Establishing alternative pathway for breathing

1. TRACHEOSTOMY
--- Prashiddha Dhakal
MBBS,KUSMS

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

4. Functions of Tracheostomy
1. Alternative pathway for breathing
2. Improves alveolar ventilation In cases of respiratory insufficiency :
(a) Decreasing the dead space by 30-50% (normal dead space is 150 ml).
(b) Reducing the resistance to airflow.
3. Protects the airways By using cuffed tube, tracheobronchial tree is protected against
aspiration of:
(a) Pharyngeal secretions, as in case of bulbar paralysis or coma.
(b) Blood, as in haemorrhage from pharynx, larynx or maxillofacial injuries. With
tracheostomy, pharynx and larynx can also be packed to control bleeding.
4. Permits removal of tracheobronchial secretions
When patient is unable to cough as in coma, head injuries, respiratory paralysis; or
when cough is painful, as in chest injuries or upper abdominal operations, the
tracheobronchial airway can be kept clean of secretions by repeated suction through the
tracheostomy, thus avoiding need for repeated bronchoscopy or intubation which is not
only traumatic but requires expertise.
5. Intermittent positive pressure respiration (IPPR)
If IPPR is required beyond 72 hours, tracheostomy is superior to intubation.
6. To administer anaesthesia
laryngopharyngeal growths or trismus.

5. Indications of Tracheostomy
There are three main indications
A. Respiratory obstruction.
B. Retained secretions.
C. Respiratory insufficiency.

6. A. Respiratory obstruction
1. Infections
Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria, Ludwig's angina,
peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess
2. Trauma
External injury of larynx and trachea ,Trauma due to endoscopies, especially in
infants and children,Fractures of mandible or maxillofacial injuries
3. Neoplasms
Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and
thyroid
4. Foreign body larynx
5. Oedema larynx
due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity),
radiation
6. Bilateral abductor paralysis
7. Congenital anomalies
– Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia

7. B. Retained secretions
1. Inability to cough
– Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic
overdose
– Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre
syndrome, myasthenia gravis
– Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning
2. Painful cough
– Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
– Bulbar polio, polyneuritis, bilateral laryngeal paralysis

8. C. Respiratory insufficiency
• Chronic lung conditions, viz. emphysema, chronic bronchitis,
bronchiectasis, atelectasis.

9. Types of Tracheostomy
• Emergency tracheostomy
• Elective or tranquil tracheostomy
• Permanent tracheostomy
• Percutaneous dilatational tracheostomy
• Mini tracheostomy (cricothyroidotomy)

10. 1. Emergency tracheostomy
• It is employed when airway obstruction is complete
or almost complete and
• There is an urgent need to establish the airway.
• Intubation or laryngotomy are either not possible or
feasible in such cases.

11. 2. Elective tracheostomy
(syn. tranquil, orderly or routine tracheostomy)
• This is a planned, unhurried procedure. Almost all operative
surgical facilities are available, endotracheal tube can be
put and local or general anaesthesia can be given.
• It is of two types:
(a) Therapeutic: to relieve respiratory obstruction, remove
tracheobronchial secretions or give assisted ventilation.
(b) Prophylactic: to guard against anticipated respiratory
obstruction or aspiration of blood or pharyngeal secretions
such as in extensive surgery of tongue, floor of mouth,
mandibular resection or laryngofissure.

12. 3. Permanent tracheostomy
• Required for case of bilateral abductor
paralysis or laryngeal stenosis.

13. BASED ON LEVEL
TRACHEOSTOMY
HIGH
MID
LOW
above the level of thyroid isthmus
perichondritis of the cricoid cartilage
and subglottic stenosis and is always
avoided.
Only indication - carcinoma of larynx
because in such cases, total larynx
anyway would ultimately be removed and
a fresh tracheostome made in a clean
area lower down
(THYROID isthmus lies against II, III and IV
tracheal rings).
preferred one
Through the II or III rings and would entail
division of the thyroid isthmus or its retraction
upwards or downwards to expose this part of
trachea.
below the level of isthmus.
Trachea is deep at this level and close to several
large vessels; also there are difficulties with
tracheostomy tube which impinges on
suprasternal notch.

14. Technique
• Whenever possible, endotracheal intubation
should be done before tracheostomy. This is
specially important in infants and children.
• Position
Supine with a pillow under the shoulders so
that neck is extended.

16. Anaesthesia
2 % lignocaine & 1 in 2 lakh adrenaline injected into incision line

17. Steps Of Operation
1. A vertical incision in the
midline of neck, extending
from cricoid cartilage to just
above the sternal notch.
This is the most favoured
incision and can be used in
emergency and elective
procedures. It gives rapid
access with minimum of
bleeding and tissue
dissection.

18. A transverse incision, 5 cm long, made 2
fingers' breadth above the sternal notch can
be used in elective procedures. It has the
advantage of a cosmetically better scar .

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

20. 3. Strap muscles are separated in the midline and
retracted laterally.
4. Thyroid isthmus is displaced upwards or divided
between the clamps, and suture-ligated.

21. 5. Trachea is fixed with a hook and opened with
a vertical incision in the region of 3rd and 4th
or 3rd and 2nd rings.
This is then converted into a circular opening.
The first tracheal ring is never divided as
perichondritis of cricoid cartilage with
stenosis can result

22. Confirmation of trachea
• 5 ml syringe containing 4 % Lignocaine taken, its needle
inserted into trachea & aspirated. Air bubbles confirm
presence of needle in trachea.
• 2 ml of solution injected into trachea & needle
removed quickly to avoid breaking of needle during
violent cough movements.

23. 6. Tracheostomy tube of appropriate size is inserted and
secured by tapes
Lubricated tracheostomy tube inserted into trachea
Confirm presence of tube in trachea with help of ambu
bag & auscultation

24. Jackson’s metallic tube

25. Jackson’s metallic tube
• Made of German silver (alloy of Ag + Cu + P)
• Has obturator (pilot), inner tube & outer tube
• Inner tube is longer than outer tube for its removal &
cleaning. Outer tube maintains patency. Pilot is inserted
into outer tube for smooth & non-traumatic insertion of
tube
• Lock prevents expulsion of tube during cough

26. Fuller’s bivalve metallic tube
I
O

27. Fuller’s metallic tube
• Outer tube bi-valved. The 2 blades when pressed together,
help in smooth entry of tube.
• Inner tube is longer & has a vent for phonation
• Pt phonates by closing main tube opening
• Vent also helps in decannulation of tube

28. Portex cuffed tube

29. Portex cuffed tube
• Made of siliconized Poly Vinyl Chloride. It is thermolabile
& prevents crusting.
• Low pressure high volume cuff maintains an air-tight
seal required for:
 Prevention of aspiration of secretions
 Positive pressure ventilation

30. Cuffed fenestrated tube

31. Portex uncuffed tube
For tracheostomy patient receiving radiation

32. TYPES OF TRACHEOSTOMY
TUBES
• Plastic or metal
• Cuffed or uncuffed
• Fenestrated or unfenestrated
• Double canula or single canula

34. 7. Skin incision should not be sutured or packed tightly as it may
lead to development of subcutaneous emphysema.
8. Gauze dressing is placed between the skin and flange of the
tube around the stoma

35. 9.Tapes of tracheostomy tube tied around the neck
keeping a space for 1 finger. Neck kept flexed.
Skin incision closed loosely to avoid surgical emphysema.

36. Insertion of medicated gauze
Betadine soaked gauze or Sofratulle put around the
tracheostomy opening.

37. Paediatric Tracheostomy
-Soft and compressible trachea ,so difficult to
identify and may get displaced & injure recurrent
laryngeal nerve
-Preferably in general anaesthesia
-Don’t extend neck too much as pleura,innominate
vessels,thymus may get injured
-Post operative x-ray of the neck to know position
of the tube
-Use of soft silastic and portex tube

38. Post Operative Care
1.Constant Supervision
• For bleeding, displacement, blocking of tubes, removing
secretions
• Patient is given a bell or paper pad to communicate
• Pt given 100 % oxygen. Deflate the tube cuff.

39. 2.Suction
• Suction catheter with negative suction pressure (10 -15
mmHg) used.
• Catheter diameter should be < 1/3rd of internal diameter of
tracheostomy tube
• Catheter length introduced just enough to go beyond inner
tube (10 cm)

41. 3.Tracheostomy tube care
• Inner tube is removed & cleaned when blocked
• Outer tube never removed before 72 hrs to allow formation of
tracheo-cutaneous tract
• Cuff of Portex tube deflated for 10 minutes every 2 hours to
prevent pressure necrosis & dilatation of trachea

42. Cleaning of inner tube

43. 4. Others
• Chest auscultated for confirmation of adequate suctioning. Re-inflate
cuff to a pressure of 25 mmHg. Patient oxygenated again.
• Tracheostomy wound dressing done BID
• Steam inhalation TID. Moist gauze piece placed over tracheostomy
tube opening. Regular chest physiotherapy, expectorants &
mucolytics given.

44. 5.Prevention of crusting and tracheitis
-Proper humidification using
humidifier,nebulizer or keeping boiling kettle in
room.
-Using a few drops of ringer lactate or normal
saline or hypotonic saline
-Every 2-3 hrs

45. Decannulation
• Adult: plug or seal tube opening & if tolerated for 24 hrs, remove tube.
• Child: Sequentially reduce size of tube. After tube removal  close
wound. Healing occurs within 1 week. Secondary closure after
freshening the wound margin is required rarely.
• Infant or a young child
-Decannulate in operation theatre
-Equipment for re-intubation should ne available like good headlight,
laryngoscope, proper sized endotracheal tubes and a tracheostomy tray
-After decannulation observe for respiratory distress,t achycardia, colour.
-Oximetry is useful

47. Decannulation difficulty
Organic causes
• Persistence of cause requiring
tracheostomy
• Obstructing tracheal granulations
• Tracheal oedema
• Subglottic stenosis
• Collapse of tracheal wall
(tracheomalacia)
Non-organic causes:
• Emotional dependence in children
• Inability to tolerate upper airway
resistance
• In-coordination of laryngeal opening
reflex
• Long-standing tube leads to impaired
laryngeal development

48. Complications of tracheostomy
1. Immediate Complications (During
tracheostomy)
2. Intermediate Complications (Few hours or
days later)
3. Late Complications (Due to prolonged use of
tube for weeks-months)

49. Immediate complications
• Haemorrhage
• Aspiration of blood
• Injury to recurrent laryngeal
nerve
• Injury to apical pleura
(Pneumothorax)
• Injury to oesophagus (May
cause tracheoesophageal
fistula)
• Apnoea (Due to Carbondioxide
wash out)

50. Intermediate Complications
• Haemorrhage
• Displacement of tube (Due to use of improper
size tube)
• Blocking of tube (Due to excessive crusting/poor
humidification)
• Subcutaneous emphysema
• Tracheitis/Tracheobronchitis with crusting in
trachea
• Pulmonary infections (Due to compromised
airway defense mechanism)
• Wound infection & granulation

51. Late Complications
• Haemorrhage (Due to erosion of major vessels esp
innominate/bracheocephalic art)
• Laryngeal stenosis (Due to perichondritis of cricoid
cartilage)
• Tracheal stenosis (Due to tracheal ulceration &
infection)
• Tracheoesophageal fistula (Due to erosion of
trachea by tip of the tube)
• Persistent tracheocutaneous fistula
• Keloid/Unsighty scar at tracheostomy site
• Difficult decannulation

53. Procedure for immediate airway
management
1. Jaw thrust
• Lifting the jaw forward & extensing the neck
• Improves airway by displacing the soft tissues
• Avoided in spinal injuries

54. 2. Oropharyngeal airway
• Displaces the tongue anteriorly & relieves soft
tissue obstruction
• Face mask can also be kept

55. 3. Nasopharyngeal airway (Trumpet)
• Inserted transnasally into posterior
hypopharynx
• Releives soft tissue obstruction caused by
tongue & pharynx

56. 4. Laryngeal mask airway
• It is a device with a tube & a triangular distal
end which fits over the laryngeal inlet
• Oxygen can be delivered directly into the
trachea

57. 5. Transtracheal jet ventillation
• An IV cathether with a syringe
is inserted into the
cricothyroid membrane &
directed caudally.
• Then the needle is withdrawn
leaving the catheter in
position & jet ventillation is
started

59. 6. Endotracheal intubation
• Larynx is visualized with a laryngoscope &
endotracheal tube is inserted
• Helps to avoid a hurried tracheostomy in
which complications are likely
• After intubation, an orderly tracheostomy can
be performed.

60. 7. Cricothyrotomy/Laryngotomy/Mini tracheostomy
• Opening of airway through
cricothyroid membrane
• Done only to buy time to
allow patient to be carried
to OT
• Complications–
Perichondritis,Laryngeal
stenosis, Sub glottic edema

61. Percutaneous Dilational Tracheostomy
•A minimally invasive alternative to conventional
tracheostomy.
•Advantages:
No need of OT, thus is cost effective.
Forms a stoma between tracheal rings, resulting in
reduced blood loss as there is usually no disruption of
blood vessels.
•Avoided in patients who are obese, have neck mass,
difficult to intubate, difficult to extend neck, larynx &
trachea aren’t easily palpable

62. • Steps:
1. Neck is extended & incision is given 2cm
below the lower border of cricoid
2. Trachea is exposed & thyroid isthmus is
pushed down
3. Bronchoscope is inserted to monitor the
passage of needle,guide wire & dilator which
are passed into trachea between 2nd & 3rd
tracheal ring.
4. After dilatation tracheostomy tube is
inserted.