1. Tracheostomy – Indications and Complications
Dr Gary Kroukamp Ear,Nose and Throat Specialist Tygerberg and Kingsbury Hospitals

2. History Rigveda - 2000 BC Alexander the Great - 4th Century BC
Ancient Greeks - Asclepiades 124 BC
Diptheria - early 1800s - 32% survival
Intubation prior to ET tube - mid 1800s
Polio s
Chevalier Jackson

3. Respiratory Functional
Why a trachy ?
Airway patency for ventilation where intubation via the upper airway is not appropriate.
Upper airway
Obstruction
Respiratory Functional

4. Indications for tracheostomy Obstructive
Congenital subglottic stenosis,
Traumatic tracheal, laryngeal injuries, facial fractures
Neoplastic laryngeal, thyroid, oesophageal
Infective epiglottitis, oropharyngeal abscess
Inflammatory angioedema, corrosives,burns
Neurological vocal cord palsy, MND, MS, MG
Postoperative tracheal/laryngeal/oral surgery
Difficult airway emergency trachy

5. Indications tracheostomy - combined (head, facial and chest injuries)

6. Functional indications
Ventilation/ Weaning
Predicted ventilation > 10 days
Flail chest, polytrauma, head injuries, severe burns
Narcotic overdoses, Tetanus, Pneumonias,
Muscle weakness,
Postop elective ventilation in resp failure
Sputum production

7. Advantages over ET Tubes
Comfort
Easier to nurse
 Dead space (70-100ml / 10-50%)
Better oral hygiene
No sinusitis, nasal or oral ulceration, subglottic stenosis
Less nosocomial pneumonia
Better airway toilet
Weaning easier
Awake patient

8. Causes of ET tube trauma
Duration of laryngeal intubation
>48 h: significant laryngeal ulceration
>96 h: severe damage, possible permanent damage
Inadequate fixation of tube
Wrong size tube
Overinflated cuff
(Gastro-oesophageal reflux)

10. “Gold Standard” Technique
Open procedure
Vertical midline incision
Blunt dissection
Thyroid isthmus displaced or divided and tied off
Tracheal vertical slit – Paediatric or round/oval window – Adult
Appropriate sized tube – adjustable length if obese or severe soft tissue swelling
Single suture through flange superiorly, midline
Tapes around neck in neutral position – not tied with bow
Post-op CXR

13. Post-operative Dislodgement of tube Surgical emphysema
Pneumothorax/Pneumomediastinum
Obstruction of tube – crusting
Infection(perichondritis,wound infection,secondary haemorrhage)
Tracheal necrosis - leading to tracheal stenosis or tracheo-oesophageal fistula
Post obstructive pulmonary oedema

14. Prevention Routine CXR post op Humidification
Regular suctioning with saline
Treat infection
Removal as soon as is safe

15. Late Subglottic and tracheal stenosis Granulation tissue
Tracheo-arterial fistula
Tracheocutaneous fistula
Decannulation difficulty
Scar hypertrophy or keloid

16. Prevention Large volume, low pressure cuff Slight air leak in children
Properly positioned and fixed
Restless patient
Gentle suctioning

17. Paediatric complications
More common esp < 1 year
38% late complications
Granulation and tracheal stenosis
Duration the most important factor
Preterm

18. Complications – wound Closed suction system
Velcro skin protection less movement
Alewyn clean and dry avoid bulk
Traction Support piping
Evac system

19. Normal larynx

20. Intubation trauma

21. Interaritenoid adhesion

22. Vocal granuloma/nodule

23. Subglottic trauma

24. What’s new? – tracheal stenosis
Cuff design
High volume/low pressure
Less traumatic
More flexible softer materials

25. Pooling above the cuff – aspiration pneumonia
Aspiration port
cuff
shlop

26. Suction above the cuff

27. Extended length trachy
Securing Bolt
Variable length adjustor

28. Percutaneous technology

29. Percutaneous trachy

30. Percutaneous trachy

31. Percutaneous trachy

32. Tracheo-Innominate fistula
1%, mortality, week old, site, sentinel bleed, management

33. The Happy Trachy Team work and Attention to Detail
Most problems are preventable
Operative technique
Movement
Strapping, dressings
Patency
Humidification
Patient teaching
Team work and Attention to Detail