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

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

3. 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

4. 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)

5. (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

9. (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

10. (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

11. (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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

18. Tracheostomy tube with cuff, pilot inflating balloon and pressure manometer

19. 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

20. 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

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

22. 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

23. (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

24. 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

25. Percutaneoud dilatational tracheostomy
Introduction of tracheal needle
Placement of guide wire

26. Insertion of guiding catheter
Serial dilation

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

28. 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 mm Hg)

29. 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

31. 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

32. 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

33. 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