Department of surgery, JNMCSawangi(M), Wardha

LERNING OBJCTIVES

To know about surgical anatomy of tracheaTo know about various techniques of

tracheostomyTo know about various tubes usedTo know about things to look for during

tracheostomyTo know about complications occurring

during the procedure and their management

What is a Tracheostomy?

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

Why Perform a Tracheostomy 1Upper airway obstruction

urgent (cricothyroidotomy)non-urgent (conventional tracheostomy)

Facilitation of airway toiletLong term ventilation

Difficulty in weaning the ventilator Decreases airway resistance (tube size)

Paralysis of respiratory muscles (e.g. disease)Eliminates dead space

Why Perform a Tracheostomy 2Surgical reasons

Including head and neck surgeryTrauma

Including burns

How To Create a TracheostomyCricothyroidotomy

For Urgent ProceduresPercutaneous Tracheostomy

Can be done in the ICU at the bedsideSurgical Tracheostomy

Subthyroid incision to trachea between 2nd and 3rd tracheal rings

When to Create a TracheostomyControversial

ETT can be in situ for over 4 weeks in some studies!!!

Generally, consider a tracheostomy if patient intubated for 7 days with no foreseeable extubation in the next few days

Procedure

SkinDissectionSeparate strapsDivide thyroid

isthmusWindow in tracheaBelow 1st ringStitch in placeIncision=ba

d

Hole=good

Landmarks

Thyroid cartilage

Cricothyroid membrane

Crycoid cartilage

Types of Tracheostomy Tubes 1Cuffed, Uncuffed, Fenestrated,

UnfenestratedCuffed required for

Aspiration risk PPV

Fenestrated Facilitates weaning Allows vocalisation

Types of Tracheostomy Tubes 2“Button”

A plugUseful when there is a possibility of requiring

the tracheostomy tube again

Percutaneous Tracheostomy

Tracheostomy

cuffsTo protect airwayTo allow

ventilation

Uncuffed Cuffed

Single/Double lumen

Double lumen allows easy cleaning

Single lumen has a greater internal diameter

Immediate Problems 1PTX (4%)Wound infection (reasonable common)Bleeding

Usually only in coagulopathic patientsDifficult insertionAccidental decannulation

hypoxia and possible difficult re-insertionOcclusion due to secretions

Immediate Problems 2Air embolismAspirationSurgical emphysema

Long Term Problems 1Subglottic stenosis

Incidence decreased by low pressure cuffsIncidence increased by cricothyroidotomy over

surgical tracheostomyTracheal stenosisOesophago-tracheal fistulaIncreased bacterial colonisation of the

airways

Long Term Problems 2Vocal cord dysfunction

Chronic Recurrent laryngeal nerve injury

TemporaryStomal granulations and scarringNon healing of woundErosion into the innominate artery (<1%)

Occurs in 1st and 2nd weekSwallowing Problems

Benefits of a TracheostomyMore comfortable and more stableTube size can be larger (less resistance)Allows tubes to be changed more easilyBetter quality suctioningDepending on indication for tube and the

type of tube, patients can eat and talkCan promote oral nutrition

Post-op careNursing job with medical responsibilityRegular gentle suctioningMeticulous wound and stoma carePrimary goal is to keep tube in stomaTube change after 5 days if required –

earlier can be riskyENT do not normally need to be involved

in all aspects of trache care!!

General Care of a TracheostomySterile suctioning (as prone to infections)Gases given should be humidifiedEmergency equipment should be immediately

present (at bedside)

fenestrations

Allow patient to ventilate past tube via upper airway

Allow speech

Equipment of tube change

Nurse or assistantOxygen maskTracheal dilatorsSuctionNew tube (tested)Good light source BougieIntubation equipment available

DecannulationWhen ventilation or suctioning no longer

needed, and patient can control their own airway and not be at risk for aspiration

Can occur when patient has Good cough Good ABGs (relative, for the patient) Clear lungs No pathogens in sputum

Make sure…

Ready to be decannulatedNo further need for tracheostomyMaintaining own airwayNot aspirating

Steps to decannulation

1. Involve physio2. Change to fenestrated uncuffed tube3. Start capping off tracheostomy (NOT with

a cuffed unfenestrated tube!)4. When 24 hrs of uninterrupted capping at

normal sats, decannulation is possible

Decannulation itself

1. Prepare equipment (Same as for tube change, including fresh tube)

2. Take a deep breath3. Remove tube and suction stoma4. Close with steristrips and sleek5. Daily dressing and steristrip change6. Patient to cover wound when talking

• Always follow ABC

• A blocked tube is invariably the problem

• Remove tube if rapid suctioning fails or is even slightly delayed

• Direct ventilation over stoma may be effective

• An ET tube works well through a tracheal stoma

In SummaryMost traches are elective for a specific

cause (or perhaps multiple causes)Not free of complications which can be

early (immediate) or lateHave many benefits over a conventional

ETTMay be permanent or temporaryCuffed or uncuffed, fenestrated or

unfenestrated