3. Definitio
n
Tracheostomy is a surgical procedure to
create an opening in the anterior wall of the
trachea and converting it into a stoma in the
skin surface of the neck to exteriorize the
upper airway.
4.
5. Trachea
• The trachea is a wide tube lying more or less in the
midline , in the lower part of neck and superior
mediastinum .
• It has fibroelastic wall supported by a cartilaginous
skeleton formed by 16-20 C shaped tracheal ring.
• 10-15cm in length
• The lumen is about 3mm at one year of age and it
corresponds to the age ,maximum of about 12mm in
adults.
• Upper end starts at lower border of cricoid cartilage
opposite the 6th cervical vertebra
• Lower end-in front of sternal angle against the lower
border of 6th thoracic vertebrae.
6. Relations of Cervical part of trachea
Anteriorly:
• The isthmus of the
thyroid gland
(2nd, 3rd and 4th tracheal
rings)
• The inferior thyroid veins
• The sternothyroid and
sternohyoid muscles
• The cervical fascia
• Thyroidea Ima Vein
7. Posteriorly :
• The esophagus
Laterally:
• Common carotid
arteries
• Right and left lobes
of the thyroid gland
• Inferior thyroid
arteries
• The recurrent
laryngeal nerves
8. Objectives/Functions of
Tracheostomy
1. Alternative pathway for breathing
2. Improves alveolar ventilation In cases of
respiratory insufficiency :
3. Protects the airways By using cuffed tube,
tracheobronchial tree is protected against
aspiration
4. Permits removal of tracheobronchial
secretions
5. Intermittent positive pressure respiration
(IPPR)
9. Effects of tracheostomy
•Laryngeal bypass . All the normal laryngeal functions are
lost , the patient is unable to cough, phonate, crying,
laughing, climbing and lifting
•A reduction in respiratory dead space .
•A redundant area is created between the tracheal
opening and the larynx in which mucous tends to
accumulate and then fall back into the lung.
•The filtration of particulate matter and humidification of
inspired air by nasal mucosa is lost
•An increased risk of infection
•The tracheostomy tube act as a foreign body causing
local inflammation and swallowing difficulty.
10. Indications of
Tracheostomy
There are Four main
indications
A. Upper airway
obstruction
B. Removal of secretion
C. Prolonged ventilation
D. Part of another
procedure
11. A. Upper airway
obstruction
1.Infections
Acute laryngo-trachea-bronchitis, Acute epiglottitis ,
Diphtheria , Ludwig angina , Peritonsillar abscess ,
Retropharyngeal or Parapharyngeal abscess
2.Trauma
External injury of larynx and trachea ,Trauma
due to endoscopies, especially in infants and
children,Fractures of mandible or maxillofacial
injuries
3.Neoplasms
Benign and malignant neoplasms of larynx,
pharynx, upper trachea, tongue and thyroid
12. 4.Foreign body larynx
4.Oedema larynx
•Due to steam, Irritant fumes or gases, allergy
(angioneurotic or drug sensitivity), Radiation
6.Bilateral abductor paralysis
6.Congenital anomalies
•Laryngeal web, Cysts, Tracheo-oesophageal
fistula ,Bilateral choanal atresia
13. B. Removal of
secretion
1.Congestive cardiac failure
2.Infection
3.Pulmonary oedema
4.Bulbar palsy
C. Prolonged ventilation
IIPR is required beyond 72 hours
D. Part of another
procedure
Major head-neck surgery
14. Types of
Tracheostomy
According to situation
1. Emergency tracheostomy
2. Elective tracheostomy
According to duration
1. Temporary tracheostomy
2. Permanent tracheostomy
According to site
1. High tracheostomy
2. Mid tracheostomy
3. Low tracheostomy
15. Emergency
tracheostomy
• It is employed when airway obstruction is
complete or almost complete
• There is an urgent need to establish the
airway.
• Intubation or laryngotomy are either not
possible or feasible in such cases.
16. Elective tracheostomy
• This is a planned, unhurried procedure. Almost all
operative surgical facilities are available,
endotracheal tube can be put and local or
general anaesthesia can be given.
• It is of two types:
(a)Therapeutic: to relieve respiratory obstruction,
remove tracheobronchial secretions or give
assisted ventilation.
(b)Prophylactic: to guard against anticipated
respiratory obstruction or aspiration of blood or
pharyngeal secretions such as in extensive
surgery of tongue, floor of mouth, mandibular
resection or laryngofissure.
18. Based on site
• High : At the level of 1st tracheal
ring.eg- patient of carcinoma
larynx need laryngectomy
• Mid : At the level of 2nd to 4th
tracheal ring.
• Low : Close to the
suprasternal notch
21. Steps Of Operation
1. A vertical incision in
the midline of neck,
extending from cricoid
cartilage to just above
the sternal notch.
This is the most
favoured incision and
can be used in
emergency and
elective procedures. It
gives rapid access with
minimum of bleeding
22. A transverse incision, 5 cm long, made 2 fingers'
breadth above the sternal notch can be used in
elective procedures. It has the advantage of a
cosmetically better scar .
23. 2. After incision, tissues are dissected in the midline.
Dilated veins are either displaced or ligated.
24. 3. Strap muscles are separated in the midline and
retracted laterally.
4. Thyroid isthmus is displaced upwards or
divided between the clamps, and suture-ligated.
25. 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.
26. 5. Trachea is fixed with a hook and opened
with a vertical incision in the region of 3rd
and 4th or 3rd and 2nd rings.
This is then converted into a circular
opening.
The first tracheal ring is never
divided as perichondritis of
cricoid cartilage with stenosis can
result
6. Tracheostomy tube of appropriate size is
inserted and secured by tapes
27. 7.Skin incision should not be sutured or packed tightly as it
may
lead to development of subcutaneous emphysema.
8.Gauze dressing is placed between the skin and flange of
the
tube around the stoma
29. 9.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.
31. 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
33. 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
35. Portex cuffed
tube
• Made of siliconized Poly Vinyl Chloride. It is
thermolabile & prevents crusting.
• Low pressure high volume cuff maintains an
air-tight seal required for:
a) Prevention of aspiration of secretions
b) Positive pressure ventilation
39. Paediatric Tracheostomy
• Soft and compressible trachea ,so difficult to
identify and may get displaced & injure recurrent
laryngeal nerve
• Preferably in general anaesthesia
• Don’t extend neck too much as pleura,innominate
vessels,thymus may get injured
• Post operative x-ray of the neck to know position
of the tube
• Use of soft silastic and portex tube
41. 1.Care of the patient
• Patient will be propped up in position
• Paper , pen & calling bell to the patient for
communication
• Nursing- patient should be nursed by a
trained nurse for 24-48hrs
• Regular checkup of respiration , cyanosis ,
pulse , BP & temperature
• O2 inhalation if needed
42. 2.Care of the tube
A. Suction
• Patient is unable to cough & clear secretion,
so periodic suction is needed by sterile
catheter.
• Suction should be done with finger control
(during withdrawal time )aseptic procedure
with soft rubber catheter
• Diameter of suction tube not more than half of
the diameter of tracheostomy tube
• Duration of suction not more than 10 seconds
at a time to prevent lung collapse
• Suction tube should not be inserted beyond
the lower end of tracheostomy tube
43. •Suction tube should be preserved I savlon
and wash with sterile normal saline before
use
•Suction may be given every 30minutes
interval for 1st 48hrs or if needed
To remove dry crust 1-2ml of normal saline
should be given before suction
B. Cuffed tube
Tracheostomy cuffed tube should be deflate for
5minutes 2 hourly . Cuff of the tube should be
released after 24 hours , if patient is not under
ventilation. 1st tube should be changed after 72
hours
44. C. Humidification
•A wet gauge piece should be kept over the tube
•Installation of normal saline 1-2ml hourly
Humidifier or boiling water kettle in a closed room
3.Care of the stoma
•Regular dressing of the wound to avoid infection
•Skin stiches should be removed after 5-7days
45. Decannulation
When
• Ventilation or suctioning no longer needed
• Patient can control their own airway
• Not be at risk for aspiration
Should be done in a stepwise fashion
• Step 1: Cuff tube replaced by uncuffed
fenestrated tube
• Step 2: Downsize the uncuffed fenestrated
tube
• Step 3: Blocked off the tube for day
time(12hours)
46.
47. Great Ormond Streetprotocol for
ward decannulation
Day Procedure
1 Admission ,downsize the tube to 3.0 tube
2 Block for 12 hours from 8am, if successful
continue overnight for further 12 hours
3 Decannulate ,occlude stoma with adhesive
tape and dressing. Observe on the ward
4 Observe off the ward
5 Discharge
48. Decannulation
difficulty
• Organic causes
• Persistence of cause
requiring tracheostomy
• Obstructing tracheal
granulations
• Tracheal oedema
• Subglottic stenosis
• Collapse of tracheal wall
• (tracheomalacia)
Non-organic causes:
• Emotional dependence in
children
• Inability to tolerate upper
airway
resistanc
e
• In-coordination of laryngeal
opening
refle
x
• Long-standing tube leads to
impaired
laryngeal development
49. Complications of tracheostomy
1. Immediate
Complications(During
tracheostomy)
2. Intermediate Complications (Few
hours or days later)
3. Late Complications (Due to prolonged
use of tube for weeks-months)
50. Immediate
complications
• Haemorrhage
• Aspiration of blood
• Injury to recurrent
laryngeal nerve
• Injury to apical
pleura
(Pneumothorax)
• Injury to oesophagus
(May cause
tracheoesophageal
fistula)
• Apnoea
51. Intermediate
Complications
• Haemorrhage , reactionary or secondary
• Displacement of tube (Due to use of
improper size tube)
• Blocking of tube (Due to excessive
crusting/poor humidification)
• Subcutaneous emphysema
• Tracheitis/Tracheobronchitis with
crusting in trachea
• Pulmonary infections (Due to
compromised airway defense
mechanism)
• Wound infection & granulation
52. Late
Complications
• Haemorrhage (Due to erosion of major
vessels esp innominate/bracheocephalic art)
• Laryngeal stenosis (Due to perichondritis of
cricoid cartilage)
• Tracheal stenosis (Due to tracheal
ulceration & infection)
• Tracheoesophageal fistula (Due to
erosion of trachea by tip of the tube)
• Persistent tracheocutaneous fistula
• Keloid/Unsighty scar at tracheostomy site
• Difficult decannulation
53. Cricothyroidotomy / Mini tracheostomy
•It is an emergency procedure to buy time to
allow patient to be carried to operation
theatre. As an elective procedure it has been
done to clear the bronchial secretion following
thoracic surgery.
•The patient is positioned with the neck
extended over a pillow. The cricothyroid
membrane can be palpated and the area is
infiltrated with local anaesthetic and
epinephrine.
54. The cricothyroid membrane can be incised
either with a scalpel or a wide bore cannula
attached to a syringe half filled with saline. In
the former case, once the airway has been
opened the blunt handle of the scalpel can be
inserted and rotated to create space for a tube
to pass into the trachea.
•A minitracheostomy tube should not be left
in situ for more than a short time as there
will inevitably be some friction between it
and the cricoid cartilage that will predispose
the patient to subglottic stenosis.
55. Large bore cannula with adaptation to connect to anaesthetic circuit
Mini tracheostomy kit
56. Percutaneous Dilational Tracheostomy
•A minimally invasive alternative to
conventional tracheostomy.
•Advantages:
No need of OT, thus is cost effective.
Forms a stoma between tracheal rings,
resulting in reduced blood loss as there is
usually no disruption of blood vessels.
•Avoided in patients who are obese, have neck
mass, difficult to intubate, difficult to extend
neck, larynx & trachea aren’t easily palpable
57. Steps:
1. Neck is extended & incision is given
2cm below the lower border of
cricoid
2. Trachea is exposed & thyroid
isthmus is pushed down
3. Bronchoscope is inserted to monitor the
passage of needle,guide wire & dilator
which are passed into trachea between
2nd & 3rd tracheal ring.
4. After dilatation tracheostomy tube
is inserted.
