Tracheostomy

Indication Airway obstruction Ventilation support Pulmonary toilet Elimination of dead space Airway protection

Function of a tracheostomy 1.Decreasing dead space in tracheobronchial tree 2.Reduction of resistance to airflow – effective alveolar ventilation 3.Protection against aspiration 4.Enables swallowing without reflex apnea 5.Access to the trachea for cleaning 6.Decreasing the power of the cough

Techniques Preoperative management Preparation Position Anesthesia

Operation technique The skin of anterior neck and chest is prepared and the neck draped The cricoid cartilage should be located by palpation Horizontal or vertical incision is made approximately 1 FB below the cricoid cartilage in adult and 1 CM. above sternum in children The midline is identified and the strap muscles are separated and retracted laterally The thyroid can usually be reflected superiorly to allow access to the trachea Bleeding is contrlled before opening the airway Tracheal incision : inverted U shape for adult (2nd -3rd) Stay suture of 2-0 silk inserted on either side of the incision provides traction force Tracheostomy tube is inserted under directed visualization Ties should be applied around the neck , tight enough to admit a finger and no more

Choice of tube Age Size of trachea and tracheostomy tube Type of tube : metal , plastic Cuff or no cuff

Complications of tracheostomy 1.Operative complication Hemorrhage Pneumothorax and pneumomediastinum Subcutaneous emphysema Failure to obtain an airway Accidental decannulation , improper position of tube Tracheoesophageal fistula Pulmonary edema Recurrent laryngeal nerve paralysis High tracheostomy

2. Delayed complications hemorrhage (innominate artery erosion) Tracheoesophageal fistula (following decannulation) laryngotracheal lesion aspiration Tracheocutaneous fistula Displacement or obstruction of a tube and cuff Atelectasis and pulmonary infection Cosmesis

Postoperative care CXR : tube and complication Humidification Pulmonary toilet : suction , clean inner tube 1-2 hr. Prevention of infection Maintenance of airway ; 48-72 hr. Decannulation