TRACHEOSTOMY Medrockets.com

INTRODUCTION Tracheostomy is the surgical creation of an opening maintained by a tube on the anterior aspect of the cervical tracheal wall (windpipe). A tracheotomy – opening is not maintained by a tube (temporary opening). Sometimes the terms "tracheotomy" and "tracheostomy" are used interchangeably. The opening, or hole, is called a stoma. Medrockets.com

ANATOMY The trachea lies below the thyroid cartilage, which forms the front wall of the larynx. The thyroid isthmus crosses the trachea and the recurrent laryngeal nerve (to the vocal cords) lies on each side of the trachea. Medrockets.com

ANATOMY Section through the neck showing the relationships of the trachea to the larynx, esophagus and thyroid isthmus.

ANATOMY AND PHYSIOLOGY The trachea is a rigid structure formed from rings of cartilage to ensure that the airway always remains open. Its function is to maintain and protect the airway. The trachea is lined with mucus glands, which humidifies air as it passes through the trachea and catches small particles before they reach the lungs. Medrockets.com

ANATOMY AND PHYSIOLOGY The trachea also has specialized hair like structures called cilia that move rhythmically to sweep mucus and particles back up to the throat. The trachea also has many defensive cells that kill organisms that enter the trachea The trachea is supplied by nerves that are part of the cough reflex that helps get rid or irritants

INDICATIONS To bypass upper airway obstruction To protect the lower respiratory tract /provide pulmonary toilet To provide a long-term route for mechanical ventilation in cases of respiratory insufficiency Prophylaxis (as preparation for extensive head and neck procedures and the convalescent period) Medrockets.com

INDICATIONS UPPER AIRWAY OBSTRUCTION Congenital anomalies: bilateral Choanal atresia, subglottic stenosis/web, laryngeal web/cysts, Tracheomalacia, Vocal Cord Paralysis (VCP), Congenital abnormalities of the airway, Treacher Collins and Pierre Robin Syndromes Medrockets.com

INDICATIONS Acquired: Infection/Inflammation: Acute epiglottitis, Croup (LTB), Ludwig’s angina, Retropharyngeal abscess, Anaphylaxis (severe allergic reaction) TRAUMA: Foreign body obstruction, Airway burns from inhalation of corrosive material, smoke or steam, radiation, Severe neck or mouth injuries, Laryngeal injury or spasms Medrockets.com

INDICATIONS TRACHEO-BRONCHIAL TOILETING TUMOURS: Benign (eg RRP, Haemangioma, Angiomas, Cystic Hygroma, etc) or Malignant (eg SCCa, Lymphoma) Miscellaneous TRACHEO-BRONCHIAL TOILETING Long-term unconsciousness or coma, Tetanus Aspiration related to muscle or sensory problems in the throat Bulbar palsy Medrockets.com

INDICATIONS RESPIRATORY INSUFFICIENCY Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm Chronic pulmonary disease to reduce anatomic dead space Chest wall injury Diaphragm dysfunction Disorders of respiratory control such as Congenital Central Hypoventilation or Central Apnea Fracture of cervical vertebrae with spinal cord injury Need for prolonged respiratory support, such as Bronchopulmonary Dysplasia (BPD) Medrockets.com

INDICATIONS ADJUNCT FOR HEAD & NECK SURGERY Maxillofacial surgery, laryngectomy, Maxillectomy, Other major head and neck surgeries Medrockets.com

CLASSIFICATIONS Timing: Elective or Emergency Duration: Temporary or Permanent Site: High, Middle or low Medrockets.com

SURGICAL TYPES Tracheostomy Emergent ("slash") – when patient is in respiratory arrest Urgent ("awake") – usually done under L.A. Elective (with patient already intubated) Classical or Percutaneous Medrockets.com

INTRAOPERATIVE DETAILS (Classical Tracheostomy) Position sitting or semirecumbent position with extension of the neck Palpate the landmarks. Infiltrate lidocaine (1%) with 1:200,000 parts epinephrine Make the horizontal skin incision Landmarks: midway between sternal notch and the cricoid cartilage, Medrockets.com

INTRAOPERATIVE DETAILS Dissection through skin, subcutaneous tissue, and platysma to reveal the strap muscles At the level of the strap muscles, the dissection is changed to the vertical plane. The pair of sternohyoid and sternothyroid muscles are separated from each other in the midline by vertically incising the fascia that connects the muscles Medrockets.com

INTRAOPERATIVE DETAILS Retractors then pull the strap muscles to each side, revealing the thyroid isthmus. At this point, the cricoid cartilage is identified by palpation through the wound, and the overlying fascia is sectioned near its inferior border. the thyroid isthmus, which typically lies anteriorly over the first 2-3 tracheal rings, may be retracted out of the field, often it must be divided. Medrockets.com

INTRAOPERATIVE DETAILS Injection of topical anesthesia can stem the cough reflex of an awake patient before incision is made to enter the trachea. suction secretions and blood out of the lumen and insert the previously tested tracheostomy tube with or without the aid of tracheal dilator. Medrockets.com

INTRAOPERATIVE DETAILS After an intact airway is confirmed with carbon dioxide return and bilateral breath sounds, secure the tracheostomy tube to the skin with 4- 0 permanent sutures. Attach a tracheostomy collar with the head flexed to avoid unnecessary slack in the collar. The skin is not closed tightly to avoid the risk of subcutaneous emphysema and subsequent pneumomediastinum. Medrockets.com

EMEGENCY TRACHEOTOMY Emergency tracheotomy performed through a vertical incision in the midline of the neck over cricoid cartilage and tracheal ring Medrockets.com

TRACHEOSTOMY PROCEDURE A horizontal skin incision is marked midway between the cricoid cartilage and the sternal notch. The skin is infiltrated with Xylocaine- Epinephrine to decrease the bleeding. Medrockets.com

TRACHEOSTOMY PROCEDURE The isthmus of the thyroid gland is either retracted or divided in the midline. (In this picture, the isthmus has been divided and retracted laterally, along with the strap muscles.) The anterior tracheal wall is divided between the third and fourth tracheal rings. A clamp is used to widen the tracheal opening. The endotracheal tube is seen inside the tracheal lumen. Medrockets.com

TRACHEOSTOMY PROCEDURE To prevent a tight fit around the neck, the umbilical tape is tied over a finger, while the neck is flexed. Medrockets.com

TRACHEOSTOMY TUBES METALS (usually has an obturator, an inner and outer tube) Chevalier Jackson, Negus, Durham, Koenig, Alder Hey SYNTHETIC (most are made from PVC, silicone or other synthetic plastics that are non-toxic) Portex & Shiley (have low-pressure cuffs) Paediatric types – Franklin tube of GOS, Portex, Shiley. None has a cuff Medrockets.com

TRACHEOSTOMY TUBES

TRACHEOSTOMY TUBES

POSTOPERATIVE MANAGEMENT NURSING CARE SUCTION HUMIDIFICATION MONITORING – RISK OF APNOEA SPEECH SWALLOWING CARE OF THE TUBE DECANNULATION

COMPLICATIONS IMMEDIATE INTERMEDIATE LATE Medrockets.com

IMMEDIATE ANAETHETIC Trauma to local structures cricoid cartilage, recurrent laryngeal nerve, oesophagus, brachiocephalic vein Cardiac arrest 20 to apnoea, hypotension, arrhythmias Primary haemorrhage Pneumothorax or pneumomediastinum Postobstructive pulmonary edema (transient) Medrockets.com

INTERMEDIATE Dislodgement/displacement of tube Surgical emphysema Pneumothorax Obstruction of tube (excessive crusting) Infections – cellulitis, perichondritis, wound infection, tracheitis, tracheobronchitis, pneumonia, lung abscess, mediastinitis. Secondary haemorrhage (tracheo- innominate artery fistula) Atelectasis

TRACHEAL STENOSIS & TRACHEO-INNOMINATE ARTERY FISTULA

LATE Subglottic/tracheal stenosis Tracheo-oesophageal fistula Trachoecutaneous fistula Persistent stroma Tracheomalacia Granulation Scarring ( hypertrophic or keloid) Difficult decannulation

DECANNULATION METHOD INVOLVES: Adequate re-evaluation of the indication to be sure it is no longer required Observe speech/cry with tube blocked temporarily Indirect Laryngoscopy (adult) Fiberoptic laryngoscopy and bronchoscopy through the stoma X-ray soft tissue neck is necessary

METHOD PROCESS: Change tube to a smaller size Spigot for most of the day, leaving it open during the night If tolerated, spigot for 24 hours, including a period of sleep. A close watch should be kept for any sign of respiratory distress. Difficult decannulation is usually done as a surgical procedure if the normal process fails Medrockets.com

DIFFICULT DECANNULATION Usually seen in children, but could occur in adult Reasons: Failure to correct the reason for the tracheostomy Granulation tissues obstructing the airway Tracheomalacia Disuse of acquired reflexes controlling glottic closure & opening during breathing & swallowing Psychological dependence on the tracheostomy Medrockets.com

DIFFICULT DECANNULATION Process: Usually done under general anaesthesia via oro/naso-tracheal intubation the T. tube is removed and the stoma is closed in layers and sterile dressing applied Patient allowed to be fully awake with the ETT in place, before extubation. If the patient is a child, he is kept in an intensive care unit, and the endotracheal tube is removed after a day or two and dressing applied to the stoma for 24 – 48 hours by which time its closure would have been completed.

How to Perform an Emergency Tracheotomy Find the indentation between the Adam's apple and the Cricoid cartilage. Make a half-inch horizontal incision about one half inch deep. Medrockets.com

How to Perform an Emergency Tracheotomy Pinch the incision or insert your finger inside the slit to open it. Insert your tube into the incision, roughly one-half to one inch deep.

Percutaneous Tracheostomy Technique Introduction of tracheal needle Placement of guide wire

Percutaneous Tracheostomy Technique Insertion of guiding catheter Serial dilation Placement of tracheostomy tube