Tracheostomy - Dr Rahul Tiwari OMFS SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh

1. TRACHEOSTOMY
Dr. Rahul Tiwari
Final Yr. PG
OMFS - SIDS10/25/2016 6:27:15 AM RT/13/TRACHEOSTOMY/50 1
Good Morning

2. CONTENTS
• INTRODUCTION
• INDICATIONS
• CONTRAINDICATIONS
• EFFECTS
• TIMINGS
• TYPES
• FEATURES
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• TECHNIQUES
• CARE
• DECANULATION
• COMPLICATIONS
• CONCLUSION
• REFERENCES

3. INTRODUCTION
• Tracheotomy refers to the surgical opening of the trachea.
• Tracheostomy refers to the creation of a stoma at the skin surface,
which leads to the trachea.
• Chevalier jackson described the principles of tracheostomy at the
beginning of the 20th century.
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4. INDICATIONS FOR TRACHEOSTOMY
• 1. Upper airway obstruction.
• 2. Prolonged ventilation.
• 3. To provide pulmonary toilet and/or to protect the airway
• 4. As part of another procedure, for example, head and neck surgery.
• 5. Emergency airway access
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5. CAUTIONS AND RELATIVE CONTRAINDICATIONS FOR TRACHEOSTOMY
1. Difficult anatomy – obese, spine injury, tracheal pathology, short neck.
2. Moderate coagulopathy – platelets<50000/ml.
• Prothrombin time or activated partial thromboplastin time >1.5
3. Significant gas exchange problems: e.G. PEEP > 10 cm H2O
4. Evidence of infection in the soft tissues of the neck at the insertion site
5. Age less than 12 years.
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6. EFFECTS OF A TRACHEOSTOMY
• Larynx is by passed - unable to phonate (unless a valved device is used).
• Anatomical and respiratory dead space - breathing.
• Loss of the humidification and filtration function of the nasal mucosa.
• Increased risk of respiratory tract infection.
• Redundant area above the tracheal opening and below the larynx in which
mucus can accumulate and fall back into the lungs.
• A foreign body reaction can occur causing local inflammation.
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7. TIMING OF TRACHEOSTOMY FOR PROLONGED VENTILATION CASES
• Timing - issue of debate.
• Terragni et al - no difference – intubated case- ventilator-associated pneumonia
with early (6-8 days) versus late (13-15 days).
• Tracman study was carried out in the united kingdom to assess the impact of
early (day 1-4 of icu admission) versus late (day 10 or later) tracheostomy - no
significant difference in mortality in icu or hospital length.
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8. TUBES AVAILABLE
• Metallic
• Fuller
• Jackson
• Alder hey
• Nonmetallic
• Portex – cuffed and
noncuffed
• Others
• Portex paediatric
• Shiley paediatric
• Rusch
• Franklin
• Edinburgh
• Negus
• Durhams lobster tail
- Parker
- Aberdeen
- Cole’s
- Patterson
- King college
- Holinger
- Salpekar
- KCH pattern
- Koenig’s
- Bivona foam
- Pit speaking
- Mc Ginnis
- Desaut
- Molyncke

10. Silver Tube
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11. Synthetic cuffed tube
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Synthetic uncuffed tube

12. Fenestrated tube
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Passy Muir speaking valve

13. FEATURES OF TRACHEOSTOMY TUBES
1. Diameter: internal diameter (ID) - 5.0mm to 9.0mm in adult
practice.
2. Cuff: reduces aspiration and leakage of air.
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14. FEATURES OF TRACHEOSTOMY TUBES
3. Inner tube:
• The inner tube has the safety advantage of being easily and quickly
removed to relieve life threatening obstruction due to blood clots or
secretions.
• It is recommended that dual cannula tubes should be used whenever
possible because of the safety advantage.
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15. FEATURES OF TRACHEOSTOMY TUBES
4. Fenestration:
• Phonation
• Simply deflating the cuff
may be an alternative
approach in patients who
do not require positive
pressure respiratory
support
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16. FEATURES OF TRACHEOSTOMY TUBES
5. Flexibility
6. Adjustable flange:
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17. FEATURES OF TRACHEOSTOMY TUBES
7. Subglottic suction: reduce the incidence of ventilator-associated pneumonia.
8. Speaking valve: speaking valves (like the passy muir valve)- phonation.
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18. The Blue Rhino single stage dilator
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This hydrophilically coated, curved
dilator allows progressive dilatation
of the tracheal stoma in a single step,
reducing the risk of posterior
tracheal wall injury, intraoperative
bleeding and the adverse effect on
oxygenation during repeated airway
obstruction by sequential dilators.

19. ANATOMY
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20. TECHNIQUES FOR INSERTION
• Percutaneous & open surgical technique.
• Percutaneous tracheostomy - anaesthesiologist - fibreoptic bronchoscopic
guidance.
• Open surgical tracheostomies - ENT surgeons & Trauma surgeons.
• Percutaneous tracheostomy was first described in the late 1950s and 1960s.
Two initial techniques were described –
• A serial dilatational technique described by ciaglia et al in 1985
• A guidewire dilating forceps (GWDF) method described by griggs and
colleagues in 1990.
• In 2000, byhahn et al modified the ciaglia technique by introducing the blue
rhino.
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21. Percutaneous Tracheostomy Insertion
1.Indication reviewed.
2. Consent .
3. Platelet and coagulation assays, blood grouping,
ultrasound
4. Nasogastric tube feeding - stop for 2 hours – aspirate
& check.
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22. Percutaneous Tracheostomy Insertion
5. Equipment- percutaneous tracheostomy set, a fibreoptic bronchoscope,
drapes and sterile skin preparation, LA.
6. Two clinicians - bronchoscope and tracheostomy insertion, nurse
7. Sedation, analgesia and muscle relaxation - propofol, fentanyl and
atracurium.
8. Position - neck extended- monitored and ventilated with 100% oxygen during
the procedure.
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23. Percutaneous Tracheostomy Insertion
9. ET Tube cuff deflated - tube withdrawn – till tip is distal to the patient’s vocal cords – clears
site.
10. Mark anatomy - 2nd & 3rd Tracheal rings
Insertion above - tracheal stenosis
Insertion below - erosion of thoracic inlet great vessels.
11. Aseptic technique - gown, gloves, and mask and eye protection. patient’s skin - antiseptic
cleaning solution
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24. Percutaneous Tracheostomy Insertion
12. LA - Small transverse skin incision - Blunt
dissection with forceps until the tracheal rings are
felt – Cannulization – Conform via Bronchoscope.
13. Next steps - bronchoscope. Guidewire is passed
into the trachea - intermediate rigid dilator is
passed over the guidewire - curved dilator - as far
as the thick black line, in one smooth movement.
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25. Percutaneous Tracheostomy Insertion
14. Curved dilator removed – insert introducer - tracheostomy tube.
15. Introducer is removed - cuff is inflated - ventilation connected – confirm
(capnography).
16. Secure via supplied tapes – document the procedure.
17. A chest X-ray to exclude pneumothorax.
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27. STANDARD OPEN TRACHEOSTOMY TECHNIQUE
• GA – Operating room.
• Supine - maximal neck extension.
(History of an unstable cervical spine, spinal stenosis, kyphosis, or
severe cervical osteophyte disease may preclude extension of the neck)
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28. The patient is positioned supine with the neck
extended. A transverse incision is fashioned
about 2cm above the suprasternal notch and
below the cricoid cartilage.10/25/2016 6:27:15 AM RT/13/TRACHEOSTOMY/50 28
The subcutaneous tissue and platysma
muscle are divided transversly entering
the sub platysmal plane.

29. • Sterile surgical preparation - 2 cm to 3 cm transverse incision crossing the midline - about 2
cm above the suprasternal notch.
• Subcutaneous tissue & platysma – enter subplatysmal plane
• Longitudinal dissection – superficvial cervical fascia & strap muscles (midline)
• Anterior jugular veins - lateral to the dissection - rarely require ligation.
• Lateral retraction of the sternohyoid and sternothyroid muscles helps to develop the
midline - thyroid gland into view.
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STANDARD OPEN TRACHEOSTOMY TECHNIQUE

30. • The pretracheal fascia & fibrofatty tissue incised inferior to thyroid isthmus.
• Retract beneath the strap muscles - catch edge of isthmus - under surface of
the thyroid lobes - tracheal rings.
• Avoid avulsing small veins that may drain directly into the innominate vein,
and if present, the thyroid ima artery needs to be ligated.
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STANDARD OPEN TRACHEOSTOMY TECHNIQUE

31. Gentle lateral retraction of the strap muscles
helps develop the midline and expose the
underlying thyroid gland and trachea. Rarely it is
necessary to ligate anterior jugular veins
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The thyroid isthmus is retracted cephalad
and lateral traction sutures placed around
the 2nd or 3rd tracheal ring.

32. • Complete homeostasis - insertion of the tracheostomy tube
• The cuff is inflated, checked for leaks and deflated.
• Care should be taken to fully deflate and lubricate the cuff to avoid its getting caught and
torn by the cut edge of a calcified tracheal ring.
• A #15 knife blade, tracheal hook, and tracheal dilators should be readily available.
• The midline is identified, the tracheal rings carefully counted, and lateral traction sutures are
placed around the second or third tracheal ring
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STANDARD OPEN TRACHEOSTOMY TECHNIQUE

33. • A vertical linear tracheostomy is created in the midline, ideally between rings 2 and
4, and gently dilated.
• The tracheostomy tube is passed into the airway, the cuff inflated, and ventilation
resumed.
• The skin is sutured loosely around the tube with absorbable suture and the flange of
the tracheostomy secured to the skin in all four quadrants.
• Finally the tube is further secured by the passage of a tracheal tie around the neck.
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STANDARD OPEN TRACHEOSTOMY TECHNIQUE

34. #15 blade scapel is used to create longitudinal tracheostomy. The laterally placed traction
sutures provide enough. Distraction to allow for tracheostomy tube placement without
excessive dilation. After confirming tube placement the traction sutures are removed.
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35. Comparison - Types of Tracheostomy
Surgical
tracheostomy
Percutaneous
dilation
Crico
Thyroidotomy
Site 2nd – 3rd or
3rd – 4th
1st and 2nd or
2nd – 3rd
Cricothyroid membrane
Method •Surgical
dissection
•Cut the trachea
Puncture and
dilatation
Puncture with needle
Elective or
emergency
Always elective (in
OT or ICU setting)
For emergency access to
airway
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36. CARE OF THE TRACHEOSTOMY
1.Changing tracheostomy tubes:
• Without inner tubes every 7-14 days
• With inner tubes - thirty days.
• First change -72 hours (infection, reliable track)
• Emergency airway equipment – keep during the change.
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37. 2. Method of suctioning & the interval
in between the two suctions
The interval in adults is 10 to 15 sec.
The duration of suctioning should also
be the same.
In children there should be 3 to 4
breaths in between the two suctions
even if the child is drowning in
secretions.
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38. 3.Humidification:
• Cold and unfiltered air is an irritant - cause tracheal mucosal keratinisation.
• Viscous secretions - difficult to clear, can be life threatening if blocked.
• Inhaled oxygen is appropriately humidified using heat and moisture exchange
(HME) filters or heated water baths.
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39. 4.Nutrition:
• Via a nasogastric or nasojejunal tube.
• Patients may be fed orally, with the cuff inflated or partially deflated, but staff
must be alert to signs of aspiration, such as coughing, increased secretions and
impaired gas exchange.
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40. COMPLICATIONS OF TRACHEOSTOMY
Immediate :
aspiration
Haemorrhage
Air embolism
Failure of procedure
Structural damage to tracheal rings
Injury to recurrent laryngeal nerve
Injury to esophagus
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41. COMPLICATIONS OF TRACHEOSTOMY
• Intermediate complications :
• Delayed haemorrhage • Tube displacement
• Surgical emphysema • Pneumomediastinum
• Pneumothorax • Infection
• Tracheal necrosis • Tracheoarterial fistula
• Tracheoesophageal fistula • Dysphagia
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Massive hemorrhage 1 to 6 weeks caused by tracheoinnominate artery fistula.

42. COMPLICATIONS OF TRACHEOSTOMY
• Management of tracheoinnominate artery fistula hemorrhage :
1.Overinflate the tracheostomy cuff to tamponade the hemorrhage
2.Replace the tracheostomy tube with an oral endotracheal tube. Position the cuff with
fiberoptic bronchoscopic guidance just above the carina.
3.Use digital compression of the innominate artery against the posterior sternum using a
finger passed through the tracheostomy stoma
4.Slowly withdraw the endotracheal tube and overinflate the cuff to tamponade
5.Then proceed with definitive therapy: sternotomy and ligation of the innominate artery.
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43. COMPLICATIONS OF TRACHEOSTOMY
• Delayed complications :
• Tracheal stenosis - due to collapse of the cartilaginous ring - fibrosis.
• Decannulation problem
• Tracheocutaneous fistula – tracheal granuloma.
• Disfiguring scar
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44. WEANING AND DECANNULATION
• Removal as Required.
• Decannulation - Resume breathing
• Patients can be trialled cuff deflation – swallowing and cleaning
• Decannulation - Not dependent on ventilatory support & able to
cough and clear his secretion
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45. WEANING AND DECANNULATION
• Decannulation done in morning so to review their progress the whole day.
• Tube is removed and the stoma is covered with a semi-permeable dressing.
• Encourage to gently press over this defect with whilst speaking or coughing.
• Subsequent monitoring for signs of respiratory distress.
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Is a hollow, 16- or 20-French, silicone tube
that has a one-way flap valve positioned
within its proximal tip - used in phonation
& prevents aspiration.

47. Complications of Bloom-Singer valve:
• Candida infection in and around the prosthesis
• Leakage through the valve due to defective one-way valve
• Peri-prosthetic leakage
• Occlusion of the prosthesis
• Inadvertent displacement and aspiration
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50. REFERENCES
• 1. Tracheostomy–a Multiprofessional Handbook Claudia Russel & Basil Matta–1st Ed
• 2. Tracheostomy - Eliana Soto, Downstate Medical Center.
• 3. Bailey & Love’s Short Practice Of Surgery 23rd Edition.
• 4. An Atlas Of Head & Neck Surgery-lore’ 3rd Edition.
• 5. Operative Otolaryngeo, Head & Neck Surgery- Myers,vol I.
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