1. Tracheostomy
Dr. Vishal Sharma

2. Jackson’s metallic tube

3. Jackson’s metallic tube

4. Jackson’s metallic tube
Made of German silver (alloy of Ag + Cu + P)
Has obturator (pilot), inner tube & outer tube
Inner tube is longer than outer tube for its removal & cleaning. Outer tube maintains patency. Pilot is inserted into outer tube for smooth & non-traumatic insertion of tube
Lock prevents expulsion of tube during cough

5. Fuller’s bivalved metallic tubeO

6. Fuller’s metallic tube
Outer tube bi-valved. The 2 blades when pressed together, help in smooth entry of tube.
Inner tube is longer & has a vent for phonation
Pt phonates by closing main tube opening
Vent also helps in decannulation of tube

7. Phonation via vent

8. Portex cuffed tube

9. Portex cuffed tube
Made of siliconized PolyVinylChloride. It is thermolabile & prevents crusting.
Low pressure high volume cuff maintains an air-tight seal required for:
Prevention of aspiration of secretions
Positive pressure ventilation

10. Cuffed double lumen tube

11. Cuffed fenestrated tube

12. Portex uncuffed tube
For tracheostomy patient receiving radiation

13. Uncuffed double lumen fenestrated tube

14. Hands free speaking valve

15. Mechanism of speaking valve

16. Adjustable flange tube
Used in obese neck, oedema neck

17. Salpekar double cuff tube
Prevents ischemic necrosis of tracheal cartilage

18. Cold & hot water humidifiers

19. Heat & moisture exchanger

20. Nebulization attachment

21. Metallic Tubes Plastic Tubes
Easily cleaned without suction
Cleaning requires suction
Cuff is absent
Cuff is present
Cannot be connected to ventilator
Can be connected
Rigid & less comfortable to patient
Soft & more comfortable
Concomitant radio-therapy is to be avoided
Can be given

22. Tracheostomy tube size
Age of pt
Tracheostomy tube size
Portex (I.D. in mm)
Metallic (Fg)
1 – 3 yrs
4.0 – 4.5 16
4 – 6 yrs
5.0 18
7 – 9 yrs
5.5
20, 22
10 – 12 yrs
6.0
24, 26
13 – 18 yrs
7.0 – 7.5
28, 30
Adult
8.0 – 9.0
32, 34, 36

23. Functions of Tracheostomy
1. Relieves upper airway obstruction
2. Improves alveolar ventilation by ing dead space by 30-50% & ing airflow resistance
3. Prevention of aspiration of blood & secretions
4. Removal of airway secretions in patient with inability to cough or with painful cough
5. Administration of anesthesia

24. Indications for Tracheostomy

25. A. Respiratory obstruction
 Trauma to airway : external, endoscopic
 Infection: epiglottitis, croup, Ludwig’s angina, para-pharyngeal /retro-pharyngeal abscess
 Neoplasm: laryngo-tracheal, pharyngeal
 Foreign body in airway
 Oedema of larynx: irritant, allergic, irradiation
 Paralysis of larynx: B/L abductor palsy
 Congenital: laryngeal web, cyst, choanal atresia

26. B. Retained airway secretions
 Inability to cough: coma, respiratory muscle palsy or spasm, laryngectomy
 Painful cough: chest injuries, pneumonia
 Excessive secretions: pulmonary oedema
C. Respiratory insufficiency
 Chronic bronchitis, bronchiectasis, atelectasis, reatined airway secretions

27. D. Anesthesia administration in:
 Laryngo-pharyngeal growths
 Maxillo-facial trauma
 Trismus
 Severe Ludwig’s angina
 Positive pressure ventilation for > 72 hrs

28. Types of Tracheostomy  Emergency  Elective  Temporary  Permanent
 Therapeutic  Prophylactic
High (1st ring): above thyroid isthmus
Mid (2nd – 4th ring): behind thyroid isthmus
Low (below 4th ring): below thyroid isthmus

29. Mid tracheostomy preferred
High tracheostomy leads to subglottic stenosis
Low tracheostomy is avoided as:
 Trachea is deeper
 Displacement of tracheostomy tube is common
 Proximity to great vessels
 Surgical emphysema is common
 Tracheostoma is close to tracheal bifurcation

30. Steps of Tracheostomy

32. Positioning
Supine position with extension of neck. General anesthesia with endotracheal intubation.

33. Infiltration
 Cricoid palpated & a 5 cm horizontal incision marked 2 cm below it
 2 % lignocaine & 1 in 2 lakh adrenaline injected into incision line

34. Horizontal Incision A 5 cm horizontal incision made with # 15 blade &
deepened below subcutaneous tissue

35. Vertical Incision
A 5 cm midline vertical incision can be made below cricoid in emergency tracheostomy. This avoids injury to blood vessels.

38. Exposure of strap muscles
Investing layer of deep cervical fascia opened vertically with artery forceps. Palpation for tracheal rings done regularly during the dissection.

40. Retraction of strap muscles

41. Exposure of thyroid isthmus
Strap muscles retracted laterally with Langenbeck retractors to expose the trachea & thyroid isthmus

42. Isthmus separation from trachea
Thyroid isthmus detached from tracheal surface & retracted with blunt tracheal hook.

43. Isthmus retraction to expose pre-tracheal fascia

44. Division of thyroid isthmus
If required, thyroid isthmus is divided between clamps.
Transfixion sutures applied at the ends.

45. Confirmation of trachea
5 ml syringe containing 4 % Lignocaine taken, its needle inserted into trachea & aspirated. Air bubbles confirm presence of needle in trachea.
2 ml of solution injected into trachea & needle removed quickly to avoid breaking of needle during violent cough movements.

46. Creation of tracheal window
Sharp cricoid hook inserted below cricoid to steady trachea. Tracheal window created by excising anterior 1/3rd of 2nd & 3rd tracheal ring with No. 11 blade & Allis tissue forceps.

47. Cautery assisted window

48. Holding cartilage with Allis forceps

49. Tracheal window

50. Other options

51. Inferiorly based tracheal flap made & sutured
Bjork flap
Inferiorly based tracheal flap made & sutured
to lower skin edge

52. Insertion of tracheostomy tube
Endotracheal tube withdrawn into larynx
Lubricated tracheostomy tube inserted into trachea
Confirm presence of tube in trachea with help of ambu bag & auscultation

55. Suturing of flanges
Cuff inflated with 5 ml of air & anesthetic circuit connected to the tube
Neck extension released & flanges of tube sutured to skin to avoid tube movement

56. Tying the tapes
Tapes of tracheostomy tube tied around the neck keeping a space for 1 finger. Neck kept flexed.
Skin incision closed loosely to avoid surgical emphysema.

57. Padded tapes

58. Insertion of medicated gauze
Betadine soaked gauze or Sofratulle put around the tracheostomy opening.

60. Shower collar

61. Shower guard

62. Tracheostomy locket

63. Immediate Complications
Occurs during operation
Primary Haemorrhage  Air embolism
Cardiac Arrest  Aspiration of blood
CO2 withdrawal Apnoea
Injury to: Apical pleura (pneumothorax),
recurrent laryngeal nerve, oesophagus

64. Intermediate Complications
Occurs within first few days
Reactionary & secondary haemorrhage
Blocking or displacement of tube
Subcutaneous emphysema, pneumothorax
Tracheitis & crusting
Atelectasis & lung abscess
Wound infection & granulation tissue

65. Surgical emphysema

66. Causes of surgical emphysema after tracheostomy
Dissection into many tissue planes in neck
Use of smaller tracheostomy tube
Tight closing of skin incision
Excessive struggling & coughing of pt during extubation

67. Tracheostomy site granulation

68. Late Complications Occurs after weeks / months
Subglottic stenosis, tracheal stenosis
Tracheo-arterial or Tracheo-venous fistula
Tracheo-oesophageal fistula
Persistent tracheo-cutaneous fistula
Decannulation difficulty
Tracheostomy wound scar / keloid
Metallic tube corrosion & fragment aspiration

69. Anatomy of tracheal fistulae

70. Tube fragment aspiration

71. Tracheostomy care Pt given 100 % oxygen. Deflate the tube cuff.
Suction catheter with negative suction pressure ( mmHg) used
Catheter diameter should be < 1/3rd of internal diameter of tracheostomy tube
Catheter length introduced just enough to go beyond inner tube (10 cm)

72. Tracheostomy care
Multiple-eyed catheters produce less trauma than whistle tip catheters
Lubricated catheter tip inserted (with suction off) as pt is inspiring. At end inspiration, suction put on & catheter withdrawn in rotating motion.
Each suction procedure should last for seconds. Instill 0.5 ml NaHCO3 to liquefy crusts.

73. Tracheostomy care
Chest auscultated for confirmation of adequate suctioning. Re-inflate cuff to a pressure of 25 mmHg. Patient oxygenated again.
Tracheostomy wound dressing done BID
Steam inhalation TID. Moist gauze piece placed over tracheostomy tube opening. Regular chest physiotherapy, expectorants & mucolytics given.

75. Wall suction

76. Portable suction

77. Closed-system Multiple-use Suction Unit (CMSU)

78. Communication chart for pt

79. Electronic communication

80. Hand bells

81. Tracheostomy tube changing
Inner tube is removed & cleaned when blocked
Outer tube never removed before 72 hrs to allow formation of tracheo-cutaneous tract
Cuff of Portex tube deflated for 10 minutes every 2 hours to prevent pressure necrosis & dilatation of trachea

82. Pt position in tube changing

83. Cleaning of inner tube

84. Tube removal over bougie

85. Obturator guide wire insertion

86. Decannulation
Adult: plug or seal tube opening & if tolerated for 24 hrs, remove tube.
Child: Sequentially reduce size of tube.
After tube removal  close wound. Healing occurs within 1 week. Secondary closure after freshening the wound margin is required rarely.

87. Capping of tube opening

88. Decannulation difficulty
Organic causes:
Persistence of cause requiring tracheostomy
Obstructing tracheal granulations
Tracheal oedema
Subglottic stenosis
Collapse of tracheal wall (tracheomalacia)

89. Decannulation difficulty
Non-organic causes:
Emotional dependence in children
Inability to tolerate upper airway resistance
In-coordination of laryngeal opening reflex
Long-standing tube leads to impaired laryngeal development

90. Tracheostomy Intubation
Invasive
Non-invasive
Complications are more
Less
Can be kept for > 7 days
Should not be kept
Pt can speak
Cannot speak
Tracheo-bronchial toilet is easy
Difficult
Decreases dead space by 30-50%
Does not

91. Disadvantages of Tracheostomy
Anosmia: no nasal air entry
Aphonia: avoided by phonatory vent
Aspiration: avoided by cuffed tube
Inability to lift heavy weight
Inability to perform strenuous exercise
Inability to swim

92. Percutaneous Tracheostomy

93. Insertion of cannula

94. Insertion of guide wire

95. Tracheal dilator over guide wire

96. Insertion of tracheal dilator

97. Tracheostomy tube

98. Insertion of tracheostomy tube

100. Percutaneous Tracheostomy
Trachea punctured with needle & cannula
Needle removed & a guide wire passed into trachea via cannula
Cannula removed & graded dilators passed over guide wire till the opening can admit a tracheostomy tube

101. Cricothyrotomy

102. Cricothyrotomy
1. Midline vertical skin incision made to identify cricothyroid notch. 2. Cricothyroid membrane incised horizontally, with # 11 blade, close to cricoid. 3. Knife handle inserted & rotated by 900, to widen the horizontal opening or tracheostomy tube is inserted. 4. Elective tracheostomy done as soon as possible to avoid subglottic stenosis.

103. Tracheal fenestration

104. Tracheal fenestration

105. Tracheal fenestration

106. Tracheal fenestration
Indicated for C.O.P.D. where tracheal opening is required for mechanical cleaning.
Bilateral medial based skin flaps elevated & tracheal opening made.
Distal edges of flaps sutured to margins of tracheal window.
Lateral edges of 2 flaps sutured to each other to create watertight skin buttons.

107. Thank You