DR JUVERIA MAJEEDMS ENT,

Govt.ENT Hospital/Osmania Medical College

TRACHEOSTOMY

A Tracheostomy is an artificially( usually) surgically created airway fashioned by making a hole in the anterior wall of trachea and the insertion of a tracheostomy tube, which may or may not be permanent.

Tracheotomy is the opening into trachea where as tracheostomy is converting the opening into stoma onto the skin surface.

What is a tracheostomy?

Tracheostomy is one of the oldest surgical procedure.

A tracheotomy was portrayed by the Egyptians and Indians in the early years.

Extensive history of tracheostomy can be best divided into five periods:

1. The period of Legend (3100BC to AD 1546)- The first elective tracheotomy by Asclepiadus of

Bithynia in AD100. This operation ws described by Claudius Galen,

renowned physician in AD 131 References were made to tracheotomy, but was

considered both useless and dangerous due to high risk of wound infection

Hippocrates condemned tracheostomy

History

2. The period of Fear(AD 1546-1833) in the history of tracheostomy:

During this era, this procedure ws considered as irresponsible and barbaric.

By early 1600s, it started getting acceptable for few conditions like FBs etc.

Bcoz of fear and mistrust abt procedure, it prevented therapatic use of it, for eg. In 1799,dec4th,first US president died of acute(within 36 hours) upper airway obstruction sec. to peritonsillar abscess

3.The period of Dramatisation(AD 1833-1932):

It was considered as operation of life or death.

The operative technique of tracheostomy was studied, refined and defined by Chevalier Jackson in 1909.

He also designed the metallic double lumen tube

4. The period of Enthusiasm(AD 1932- 1965) Wherein saying “if u think tracheostomy……do it” became

popular. Indications for tr. Were actively sought for and both

surgical and medical world became strong advocates for it 5.The period of Rationalisation(AD 1965 to present): In 1965, it became apparent tht oral or nasal intubation

was quicker and safer than tr. So began this period wherein tr. Vs intubation ws debated.

Seldinger introduced PCT in 1953 PCT using guidewire introduced by Ciaglia et al. In 1990 Griggs et al developed another guidewire dilating

forceps for PCT

Surgical anatomy of trachea The trachea begins at the

lower border of cricoid cartilage(C6) superiorly to the tracheal bifurcation at the level of sternal angle(T5).

Made up of 16 to 22 C-shaped cartilage anteriorly joined by annular ligaments and posteriorly by trachealis muscle.

Located in midline position,but can be deviated to right as in advanced age or severe COPD.

The average distance from cricoid to carina is approx 12-16 cm long,2.3 cm wide.

Anterior to the trachea in the neck is the isthmus of the thyroid gland at about the level of 2nd to 4th tracheal cartilages.

Below this is the inferior thyroid veins, lymph nodes, and sometimes a thyroid ima artery.

Anterior to all of these are the strap muscles. Lateral to trachea in the neck are the lobes of

thyroid gland, great vessels and recurrent laryngeal vessels.

The innominate artery crosses the trachea either behind the sternum or in the lower portion of neck.

During tracheostomy the careful surgeon will palpate this region to assess the presenceof high riding innominate artery.

The jugular venous arch connecting two anterior jugular veins lies superficial to the strap muscles just above the suprasternal notch.

The basic anatomical relationships need to be kept in mind in performing a tracheostomy.

High tracheostomies (above 2nd tracheal cartilage) are generally associated with a higher rate of tracheal stenosis and perichondritis of cricoid cartilage.

Low tracheostomy (below 4th tracheal cartilages) will encounter more vascular structures such as thyroid veins, ant. Jugular arch, or a high innominate artery.

Neck anatomy and its relevance to tracheostomy

Horizontal skin incisions tend to be more cosmetic, although the ext. jugular veins and lateral anatomic structures must be considered during dissection.

Vertical skin incisions tend to be avascular. Paediatric larynx and tracheal anatomy

varies from adult and has a great clinical signiicance.

Paediatric vs Adult airway

Arteries of central neck: Common carotid A. Carotid bifurcation Internal carotid A Ext. carotid A. and br. Superficial veins of central neck: Ext. Jugular vein and ant jugular vein Deep veins of central neck: Internal jugular vein

Important structures to be careful while performing tracheostomy

Nerves of central neck: Cutaneous innervation Tenth nerve and its br. Twelfth nerve and ansa cervicalis

Visceral structures of neck Thyroid gland Larynx Trachea and esophagus

Indications for TracheostomyProlonged intubation

Facilitation of ventilation support

Inability of patient to manage secretions

Upper airway obstruction

Inability to intubate

Adjunct to major head and neck surgery

Adjunct to management of major head and neck trauma

Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005.

Goldenberg D, et al Tracheotomy: changing indications and a review of 1,130 cases, J Otolaryngol 31:211–215, 2002

Indications: Mechanical Obstruction

Tracheostomy in a number of medical and surgical conditions e.g.:-

Trauma to the chest. C.C.F. & pulmonary edema. C.O.P.D Head injury. Coma. Strychnine poisoning. Tetanus, Rabies, Poliomyelitis. Neurological conditions.

Before doing major head and neck surgery tracheostomy is done to prevent post operative complications.

Indications

Emergency tracheostomy

Elective – therapeutic or prophylactic

Permanent

Types of Tracheostomy

Emergency: when airway is complete or almost completely obstructing as in FBs or acute infections.

Elective: planned unhurried procedure.Often temporary and closed when indication is over.

Therapeutic: to relieve respiratory obstruction,remove tracheobronchial secretions or gv assisted ventilation.

Prophylactic: in extensive surgeries of tongue, floor of mouth, mandibular resection or laryngofissure.

Permanent tracheostomy: In b/l abd. paralysis, laryngectomy, laryngopharyngectomy.

high

Above the level of thyroid isthmus

-Violates 1st tracheal ring -Ca larynx

Types of tracheostomy

Position: supine with a pillow under the trachea. This brings trachea forward.

Anesthesia: mostly done under local with 2% lignocaine with epinephrine. Sometimes GA is used.

Incision:Vertical- midline of neck, from cricoid above to sternal notch.

Most favoured incision. Can be used in both elective and emergency. Rapid access with minimum bleeding and tissue dissection.

Horizontal -2 fingers breadth above the sternal notch. Used in elective procedure only. Cosmetically better scar.

Technique & Steps of operation

Strap muscles separated in midline and retracted laterally.

Thyroid isthmus is displaced upwards or divided-ligated.

Identification of tracheal rings by colour and palpation

confirmation- 4% lignocaine loaded syringe introduced, withdrawn to see for air bubbles, also to suppress cough.

Vertical incision given in trachea from below upwards in 3 or 4th tracheal rings

Tube of appropriate size used. Tied to neck with reaf knot.

Skin sutures not required.

Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch.

Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally

http://www.yoursurgery.com/ProcedureDetails.cfm?BR=6&Proc=54

Inserting a Tracheostomy Tube:

Baby with One Fingertip

Securing the Tracheostomy Tube

D

One Fingertip Fits Under the Adult Ties

BLS

ANATOMICAL POSITIONING OF A TRACHEOSTOMY TUBE

INFANTS

•Sub glottic haemangioma

•Sub glottic stenosis

•Laryngeal cyst

•Glottic web

•Bilateral vocal cord paralysis

CHILDREN

•Acute laryngotracheal bronchitis

•Epiglottitis

•Diphtheria

•External laryngeal trauma

•Prolonged intubation

•Juvenile laryngeal papillomatosis

•Bilateral abductor paralysis

Paediatric tracheostomy indications

GA Trachea –soft and compressible Too much of extension- Pleural injury,

innominate , thymus injury Silk sutures on either side of trachea to

secure it in midline Not to incise deeply as it can cause

posterior tracheal wall injury. Not to excise ant. Wall of trachea- only

incision is given Avoid infolding of ant tracheal wall Proper selection of T tube

Paediatric Tracheostomy

Nursing: constant supervision of pt after tracheostomy for bleeding, displacement or blocking of tube and removal of secretions.

Removal of secretions: Suction Prevention of crusting and tracheitis:

Humidification, use of normal or hypotonic saline or RL. If tenacious secretions, use of N-acetylcysteine to loosen crusts

Care of T.tube: Inner tube cleaning Care of inflatable cuff Dressing: to avoid maceration of skin from

secretions Breathing exercises: recommeded to ventilate

the lungs fully and prevent pulmonary infections

A calling bell, slate and a pencil for communication

Post operative care

ICU Bed SideTracheostomy Minimally invasive alternative to open

tracheostomy Use of guide wire and Dilators Under the vision of Bronchoscope through

endotracheal tube Less time ,Less Expensive Not suitable for thick neck and in

emergency

Percutaneus Dilational Tracheostomy

Percutaneous tracheostomy

INTRODUCTION OF TRACHEAL NEEDLE

Placement of guide wireINSERTION OF GUIDING CATHETER

SERIAL DILATIONPlacement of tracheostomy tube

Percutaneous tracheostomy

Intraoperative Complications.

Anaesthesia complications

Bleeding and injury to big vessels

Apnoea- due to sudden washout of co2

Injury to recurrent laryngeal nerve

Injury to tracheoesophageal wall

Pneumothorax- injury to apical pleura

Complications of Tracheostomy

Bleeding, reactionary or secondary Tracheostomy tube obstruction Tracheostomy tube displacement Subcutanoues empysema Tracheitis and tracheobronchitis with

crusting in trachea Atelectasis and lung abcess Local wound infection and

granulations

Early Complications

• Hemorrhage, due to erosion of major vessels• Laryngeal stenosis, due to perichondritis of

cricoid cartilage• Tracheal stenosis, due to tracheal ulceration and

infection• Tracheo –oesophageal fistula• Problems of decannulation• Persistant tracheocutaneous fistula• Problems of T.scar- keloid formation• Corrosion of tracheostomy tube and aspiration of

its fragments into tracheo bronchial tree

Late complications

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TRACHEAL STENOSIS & TRACHEO-INNOMINATE ARTERY FISTULA

T. tube should not kept longer than necessary

To decannulate, it shud be plugged or corked and the pt shud be able to sleep overnight with the tube closed before decannulation

After tube removal , pt is closely monitored for resp.distress and tachycardia

Decannulation

It may be: Persistance of the condition for which

tracheostomy was done. Obstructing granulations: around stoma or

at tip of tube Tracheal oedema or subglottic stenoses Incurving of tracheal wall at the site of

tracheostome Tracheomalacia Psychological depandance

Difficult Decannulation

1. Increased patient mobility2. More secure airway3. Increased comfort4. Improved airway suctioning5. Early transfer of ventilator-dependent

patients from the intensive care unit (ICU)

6. Less direct endolaryngeal injury7. Enhanced oral nutrition8. Enhanced phonation and communication9. Decreased airway resistance for

promoting weaning from mechanical ventilation

10.Decreased risk for nosocomial pneumonia in patient subgroups

Tracheostomy vs Intubation

TRACHEOSTOMY TUBES A tracheostomy tube

is:-◦ Inserted through the

tracheostomy to maintain a patent airway

◦ Secured in place by tapes tied around the neck

◦ Ideal T.tube: ◦ Rigid enough to maintain

the airway.◦ Yet flexible enough to

limit tissue damage◦ Comfortable to the pt.

Parts of tracheostomy tubes

Parts Description Outer cannula 1. Main body of the tube which passes

into trachea2. Diameter – inner dia of this outer

cannula

Inner cannula 1. Removable tube –passes into outer tube

2. A bit longer 3. Can be locked

Cuff 1. Balloon at the distal end2. Protection

Pilot balloon 1. Ext balloon connected by a inflation line to cuff

Flange – neck plate

1. Supports the tube2. Straight strip- adults3. Angulated- pediatric4. Adjustable flanges- bulky neck

Introducer/ obturator

1. Beveled tip shaft2. Smooth round dilating tip 3. Reduces trauma – insertion

Fenestrations 1. Single/ multiple2. Speaking 3. Coughing

Adaptor 1. Ventilatory equipment

Passy Muir valve Speaking valves are

one way valves that allow inhalation through the tracheostomy tube but block exhalation through the cannula forcing exhaled gas through vocal cords allowing phonation

Accessories- speaking valve

TYPES OF TRACHEOSTOMY TUBE

Cuffed- when inflated, this tube seals the airway and prevents the aspiration of oral or gastric secretions.

Maintains airway once aspiration risk has passed.

Increases airflow to the larynx.

Required in Long term T. pts Pts who do not

require a seal Paediatrics

Uncuffed Tube

TYPES OF TRACHEOSTOMY TUBE

Fenestrated

JACKSON’S TRACHEOSTOMY TUBE-

Metallic tracheostomy tubes

JACKSON’S TRACHEOSTOMY TUBE-

Metallic tracheostomy tubes

Metallic tracheostomy tubes

HOLLINGER’S TRACHEOSTOMY TUBE-

Metallic tracheostomy tubes

TUCKERS’ TRACHEOSTOMY TUBE-

Metallic tracheostomy tubes

MARTIN’S TRACHEOSTOMY TUBE-

Metallic tracheostomy tubes

PVC- Most cost effective, for short term use , More prone to infections.

Silicone –soft material, unique characteristic of reducing adherence of secretions and bacteria

Siliconised PVC- sufficient rigidity, Thermosensitive, More pt. comfortable. Eg Portex ultra

Silver- 92.8% silver, Cu and P with silver lining, For prolonged use. Eg Negus and Chavelier Jackson

Sialistic –silicon rubber, less rigid. Eg. Moore

What are tubes made of

Complications of tube