Tracheostomy Professor Magdy Amin RIAD MD, FRCS. Ed Department of Otolaryngology Ain Shams University

Tracheostomy Definition: Surgical opening in the trachea for respiration Temporary or permanent “Tracheotomy" and “Tracheostomy The opening, or hole, is called a stoma

Tracheostomy history One of the oldest surgical procedures Tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC The first successful tracheotomy was performed by Prasovala in the 15th century In the 16th century, Guidi invented an original method for tracheotomy Well documented studies do not appear until the early 1900's

Indications of tracheostomy (A) To bypass an upper airway obstruction (larynx, upper trachea) (B) Lower respiratory airway obstruction (lower trachea, lungs, bronchi) (C) Prophylactic (without obstruction)

(A) Bypass an upper airway obstruction (I) Laryngeal causes:  Congenital: web, stenosis,laryngomalacia Trauma: Mechanical , Chemical, physical (FB, maxillofacial injury, laryngeal fracture, Burns of the face or the neck) Inflammatory: acute LTBitis, supraglottitis, diphteria, Scleroma, Syphilis , TB  Neuromuscular: Myasthenia G, bilateral VF palsy Benign: RRP------ Malignant: Laryngeal carcinoma, extensive pharyngeal tumors

(II) Tracheal causes: (to bypass an upper tracheal obstruction)  In the neck upper tracheal tumors, enlarged goiter, malignant goiter, malignant cervical lymph nodes  In the chest Retrosternal G, enlarges thymus, mediastinal lymph nodes (III) Supra-laryngeal causes: -Ludwig’s angina -Post-cricoid carcinoma - Retropharyngeal abscess - Obstructive sleep apnea

(B) Lower respiratory airway obstruction (lower trachea, lungs, bronchi) (I) Central or peripheral causes Cough reflex depression unable to expel chest secretions 1) Central causes prolonged coma Traumatic: head injury Toxic: Barbiturates, Uremia, ketoacidosis Cerebrovascular: Hge, thrombosis, embolism Brain tumors: 2) Peripheral causes: - Paralysis of respiratory muscles (Polio, Diphteria) - Severe chest injury : Flail chest, rib fracture (II) Intact cough reflex but cannot protect the lower airway: Aspiration in bilateral adductor paralysis, Pseudo-bulbar palsy

(C) Prophylactic (without obstruction) 1) Before extensive oral or pharyngeal surgery (cancer tongue, maxillectomy) (2) Temporary in laryngeal surgery (partial laryngectomy, laryngofissure) (3) Prolonged intubation for more than 10 days

Contraindications No absolute contraindications to tracheostomy It should be done once indicated (life saving) A strong relative contraindication is laryngeal carcinoma where laryngectomy (definite management) should be planned and prior manipulations of the tumor is avoided Stoma recurrence

Value of tracheostomy (1) In upper airway obstruction  by pass the obstruction (2) In lower airway obstruction  * Suction of secretions * Administration of warm oxygen * Reduction of dead space to its half for better utilization of inspired air

Types of tracheostomy High (above the thyroid isthmus at 1st & 2nd tracheal rings) Mid (behind thyroid isthmus at 3rd &4th rings) This is the best Low (below the isthmus at 5th &6th rings) WHEN? -away from laryngeal lesion (RRP) Upper tracheal tumors After TL Disadvantages: * Deeply situated *Difficult to reach *Injury to pleura, innominate vein Advantages: Easy, rapid, trachea is fixed Disadvantages: Cricoid cartilage injuryperichondritis,necrosis?fibrosissubglottic stenosis

Tracheostomy timing Urgent ("awake"): Emergent ("slash"): This should only be considered when the patient is in extremis, which is when a cricothyrotomy should be performed. Urgent ("awake"): # Patients in acute respiratory distress may need acute surgical intervention. #This can be performed in the OR under LA. #The patient's anxiety and restless movements will challenge the surgeon and the anesthesiologist; however, the patient's vigilance is required to maintain the airway. #These patients should be sedated and paralyzed only with extreme caution. It is better to have an agitated patient with an open airway than a relaxed patient with a complete obstruction. # The risk of pneumothorax is increased in a patient with increased work of breathing, as the cupulae expand high into the neck with high negative inspiratory pressures.

Tracheostomy timing (Cont., ) Elective: # Most elective tracheostomies are performed on intubated patients; (for prolonged intubation) # Additionally, patients undergoing extensive head and neck procedures may receive a tracheostomy during the operative procedure to facilitate airway control during convalescence # A smaller population of patients with chronic pulmonary problems (eg, sleep apnea) elect to undergo tracheostomy

Operative technique Anesthesia: * No (urgent, comatosed) * LA ( 1% Novocain + adrenaline) * GA ( children, neurotic, elective) Position: Supine with extended neck more superficial position of the trachea N.B: Overextension of the neck should be avoided as it further narrows the airway Incision: * Midline longitudinal (upper cricoid cartilage to the suprasternal notch) in urgent cases  easy, less bleeding * Transverse between the above points better cosmetically

Tracheostomy tube with cuff, pilot inflating balloon and pressure manometer

Surgical notes Opening of the trachea in infants and children is called tracheotomy where no resection of the tracheal wall In infants caution must be taken as the neck is soft and pliable Tracheotomy in infants and children should be performed after bronchoscope or endotracheal tube placement  Vital control of airway, rigidity to the trachea, prevent large excursion of the copulae into the neck Midline vertical incision through 3rd,4th,5th rings Immediate postoperative A-P & lateral chest x ray  ascertain tube site, exclude pneumothorax and pneumomediastinum

Complications Immediate Delayed Operative Hemorrage Subcutaneous emphysema Pneumothorax Pneumomediastinum TOF (1ry) RLN injury Aspiration Malpositioned tube Aerophagia Delayed hemorrhage Tracheal stenosis Tracheomalacia Delayed TOF Dysphagia Tracheocutaneous fistula Complications of anesthesia 1ry hemorrhage Injury to structures Apnea & acute pulm. Oedema

Tracheostomy complications may be grouped into intra-operative, early post-operative (< 7 days), and late post-operative (> 7 days) categories (Bourjeily et al 2002).

Immediate complications (1) Reactionary hemorrhage: Slipped ligature, staining TTT  reopen the wound & ligate the bleeding vessel (2) Surgical emphysema:  SC air collection due to small tube with wide tracheostomy, tight sutures,  May extend to the mediastinum TTT  Remove sutures and replace with a large tube

(3) Pneumothorax:  Injury of the apex of the pleura  dyspnea  More common in children  Diagnosed by : PO dyspnea, no air entry, collapsed lung TTT: Intercostal tube with underwater seal (4) Mediastinal emphysema:  Extension from SC emphysema  Affects cardiac function (5) Respiratory obstruction:  Due to tube complications  Manifest as: phonation without tube occlusion, stridor reappears

Delayed complications 2ry Hemorrhage:  -Infection - Ulceration of the anterior tracheal wall by the tip of the tube  innominate artery injury (2) Infection: (wound or chest infection) (3) Tube complications:  Difficult extubation  Fistula formation (early or late)  tracheocutaneous fistula (4) Tracheal stenosis

Percutaneoud dilatational tracheostomy Introduction of tracheal needle Placement of guide wire

Insertion of guiding catheter Serial dilation

* Not indicated in emergency cases * Bed side in the ICU Placement of tracheostomy tube * Not indicated in emergency cases * Bed side in the ICU

Tracheostomy Care Daily care of the trach site is needed to prevent infection and skin breakdown under the tracheostomy tube and ties should be done at least once a day; more often if needed. Steps: 1) Clean the skin around the trach tube 2) Check the skin under the trach ties 3) Check cuff pressure every 4 hours (usual pressure 15 - 20 mm Hg)

4) Humidification 5) Frequent suction of the tube 6) Antibiotics 7) Mucolytics & amble fluids 8) Changing of the tube after the 3rd day 9) Deflation of the cuff every 2 hours for 10 minutes 10) Always ensure adequate placement of the tube

Decannulation The removal of the tracheostomy tube. Once the reason is resolved In the hospital under the care of ORL surgeon Observation for several hours If difficult  diagnostic evaluation

Decannulation (Cont.,) Some procedures for decannulation Simple removal of the tube (+/-) minor surgical procedures. Place a smaller tube and plug the tube for increased amounts of time. When the child is tolerating the plug 24 hours a day, then the tube can be removed Include the decannulation as part of a reconstructive procedure Surgical decannulation (when repair of the trachea around the tube is needed) N.B: Sleep studies in the hospital setting are often ordered to be sure apnea is not present

Causes of difficult decannulation (1) Persistance of the original etiology (2) Anterior tracheal wall dislocation (3) Stomal granulation tissue (4) Oedema of tracheal mucosa (5) Emotional dependence on tracheostomy (6) Unable to tolerate upper airway resistance (7) Subglottic stenosis (8) Tracheomalacia (9) Incoordination of laryngeal opening reflex (10) Impaired development of the larynx (11) GERD