Tracheostomy

By
Hesham Ahmed Fathy, MD
Assistant professor of Otorhinolaryngology
Head and Neck surgery
Faculty of Medicine Cairo university
• Definition: creating opening into trachea.
• Indications:
A. Upper airway obstruction:
1. Tumors, inflammation, congenital obstruction, trauma,
stenosis or foreign body of larynx or trachea.
2. Extensive maxillofacial trauma.
3. Bilateral vocal cord paralysis.
B. Mechanical respiratory insufficiency due to
respiratory failure: better than endotracheal tube
due to decreased incidence of tracheal stenosis.
C. Secretional obstruction due to retained secretions
and inadequate cough.
D. Elective:
1. To protect airway from bleeding during major operations in
pharynx, larynx or mouth.
2. Aspiration due to bulbar palsy.
• Functions:
1. Bypass obstruction.
2. Allows positive pressure ventilation in respiratory failure.
3. Allows pulmonary aspiration of secretions in secretional
obstruction
4. Protection of airway from bleeding during major
surgeries.
5. protection against aspiration.
6. Pathway to deliver medications to tracheobronchial tree.
• Site:
1. Mid tracheostomy: 3rd & 4th tracheal rings
2. High tracheostomy: 1st & 2nd tracheal rings, in laryngeal
cancer as it will be excised, if cricoid injury will lead to
subglottic stenosis.
3. Low tracheostomy: 5th & 6th trachel rings, in subglottic
stenosis, higher risk of pleural injury.
 Technique
• Anasthesia: local in emergency or general if can
be intubated (never give muscle relaxant).
• Incision: vertical in emergency or horizontal.
• Position: supine with the head extended.
• Opening trachea: vertical, horizontal or trap door.
• Sutured to skin to prevent dislodgement
• Tube sizes: 7.5mm in females, 8.5 mm in males.
• Tube types: metal or scialastic (cuffed or
uncuffed).
 Postoperative management
• Immediate chest x-ray: confirm tube position and
rule out pnuemothorax.
• Frequent suction: to remove secretions, every 30
min. in 1st 48 hrs.
• Monitoring vital signs: respiratory distress should
be reported immediately.
• Care of cuff: tracheal wall in contact with cuff is in
danger of ischemic necrosis, cuff is deflated for 5
min. every 1 hr..
• Changing of tube: not before 48 hrs. to allow for
track establishement.
 Complications
• Immediate:
1. Hge.: AJV, thyroid gland.
2. Pneumothorax: injury of pleral apex especially in low
tracheostomy, ttt. by underwater seal drainage.
3. Pneumomediastinum: air forced into deep tissues of neck then
to mediastinum.
4. Surgical emphysema: air in soft tissues of neck, due to large
incision in trachea or tube displacement diverting air into neck
or too tight closure of SC tissues and skin, ttt. by releasing skin
closure.
5. Local damage: cricoid injury in high tracheostomy, RLN injury
in too lateral dissection, thyroid gland injury.
6. TEF: due to penetration of posterior wall of trachea.
7. Malpositioned, displaced or dislodged tube: avoided by
suturing tube to skin.
• Delayed:
1. Displaced or dislodged.
2. Infection.
3. Tracheal necrosis: focal pressure by tube walls or cuff
leads to ischemic necrosis.
4. TEF: pressure necrosis of posterior wall of trachea
and anterior wall of oesophagus.
• Late:
1. Tracheal stenosis: at cuff site, tip or curve of tube,
due to ulceration that heal by 2ry intention.
2. Subglottic stenosis due to cricoid injury.
3. Neck scar.
4. Tracheocutaneous fistula: persistant wound
especially in long standing tracheostomy.