TRACHEOSTOMY

--- Prashiddha Dhakal

MBBS,KUSMS

Definition

• A tracheostomy is a artificial (usually)surgically created airway fashioned bymaking a hole in the anterior wall of thetrachea and the insertion of a tracheostomytube, which may or may not be permanent

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; orwhen 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.

Indications of Tracheostomy

There are three main indications

A. Respiratory obstruction.

B. Retained secretions.

C. Respiratory insufficiency.

A. Respiratory obstruction

1. InfectionsAcute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria, Ludwig's angina, peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess

2. TraumaExternal injury of larynx and trachea ,Trauma due to endoscopies, especially in infants and children,Fractures of mandible or maxillofacial injuries

3. NeoplasmsBenign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and thyroid

4. Foreign body larynx5. Oedema larynx

due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), radiation

6. Bilateral abductor paralysis7. Congenital anomalies

– Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia

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

C. Respiratory insufficiency

• Chronic lung conditions, viz. emphysema, chronic bronchitis, bronchiectasis, atelectasis.

Types of Tracheostomy

• Emergency tracheostomy

• Elective or tranquil tracheostomy

• Permanent tracheostomy

• Percutaneous dilatational tracheostomy

• Mini tracheostomy (cricothyroidotomy)

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.

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.

3. Permanent tracheostomy

• Required for case of bilateral abductor paralysis or laryngeal stenosis.

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because in such cases, total larynx anyway would ultimately be removed and a fresh tracheostome made in a clean area lower down

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preferred oneThrough 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 withtracheostomy tube which impinges on suprasternal notch.

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.

Anaesthesia

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

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.

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 .

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

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.

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

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.

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

Jackson’s metallic tube

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

Fuller’s bivalve metallic tube

IO

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

Portex cuffed tube

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

Cuffed fenestrated tube

Portex uncuffed tube

For tracheostomy patient receiving radiation

TYPES OF TRACHEOSTOMYTUBES

• Plastic or metal

• Cuffed or uncuffed

• Fenestrated or unfenestrated

• Double canula or single canula

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

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.

Insertion of medicated gauze

Betadine soaked gauze or Sofratulle put around the

tracheostomy opening.

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,innominatevessels,thymus may get injured

-Post operative x-ray of the neck to know position of the tube

-Use of soft silastic and portex tube

Post Operative Care1.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.

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)

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

Cleaning of inner tube

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.

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

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

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

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)

Immediate complications

• Haemorrhage

• Aspiration of blood

• Injury to recurrent laryngeal nerve

• Injury to apical pleura (Pneumothorax)

• Injury to oesophagus (May cause tracheoesophagealfistula)

• Apnoea (Due to Carbondioxidewash out)

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

Late Complications

• Haemorrhage (Due to erosion of major vessels espinnominate/bracheocephalic art)

• Laryngeal stenosis (Due to perichondritis of cricoidcartilage)

• 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

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

2. Oropharyngeal airway

• Displaces the tongue anteriorly & relieves soft tissue obstruction

• Face mask can also be kept

3. Nasopharyngeal airway (Trumpet)

• Inserted transnasally into posterior hypopharynx

• Releives soft tissue obstruction caused by tongue & pharynx

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

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

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.

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,Laryngealstenosis, Sub glottic edema

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

• 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.