the trachea. at the skin surface
which leads into
the trachea.
 ANATOMY
 The trachea is a pipe that has an inner
diameter of about 0.6 to 0.8 in and a
length of about 4in in adults.
 The trachea begins at C6 and ends at
carina opposite the sternal angle at T5.
 The trachea is surrounded by rings
of hyaline cartilage; these rings are
incomplete and C-shaped. The cricoid
cartilage is attached to the first tracheal
ring at top of the trachea and acts as the
bottom of the larynx.
 There are 15-20 rings in total.
 TYPES OF TRACHEOSTOMY
 DEPENDING UPON ETIOLOGY
1. Temporary
2. Permanent
 DEPENDING UPON TIMING
1. Emergency
2. Elective
 DEPENDING UPON SITE
1. High
2. Mid
3. Low
 Permanent Tracheostomy
 The trachea is permanently disconnected from
the pharynx and the proximal end of the trachea
is sutured to the skin.
 Permanent tracheostomy is an elective
procedure carried out as part of another
operation involving removal of the larynx, such
as a laryngectomy or laryngopharyngectomy or
as part of a diversion procedure for aspiration
problems.
 Ina permanent tracheostomy the only access to
the lower airway is via the tracheostome.
 Temporary Tracheostomy
 In temporary tracheostomy, tracheostomy tube
is inserted to bypass a trachea that is blocked
and it can be reversed once the blockage is
gone.
A temporary tracheostomy can be used
permanently; however, it differs from a
permanent tracheostomy in that there is still a
communication between the pharynx and the
lower airway via the larynx.
 High Tracheostomy
 It is done above the level of thyroid isthmus that
lies at 2nd, 3rd and 4th tracheal rings.
 Itcan cause perichondirits of cricoid cartilage
and subglottic stenosis.
 Itis done only in case of malignancy to allow
resection of the old tracheotomy site at the time
of laryngectomy and a fresh tracheostome is
made at a clean site.
 Mid Tracheostomy

 It is done at level of isthmus through

2nd or 3rd tracheal ring either by
dividing it or retracting it above or
downwards.
 It is a preferrd technique.
 Low Tracheostomy

 Itis done below the level of isthmus.

Trachea is deep at this level and also close
to deep vessels.
 Surgicalemphysema is common with this
technique.
 Indications
Upper airway obstruction
Prolonged Ventilation
Pulmonary toilet
As a part of another Procedure
Upper Airway Obstruction
 Tumors
 Infections
 Trauma
 B/L vocal cord paralysis
 Foreign body Airway
 Subglottic or Tracheal Stenosis
 Owing to improvements in intubating laryngoscopes,
nasopharyngeal airways and fiberoptic laryngoscopes,
tracheostomy no more is a first line of management
for airway obstruction.
Prolonged Ventilation
 Patients requiring Intubation for more than
10 days.
 It reduces the dead space for ventilation
 It decreses the incidence of post intubation
laryngeal or tracheal stenosis.
Pulmonary Toilet

 Removal Of Secretions
Secretions can be aspirated with minimal upset
to the patients with CCF, Infections and pulmonary
Edema.
 Prevention of Aspiration
Bulbar Palsy
Part Of Another Procedure
A temporary tracheostomy is an integral part of
many head and neck procedures where
postoperative swelling can be predicted, and
particularly when there are co-morbidities.
 Tracheostomy prevents against:
1. Airway obstruction due to swelling.
2. Aspiration due to postoperative haemorrhage.
3. Reintubation for further anesthesia administration
for complication management.
 Pre Operative Workup
 History
 Examination
 CBC
 Clotting Profile
 Informed Consent
 Techniques

 Cricothyroidotomy
 Percutaneous Tracheostomy
 Open Tracheostomy
 Minitracheostomy
 Cricothyroidotomy

 It is an emergency procedure that is done when

endotracheal intubation cannot be done.
 It has following LIMITATIONS:
1. Cannot be done in children less than 11yrs.
2. Cannot be kept for more than 3-5 days.
3. Causes subglottic stenosis and Edema.
Steps Of Cricothyroidotomy
 Patient is placed in
supine position with
extended neck.
 Local anesthesia is
given.
 Thyroid Cartilage is
gripped between
thumb and middle
finger.
 Finger is moved down
to palpate cricoid
cartilage.
 Space between thyroid
and Cricoid cartilage
is cricothyroid
Membrane.
 1cmvertical incision is given in skin and
subcutaneous fascia.
 Curved Artery Forcep is used for blunt
dissection through Planes.
 Horizontal
Incision is given on the
membrane.
 Trossueau
dilator is used to dilate the
membrane vertically.
 Tracheal tube is inserted.
 Cuff is inflated with 10 cc syringe.
 Umbo is attached for ventilation
 Tube is secured with sutures and ties.
Steps of Open Tracheostomy
Securing of Airway

 Airway is secured with

ETT if procedure is
done electively under
GA.
Positioning Of Patient
 The patient should be
positioned supine on the
operating table, with a
sandbag under shoulders.
 Patient’s shoulders should
lie square on the operating
table so that the position
of the midline structures
of the neck is maintained
throughout the procedure.
Painting And Draping

 The neck, face, upper

chest, and shoulders
are prepared with a
povidone-iodine or
other suitable
solution, and a drape
is placed.
Anesthesia
 Not necessary if the patient is unconciuos or in
emergency.
 Inj 1-2% lignocaine with epineprine is infiltrated in case
of conscious patients.
 It is useful in elective cases to infiltrate the incision
line with adrenaline to aid haemostasis.
Landmark Identification

 The surface anatomy

should be marked on
the skin surface to
highlight the position
of the lower border of
the cricoid cartilage
and the suprasternal
notch.
Incision

 A transverse incision is made

approximately 1 cm above the
suprasternal notch or 2 cm below
the cricoid cartilage or midway
between the two landmarks.
 Sharp dissection is carried through the
subcutaneous tissue.
 The skin and subcutaneous tissues are divided
horizontally to the depth of the strap muscles,
and haemostasis is achieved with vicryl ties and
diathermy.
 The strap muscles are separated vertically by
blunt dissection in the midline.
 Thyroid isthmus is identified and divided between
clamps and the ends oversewn.
 Before opening the trachea the choice of tracheostomy
tube should be made.
 The tube, its cuff and all connections to the
anaesthetic equipment should be checked.
 Once the trachea is identified, a tracheal hook is
placed in the area of the second tracheal ring and held
by an assistant to immobilize the trachea in the wound.
 In infants and children, a vertical incision is made
between the second and the third or the third and the
fourth tracheal rings without removing any cartilage.
Traction sutures are then placed just lateral to the
incision.
 In adults, the anterior portion of the
third or fourth tracheal ring removal
may facilitate insertion of the
tracheostomy tube.
 Prior to the trachea being opened, the
anaesthetist should remove any tapes
used to secure the endotracheal tube
and prepare to withdraw the tube
slowly under direct vision by the
surgeon.
 ETT is pulled slowly
and Tracheal tube
is inserted and
secured.
 Minitracheostomy

 It is an emergency procedure.
 Rapid entry to the airway through the cricothyroid
membrane is made after landmark identification with a
vertical incision.
 Once the cricothyroid has been breached the airway can
be maintained either with a minitracheostomy tube or a
large-bore cannula.
Canula, Syringe And ETT Mnitraceostomy Kit
Adaptor Assembely
Percutaneous Tracheostomy
 The patient is positioned as for a formal tracheostomy,
with the neck extended and the shoulders square.
 A needle and cannula are used to puncture the trachea
below the first tracheal ring.
 The correct positioning of the needle and cannula is
checked by the aspiration of air into a syringe half filled
with saline.
 The needle is then withdrawn and a guide wire is inserted
into the trachea through the cannula.
 The cannula is withdrawn and a single dilator or multiple
graded dilators are used to create a passage wide enough
to receive a tracheostomy tube.
 The tracheostomy tube is passed over the largest of the
dilators and is positioned in the trachea.
 The tracheostomy tube is then secured in position with
tapes or sutures.
 Post Operative Management

 X-ray Soft Tissue Neck

 Analgesics
 Antibiotics
 I/V fluid till the patient is oral free
 Tracheostmy Care

 Regular succtioning
 Wound and Skin care
 Warming and Humidification of Air
1. Hot water bath humidifiers
2. Nebulizers
 Inner Tube Care
Cuff Care
 Inflation:
1. Cufff is inflated immediately post operatively to prevent
aspiration.
2. It seals the airway when patient is on mechanical ventilation.
3. Prevents aspiration of leakage in trachea-oesophageal fistula.
4. Prevents aspiration in laryngeal incompetence.
 Deflation:
1. After an uncomplicated procedure, the cuff rarely needs to be
inflated for more than the first 12 hours.
2. Even if it is needed, it should be deflated for 5 minutes every hour.
Complications
Immediate
 Anesthesia complications
 Haemorrhage
1. thyroid veins
2. jugular veins
3. arteries
 Air embolism;
 Apnoea
 Cardiac arrest
 Local damage
1. thyroid cartilage
2. cricoid cartilage
3. recurrent laryngeal nerve
Intermediate
 displacement of the tube
 surgical emphysema
 pneumothorax/pneumomediastinum
 infection: perichondritis
 tube obstruction by secretions or crusts
 tracheal necrosis
 tracheoarterial fistula
 tracheo-oesophageal fistula
 dysphagia
Late
 stenosis
 decannulation problems
 tracheocutaneous fistula
 disfiguring scar
 Types Of Tracheostomy Tubes

 Plastic Metallic
 Cuffed Un cuffed
 Fenesterated Un fenesterated
 Single lumen Double lumen
 Metallic Tubes Plastic Tubes

 Made of silver or  Made of Polyurethane

stainless steel , PVC or silicone.
 They are not  They are either
commonly used flexible or rigid.
because:  Cuffed and uncuffed.
1. They are expensive  They can be
2. They are rigid connected to
3. They are uncuffed Ventilator.
4. They lack ventilator
connector
Fenestrated Tubes

 Allowsthe patient
to ventilate past
tracheostomy tube
via upper airway
 Allowsthe patient
to speak
 Single Lumen Double Lumen

 It has a greater  It allows easy

internal diameter cleaning. Inner tube
can be removed for
cleaning while outer
tube still maintaining
the airway
 Indications of changing a tube

 Soiled
 Displaced
 Blocked
 Ruptured cuff
 It should be avoided within 1st week.
 Decannulation

 Decannulation should be approached in a stepwise

fashion.
 Check for adequacy of airway, ability to swallow
and handle secretions.
 Start blocking the tube at daytime initially and
then for whole 24 hours.
 If patient tolerates, tube is removed and
occlusive dressing is applied.
 Bronchoscopy or D/L assessment can be done
before decannulation.
 Patient must be kept under observation for any
signs of hypoxia after decannulation.
 Wound will close spontaneously in few days.
 Sometimes, secondary closure is also required.
A patient with tracheotomy should
always have:
THANKYOU