1. TRACHEOSTOMY
Medrockets.com

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. 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

23. 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

24. 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

25. TRACHEOSTOMY TUBES

26. TRACHEOSTOMY TUBES

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

28. COMPLICATIONS
IMMEDIATE
INTERMEDIATE
LATE
Medrockets.com

29. 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

30. 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

31. TRACHEAL STENOSIS & TRACHEO-INNOMINATE ARTERY FISTULA

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

33. 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

34. 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

35. 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

36. 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.

37. 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

38. 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.

39. Percutaneous Tracheostomy Technique
Introduction of tracheal needle
Placement of guide wire

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