Tracheostomy, an emergency procedure need to understand atleast basic terminologies.

1. Tracheostomy
Submitted by-
Dr. Vandita Chaurasia
(Resident)
Department of Oral & Maxillofacial Surgery

2. CONTENTS
 DEFINITION
 INDICATION
 FUNCTIONS
 TYPES
 PROCEDURE
 PAEDIATRIC TRACHEOSTOMY
 POST OPERATIVE CARE
 DECANNULATION
 COMPLICATIONS

3. DEFINITION
 Tracheostomy is a surgically created airway done by making a
hole in anterior wall of the trachea and insertion of tracheostomy
tube which may or may not be permanent.

4. INDICATION
 There are three main indications-
A. Respiratory obstruction
B. Respiratory secretions
C. Respiratory insufficiency.

5. RESPIRATORY OBSTRUCTION
 Infections- laryngo trachea bronchitis, epiglottis, diphtheria, ludwigs angina,
peritonsillar retropharyngeal or parapharyngeal abscess.
 Trauma – injury to larynx and trachea , trauma due to endoscopes fractures
of mandible and maxillofacial injuries.
 Neoplasms – benign and malignant neoplasms of larynx ,pharynx upper
trachea,tongue , thyroid.
 Foreign body
 Oedema
 Bilateral abductor paralysis
 Congenital anomalies- cysts , tracheooesopageal fistula

6. RESPIRATORY SECRETIONS
 Inability to cough – coma of any cause eg head injuries , cerebrovascular
accidents
 Paralysis of respiratory muscle eg- spinal injuries
 Spasm of respiratory muscles eg tetanus
 Painful cough- chest injuries, multiple rib injury.
 Aspiration of pharyngeal secretions- bilateral laryngeal paralysis.

7. RESPIRATORY INSUFFICIENCY
 Chronic lung conditions like emphysema, chronic bronchitis,
bronchiectasis.

8. Tracheostomy tube
structure and parts

9. Metallic conventional
tracheostomy tube sizes 2, 3, 4,
5, and 6 with inner cannulae
inserted

10. TRACHEOSTOMY TUBE TYPES
 They are endurable, inert, and resistant
to biofilm formation; they limit bacterial
growth; they are easily sanitized and can
be sterilized
 cost effective for long-term use.
 inelastic, do not have a cuff or a
connector for mechanical ventilation,
and can harm the trachea by heat or
cold injury, hence they are not suitable
for patients on radiation therapy whose
radiation field is near the device.
 They are available from size 00 to size 12.
 Plastic tubes can be semiflexible or rigid.
 The first type adapts to the patient’s
anatomy, normally has a right angle,
and has a longer cannula.
 The second type does not collapse or
deflect, does not have a right angle,
and is usually used for neck swelling
 but it is not suitable for patients with
thick necks, since its main shaft is short
Metallic tube PLASTIC TUBE

11. plastic uncuffed tube with an
inner cannula
cuffed tube with an
inner cannula

12. Fenestrated tubes have an
opening on the posterior wall
of the cannula, which allows
the air to flow and be
exhaled through it.
This feature is important for preparing
the patient for decannulation and
phonation. When it is plugged and
the cuff (if present) is deflated, the
air flows to the upper airway through
this opening and around the
cannula. This makes it possible to
assess the patient’s ability to breathe
using the upper airway, and allows
phonation
FENESTRATED METALLIC TUBES

13. FUNCTIONS
 Alternative pathway for breathing
 Improves alveolar ventilation in cases of respiratory insufficiency
 Permits removal of tracheobronchial secretions
 Reducing the resistance to airflow

14. Types
 Emergency
 Elective or tranquil
 Permanent
 Percutaneous dilational tracheostomy
 Mini tracheostomy (cricothyroidotomy)

15. Emergency tracheostomy
 It is employed when airway obstruction is complete
 There is an urgent need to establish an airway.

16. Elective tracheostomy
 Tranquil , routine tracheostomy
 This is planned unhurried procedure, can be done under genral or local
anaesthesia.
 It is of two types:
 Therapeutic : to relieve respiratory obstruction , remove tracheobronchial
secretion or give assisted ventilation.
 Prophylactic: to guard against anticipated respiratory obstruction or
aspiration of blood or pharyngeal secretions.

17. Permanent tracheostomy
 Required for case of bilateral abductor paralysis or laryngeal stenosis.
 Whenever possible , endotracheal intubation should be done before
tracheostomy this is specially important in infants and children.

18. PROCEDURE
 Tracheostomy can be performed in either an open or percutaneous manner.
 The open tracheostomy involves a vertical or horizontal incision centered over the
second tracheal ring.
 The soft tissue is divided, with care taken to control bleeding or potential bleeding
vessels such as the inferior thyroid veins
 The trachea is exposed in the midline and the second and third tracheal rings
identified.
 A cruciform, T, or U incision is made into the trachea. A tracheal hook or hemostat is
used to expand the opening and a 7.0-8.0-mm tracheostomy tube is placed.
 The cuff is inflated, proper placement confirmed, and the tube secured with ties or
sutures.

20.  Position- supine with a pillow under the shoulders so that neck is extended.
 Anaesthesia-2% lignocaine & 1 in 2 lakh adrenaline injected into incision
line.

21. Markings and landmarks
of
tracheostomy tube

24. After incision ,
tissues are dissected in the midline.
Dilated veins are either displaced or
ligated

25. PAEDIATRIC TRACHEOSTOMY
 Soft and compressible trachea so difficult to identify and may get
displaced and injure recurrent laryngeal nerve
 In general anaesthesia
 Don’t extend neck too much as pleura, vessels and thymus may get
injured
 Postoperative xray of the neck to know position of the tube
 Use of soft and portex tube.

27. POSITION OF AN INFANT FOR
TRACHEOSTOMY
Patient in a supine position without neck
extension.
Patient correctly positioned, with neck extension.
Part of the rolled sheet can be seen under the
right shoulder (outlined in red).

28. Infant undergoing conventional
tracheostomy
Horizontal skin incision.
Horizontal subplatysmal
dissection.
Vertical dissection with
lateral retractors.

29. Vertical tracheostomy
Uncuffed tracheal tube.
Tube positioned
Tube fixated
with ties around
the neck

30. DECANNULATION
 Adult – plug or seal tube opening & if tolerated for 24 hrs, remove tube .
 Child - after tube removal close he wound. Healing occurs within 1 week.
 Infant or young children-
 Decannulate in operation theater
 Equipment for re-intubation should be available
 After decannulation observe for respiratory distress, tachycardia,colour.

31. COMPLICATIONS
 Immediate complications (during tracheostomy)
 Intermediate complications (few hours later)
 Late complications (due to prolonged use of tube for week-
months)

32. Immediate complications
 Haemorrhage
 Aspiration of blood
 Injury to recurrent laryngeal nerve
 Injury to apical pleura (pneumothorax)
 Injury to oesophagus (may cause tracheooesophageal fistula )
 Apnoea (due to carbon dioxide wash out)

33. Intermediate complications
 Haemorrhage
 Displacement of tube (due to use of improper size tube)
 Blocking of tube
 Subcutaneous emphysema
 Tracheitis tracheobronchitis
 Pulmonary infections
 Wound infection and granulation

34. Late complications
 Haemorrhage
 Laryngeal stenosis (due to perichondritis of cricoid cartilage )
 Tracheal stenosis (due to tracheal ulceration & infection)
 Tracheooesophageal fistula (due to erosion of trachea by tip of tube)
 Keloid /scar at tracheostomy site
 Difficult decannulation

35. POST OPERATIVE CARE
1. Constant supervision
 For bleeding , displacement , blocking of tubes , removing secretions
 Pt is given 100% oxygen. Deflate the tube cuff.
2. Suction
Suction catheter length introduced to go beyond inner tube (10cm)

36. Tracheostomy tube care
 Inner tube is removed and cleaned when blocked
 Outer tube never removed before 72hrs to allow formation of trachea
cutenous tract
 Cuff deflated for 10 min every 2 hours to prevent pressure necrosis &
dilational of trachea.

37. Tracheostomy Tube Changes
There are several indications for tube changing,
First change: 7–14 days after placement
• To reduce the size of the tube (as part of weaning from mechanical ventilation and to
facilitate vocalization and swallowing)
• Routine change as part of ongoing airway management (every 60–90 days)
• Malpositioned tube due to incorrect length or size
• Patient–ventilator asynchrony with a tracheostomy tube problem suspected
• Cuff leak
• Tube or flange fracture
• To allow passage of a bronchoscope (larger tube)

38. Percutaneous tracheostomy
The technique is similar to needle cricothyroidotomy.
A vertical skin incision is made and the soft tissue dissected gently until the
tracheal ring can be felt by the tip of the operator’s fingernail.
The needle is then placed into the trachea and air aspirated. A fiberoptic
bronchoscope can be used to guide proper needle placement and confirm
entry.
A guide wire is passed through the needle and the needle is removed. A
graduated dilator is passed into the trachea several times. Then the
tracheostomy tube with a customfitted dilator is passed over the wire. The
dilator and wire are removed, the inner tracheostomy cannula placed, and
the tube secured.

39. Confirming placement
 The best way to confirm placement is to visualize the tube passing through the vocal
cords.
 The use of a stethoscope to confirm placement is recommended. The epigastrium
should be auscultated for gurgling sounds, suggesting an esophageal intubation.
 If esophageal intubation is suggested, the tube should be removed and the patient
reintubated.
 The lungs should then be auscultated for equal and adequate breath sounds.
Absent breath sounds on the left suggests a right mainstem bronchial intubation. The
position of the TT should be checked and retracted until breath sounds are heard
bilaterally.

40. REFERENCES
 Tracheostomy A Surgical Guide
 Fonseca textbook of oral and Maxillofacial surgery volume 2.
 Surgical Tracheotomy Atlas Oral Maxillofacial Surg Clin (2010) 39-
50

41. THANK YOU