2. History
An old surgical procedure
A tracheotomy was portrayed on Egyptian table dated back to 3600 BC
Asclepiades of Persia is credited as the first person to perform a tracheostomy in
100 BC
The first successful tracheotomy was performed by brasovala in 15th century
In 1932 prevent pulmonary infection in neurological impair patient secondary to
infection
1943 remove of bronchial secretion in case of myasthenia gravies
1950 positive pressure ventilation through tracheostomy for patient with
poliomyelitis
3. Tracheostomy is an operative procedure that creates a surgical airway in the cervical
trachea. [1, 2] It is most often performed in patients who have had difficulty weaning off a
ventilator, followed by those who have suffered trauma or a catastrophic neurologic
insult. [3] Infectious and neoplastic processes are less common in diseases that require a
surgical airway.
Indications
The advent of the antibiotic era and advances in anesthesia have made tracheostomy a
commonly performed elective procedure.
Upper airway foreign body that cannot be dislodged with Heimlich and basic cardiac life support
maneuvers
Inability to intubate’
Inability of patient to manage secretion
Upper airway foreign body that cannot be dislodged with Heimlich and basic cardiac life support
maneuvers
4. INDICATION
Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral vocal cord
paralysis)
Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid bone, or
great vessels
Subcutaneous emphysema
Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of
the mid face and mandible)
Upper airway edema from trauma, burns, infection, or anaphylaxis
Prophylaxis (as in preparation for extensive head and neck procedures and the
convalescent period)
Severe sleep apnea not amendable to continuous positive airway pressure devices or
other less invasive surgery
5. Contra indication
No absolute contraindications exist for tracheostomy. A strong relative
contraindication to discrete surgical access to the airway is the anticipation that the
blockage is a laryngeal carcinoma. The definitive procedure (usually a
laryngectomy) is planned, and prior manipulation of the tumor is avoided because it
may lead to increased incidence of stomal recurrence. Temporary tracheostomy
may be performed just under the first tracheal ring in anticipation of a laryngectomy
at a later time.
End-of-life issues may also come to bear on the decision to perform a tracheostomy
because it may represent further mechanization of the patient's care to family
members. In fact, the performance of a tracheostomy does not affect the decision to
extend or to withdraw care. Hygiene is improved, quality of life (speaking and
eating, if relevant) is improved, and placement in long-term care is facilitated in
some cases; however, dependence on mechanical ventilation may not be changed.
6. Patient selection - Percutaneous versus
open tracheostomy
In 1969, Toy and Weinstein described a technique of tracheostomy performed
percutaneously at the bedside using essentially a Seldinger technique
modified with progressive dilation. [5]
Its main advantage is that it can be performed at the bedside; therefore, the
expense and logistics of transportation and operating room usage are
eliminated. These advantages are mitigated because bedside anesthesia is
required and bronchoscopic visualization adds to the expense and personnel
required. Moreover, preparation for the possibility of an emergent open
tracheostomy is important.
Its disadvantages stem from the decreased exposure and thus decreased
visualization and control. A study of 149 critically ill patients found a greater
risk of severe (>50%) suprastomal stenosis developing as a late complication
of percutaneous dilational tracheostomy versus surgical tracheostomy.
7. CONTINUE…
The following patients are commonly recognized to be unfavorable candidates:
Patients with obesity
Patients with abnormal or poorly palpable midline neck anatomy
Patients who need emergency airways
Patients with coagulopathy
Pediatric patients
Patients with enlarged thyroids
8. CONTINUE…
Kost reported on the use of this procedure in 500 consecutive intubated adults
in the intensive care unit. [7] When this procedure was performed in conjunction
with bronchoscopy, the complication rate was acceptably low (9.2%). No
serious complications (eg, pneumothorax, pneumomediastinum, death)
occurred. The most common complications were oxygen desaturation in 14
patients (defined as a drop, even transient, to less than 90%) and bleeding in
12 patients (when intervention was required to control the bleeding).
9. Complication prevention
Potential complications are due to direct injury. Bedside ultrasound is often used to
survey the tracheostomy site during the planning stage, especially for percutaneous
tracheostomies. This is to identify vessels that may be under the intended incision
and to help avoid injury.
The cricothyroid muscle, vocal muscles, and the vocal cords are vulnerable to injury
during tracheostomy
The innominate artery, or brachiocephalic trunk, crosses from left to right anterior to
the trachea at the superior thoracic inlet and lies just beneath the sternum. The
trachea is membranous posteriorly and is formed of semicircular cartilaginous rings
anteriorly and laterally. The spaces between the rings are membranous.
The recurrent laryngeal nerves and inferior thyroid veins that travel in the
tracheoesophageal groove are paratracheal structures vulnerable to injury if
dissection strays from the midline (see the image below). The recurrent laryngeal
nerve is also vulnerable to injury from the cuff of the tracheostomy tube, particularly
if the cuff is overinflated.
10. Continue…
The great vessels (ie, carotid arteries, internal jugular veins) could be damaged
should dissection go far afield, which is a real risk in pediatric or obese patients.
The thyroid gland lies anteriorly to the trachea with a lobe on both sides and the
isthmus, which crosses the trachea at approximately the level of the second
and third tracheal rings. This tissue is extremely vascular and must be divided
with careful hemostasis.
