Tracheostomy

Surgical procedure

wherein a stoma (window) is created connecting anterior wall of trachea to the exterior Tracheotomy: Opening the trachea Laryngotomy: (Cricothyroidotomy/ coniotomy) Opening the larynx at the cricothyroid membrane

History
Rig Veda: 2000BC Sushruta: 600 AD First successful tracheostomy was reportedly

done by Brasovala in the 15th century 1799: George Washington died of an upper airway blockage on which a tracheostomy could have been performed. Though his physician knew of the procedure, he was not willing to perform his first on his first president.

Functions of tracheostomy
Relief from upper airway obstruction By-

pass Prolonged assisted ventilation < airway resistance < dead space Tracheo-bronchial toilet, insufflation Aspiration Anesthesia

Indications for tracheostomy

Obstructive
All causes of stridor Oral, pharyngeal, laryngeal,

tracheobronchial Intraluminal/ extraluminal Congenital/ inflammatory/ traumatic/ neoplastic/ neurological

Non-obstructive

Oral
Cong. Inflam. Macroglossia, micrognathia,

congenital tumours Ludwigs angina

#mandible, odema tongue,

Trauma

hematoma, corrosive poisoning Neoplasm Ca. tongue

Neuro Unconscious

Oropharynx/ Hypopharynx
Cong. Inflam. Trauma Neoplasm

Macroglossia, Micrognathia,

congenital tumors, lingual thyroid Acute tonsillitis, quinsy, OSAS

Hematoma, corrosive poisoning, FB Ca. base tongue, tonsils, hypopharynx

Neuro Misc

Cricopharyngeal spasm-aspiration Pharyngeal pouch

Larynx
Cong. Inflam. Trauma Laryngomalacia, stenosis, web,

cyst, cong. Tumors Acute epiglottitis, ALTBS, diphtheria, laryngeal odema FB, LTT, LTS, corrosive poisoning

Neoplasm Ca. larynx, juvenile laryngeal Neuro

papillomatosis Bilateral abductor palsy- post thyroidectomy, CTS, aspirationsecretional obstruction

Tracheo-bronchial
Cong. Inflam. Trauma Atresia, tracheo-esophagial fistula ALTBS FB

Neoplasm Ca. trachea, bronchus Neuro -

Neck-Mediastinum (Extraluminal)
Cong. Inflam. Abnormal vessels, mediastinal

Trauma

tumors Mediastinitis, pneumomediastinum, retro/ parapharyngeal abscess Hematoma, pneumomediastinum

Neoplasm Thyroid malignancy, Neuro

Mediastinal tumors, lymphoma -

Non-obstructive indications
Assisted ventilation

Assist tracheo-bronchial toilet

Aspiration

Anesthesia
Alaryngeal

Assisted ventilation
Higher centre, comatosed: Head injury, CVA,

encephalitis, etc. Resp. centre: Bulbar paralysis, barbiturate poisoning, OP poisoning, drug intoxications Anterior horn cells/ nerves: Polio, polyneuritis, cervical spine injury Myo-neural junction: Tetanus Resp. muscles: Myasthenia gravis Chest wall: # ribs, pain Lungs: COPD, status asthmaticus, collapse, emphysema, pneumothorax, etc.

Types of tracheostomy
Timing Elective Emergency Semi-emergency Duration Temporary Permanent
Tracheal fenestration Post-laryngectomy

Site High Mid Low Technique Anterior wall-skin

Slit/ window/ U or H flap

End-skin

Age Adult Pediatric

Tracheostomy tubes
Metalic Jacksons Fullers Plastic (Portex) Cuffed Non-cuffed
Single cannula Double cannula

Technique
Position Place a sand bag under the shoulders Extension of neck and extension of head at the atlanto-occipetal joint

Technique: anesthesia
LA/ GA

LA: Area of infiltration- Rhomboid

Incision
Emergency- Vertical

in midline from cricoid to suprasternal notch Elective: Horizontalmidpoint between cricoid and suprasternal notch (2 fingers)

Deeper layers
Dissected vertically in the midline

Layers encountered
Superficial fascia- fatty and membranous

layers (anterior communicating vein) Investing layer of deep cervical fascia Strap muscles- retractor Pre-tracheal layer covering isthmus of thyroid

Isthmus of thyroid
May be dealt in 3 ways
1. Retract upwards using blunt single hook

(Isthmus hook) 2. Divide between clamps and later suture the stumps 3. Expose trachea either below or above isthmus Inferior thyroid veins

Technique- continued
Pretracheal layer covering trachea Expose trachea Palpate for cricoid cartilage, stabilize- cricoid

hook Inject 4% lignocaine- confirm airway and suppress cough Slit (Vertical/ horizontal) or create window between 3-5th tracheal rings Insert tube- Preferably cuffed- inflate Straps after flexing neck/ suture tube to skin Wound closure- NOT TIGHT Assist ventilation with O2

Post-operative care
Aseptic precautions Barrier nursing Tube position and patency- Ventilator

tubes pull/ restless patients Cuff management Wound dressed to prevent maceration from secretions and skin erosion from tube straps Tracheo-bronchial toilet- Suction with Y connector Change of tubes- after 72 hrs- track formation
In emergency situations (<72hrs.)- extend neck, keep tube ready, use tracheal dilator and quickly change the tube

Antibiotics, mucolytics, analgesics, supportive

Complications- Immediate
Apnoea, aspiration

Bleeding
Collapse of the lungs

Damage to adjacent structures- larynx,

esophagus, thyroid, vessels, recurrent laryngeal nerves, etc. Embolism- air

Complications- Intermediate
Tube obstruction Tube displacement Tracheal erosion Surgical emphysema Wound infection Tracheitis, tracheobronchitis, lung

infections Granulation tissue, bleeding Dysphagia- Subglottic pressure, pain, cuff

Complications- Late

Difficult decannulation Tracheomalacia Tracheo-cutaneous fistula Tracheo-esophageal fistula (cuff+nasogastric tube) Tracheo-arterial/venous fistula Laryngotracheal stenosis Scar FB

Decannulation
Rule-out proximal obstruction

Corking the Fullers tube/ small

size Jacksons tube/ fenestrated plastic tube Observe for 48 hours If able to tolerate corkingremove the tube Strap plaster/ suture the wound