Tracheostomy

TRACHEOSTOMY
INDICATIONS OF TRACHEOSTOMY
To relieve upper airway obstruction
  • Foreign body Larynx Trauma
  • Acute infection - acute epiglottitis, diphtheria,Tetanus
  • Glottic oedema,Tracheal Stenosis.
  • Bilateral abductor paralysis of the vocal cords
  • Tumours of the larynx
  • Congenital web or atresia
  • New born with a goiter large enough to cause dyspnoea
To improve respiratory function
  • Fulminating bronchopneumonia
  • Chronic bronchitis and emphysema
  • Chest injury and flail chest
  • Atelactasis
  • Respiratory paralysis
  • Unconscious head injury
  • Bulbar poliomyelitis
ADVANTAGES OF TRACHEOSTOMY OVER ORO-TRACHEAL INTUBATION
  • Reduces patient discomfort
  • Reduces need for sedation
  • Improves ability to maintain oral and bronchial hygiene
  • Reduces risk of glottic trauma
  • Reduces dead space and reduces work of breathing
  • Augments process of weaning from ventilatory support
TYPES OF TRACHEOSTOMY
  • Tracheostomy has also been divided into:
A) High tracheostomy:
  • Done above level of thyroid isthmus.
  • It violates the 1st ring of trachea.
  • Tracheostomy at this site can cause perichondritis of the cricoid cartilage and subglottic stenosis and is always avoided.
  • Only indication for high tracheostomy is carcinoma of larynx because in such cases, total larynx would ultimately be removed and a fresh tracheostome made in a clean area lower down.
 B) Mid tracheostomy:
  • It is the preferred one and done through II and III rings/IV rings division of isthmus.
  • A mid tracheostomy is done through the II or III rings and would entail division of the thyroid isthmus (isthmus lies against II, III and IV tracheal rings) or its retraction by cricoid hook upwards or downwards to expose this part of trachea.
C) Low tracheostomy: Done below level of isthmus.
  •  Trachea is deep at this level and close to several large vessels.
  • Tracheostomy can also be divided into
A.)Emergency Tracheostomy
  • It is the method to establish a safer airway in a patient with neck trauma, cricoid fracture with possibility of a difficult airway.
  • In emergency tracheostomy the following structures are damaged: Isthmus of the thyroid,Thyroid ima and Inferior thyroid vein.
  • Immediate management in a patient of carcinoma larynx with stridor presents in casualty is Immediate Tracheostomy
B.)Elective Tracheostomy
Tracheostomy can also be divided into
A.)Temporary Tracheostomy
B.)Permanent Tracheostomy
  • "Gold standard" surgical procedure for prevention of aspiration is Tracheal division and permanent tracheostome
  • Done after Larngectomy.
TRACHEOSTOMY IN INFANTS AND CHILDREN
  • Trachea of infants and children is soft and compressible and its identification may become difficult and the surgeon may easily displace it and go deep or lateral to it injuring recurrent laryngeal nerve or even the carotid.
  • During positioning, do not extend too much as this pulls structures from chest into the neck and thus injury may occur to pleura, innominate vessels and thymus or the tracheostomy opening may be made too low near suprasternal notch
  • The incision is a short transverse one, midway between lower border of thyroid cartilage and the suprasternal notch. The neck must be well extended.
  • A incision is made through two tracheal rings, preferably the third or fourth.
MINI-TRACHEOSTOMY
  • Cricothyrotomy or Laryngotomy or Minitracheostomy
  • It is the procedure to open the airway through the cricothyroid membrane.
  • Patient's head and neck are extended, lower border of throid cartilage and cricoid ring is identified. Skin in this area is incised vertically and then cricothyroid membrane is opened with a transverse incision.
  • It is an emergency procedure to buy time for the patient to be shifted to the operation theatre.

TYPES OF TRACHEOSTOMY TUBE
A tracheostomy tube may be metallic or nonmetallic
  • Metallic Tracheostomy Tube
  • Metallic tubes are formed from the alloy of silver, copper and phosphorus
  • Example Jackson's Tracheostomy tube.
  • Has an inner and an outer tube.The inner tube is longer than the outer one so that secretions and crusts formed in it can be removed and the tube reinserted after cleaning without difficulty. However, they do not have a cuff and cannot produce an airtight seal.
  • Advantages of a double lumen tracheostomy tube are easy to remove,clean and replace inner cannula.
  • Inner cannula should be removed and cleaned as and when indicated for the first 3 days. Outer tube, unless blocked or displaced, should not be removed for 3-4 days to allow a track to be formed when tube placement will be easy.
Nonmetallic Tracheostomy Tube
  • Can be of cuffed or noncuffedvariety, e.g. rubber and PVC tubes.
  • Cuffed Tracheostomy Tubes
  • Pediatric tubes do not have a cuff.
  • Cuffed tubes are used in situation where positive pressure ventilation is required, or when the airway is at risk from aspiration. (In unconscious patient or when patient is on respiration).
  • The cuff should be deflated every 2 hours for 5 mins to present pressure damage to the trachea.
Uncuffed Tracheostomy Tubes
  1. It is suitable for a patient who has returned to the ward from a prolonged stay in intensive care and requires physiotherapy and suction via trachea
  2. . This type of tube is not suitable for patients who are unable to swallow due to incompetent laryngeal reflexes, and aspiration of oral or gastric con­tents is likely to occur. An uncuffed tube is advantageous in that it allows the patient to breathe around it in the event of the tube becoming blocked. Patients can also speak with an uncuffed tube.
 COMPLICATIONS OF TRACHEOSTOMY
IMMEDIATE
  • Most common complication of tracheostomy is hemorrhage. The commonest cause of bleeding during tracheostomy is Anterior jugular vein.
  • Other Immediate Complication of tracheostomy

Air embolism Apnea (due to sudden release of retained CO2)
Cardiac arrest Local damage to structures
Pneumothorax (d/t injury to apical pleura)
INTERMEDIATE
  •  During first few hours or days
  1. Dislodgement/Displacement of the tube
  2. Surgical emphysema :May occur as the air may leak into the cervical tissues.
  3. Most common in children
  4. This is occasionally found in the immediate postoperative period.
  5. Presents as a swollen area around the root of the neck and upper chest, which displays crepitus on palpation. It is due to overtight suturing of the wound and is not dangerous unless it leads to mediastinal emyphysema and cardiac tamponade.
  6. Pneumothorax/pneumomediastinum
  7. Tubal obstruction by Scabs/crusts
  8. Infection (tracheitis and tracheobronchitis, local wound infection).
  • Dysphagia :
  1. - This is fairly common in the first few days after tracheostomy.
  2. - In normal swallowing a positive subglottic pressure is created by the closing of the vocal cords - which is why one cannot speak during swallowing.
  • This is not possible with a tracheostomy tube in place, and thus swallowing is incoordinate. - Another reason for dysphagia is that if an inflatable cuff is blown up it will press on and obstruct the oesophagus. Tracheal necrosis
  • Tracheo arterial (Tracheal innominate artery fistula) /Tracheoeshophageal fistula
  • Recurrent laryngeal nerve injury.
LATE
  • Hemorrhage due to erosion of major vessels
  • Stenosis of the trachea (at the level of stoma)
  • Laryngeal stenosis due to perichondritis of cricoid cartilage.
  • Difficulty with decannulation-common in children.
  • Tracheocutaneous fistula/scars.
Exam Question
  • Advantages of a double lumen tracheostomy tube are easy to remove,clean and replace inner cannula.
  • In emergency tracheostomy the following structures are damaged: Isthmus of the thyroid,Thyroid ima and Inferior thyroid vein.
  • High tracheostomy is indicated in Carcinoma of Larynx.
  • Cardiac tamponade,Uncomplicated Bronchial Asthma,Pneumothorax is not an indication for tracheostomy.
  • Mid tracheostomy is done over 3rd and 4th tracheal rings.
  • In Pediatric tracheostomy,most common early complication is subcutaneous emphysema and 3rd & 4th tracheal rings are incised.
  • Indications of Tracheostomy are Flail chest,Head injury,Tetanus,Tracheal stenosis,Bilateral vocal cord palsy,Foreign body larynx,Emphysema,Bronchiectosis,Atelectasis.
  • A new born with a goiter large enough to cause dyspnoea may be treated with Tracheostomy.(Partial thyroidectomy is preferred over tracheostomy).
  • Interstitial Emphysema may be found in Tracheostomy.
  • A cricoid hook is used particularly in Tracheostomy.
  • Immediate management in a patient of carcinoma larynx with stridor presents in casualty is Immediate Tracheostomy.
  • Maintenance of airway during laryngectomy in a patient with carcinoma of larynx is best done by Tracheostomy.
  • The most common indication for tracheostomy is Foreign body aspiration.
  • Tracheostomy tube(Jackson's tube) is a double tube,made of titanium silver alloy and Cuffed tube for IPPV and to prevent aspiration of pharyngeal secretion.
  • Tracheoesophageal fistula ,Tracheocutaenous fistula and Surgical emphysema are common complications of tracheostomy .
  • "Gold standard" surgical procedure for prevention of aspiration is Tracheal division and permanent tracheostome
  • Trachea can't be easily palpated during tracheostomy in infants and children.
  • Complication commonly occurring in tracheostomy in children is difficult decannulation.
  • Hemorrhage is one of the most important complication of tracheostomy .
  • Emergency tracheostomy is the method to establish a safer airway in a patient with neck trauma, cricoid fracture with possibility of a difficult airway.
  • Mini tracheostomy is performed through Cricothyroid membrane.
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