TRACHEOSTOMY

PRESENTER :

DR VIJETHA PG ASST PROF

MODERATOR : DR CHRISTOPHER

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

History
Tracheostomy is one of the oldest surgical

procedures.
A tracheotomy was portrayed on Egyptian

tablets dated back to 3600 BC.

Asclepiades of Persia is credited as the first

person to perform a tracheotomy in 100 BC.

The first successful tracheostomy was

performed by Brasovala in the 15th century.

Modern percutaneous tracheostomy (PCT) device

was developed by Toye and Weinstein in 1969,

The wireguided technique for percutaneous

tracheostomy was developed and reported in the same year by the American surgeon, Ciaglia.
Ever since the PCT has evolved, the resources

required for a surgical tracheostomy (ST), the need of operating room, and personnel have been eliminated

FUNCTIONS OF TRACHEOSTOMY
ALTERNATIVE PATHWAY OF BREATHING:

Circumvents any obstruction in the upper airway from lips to the tracheaostome
IMPROVES ALVEOLAR VENTILATION:

by decreasing dead space by 30-50%, & reducing resistance

PROTECTS THE AIRWAY: by using cuffed tubes

prevents aspiration of pharyngeal secretions(bulbar paralysis , coma) & blood (hemorrhage) with tracheastomy pharynx and larynx can be packed to control bleeding
PERMITS REMOVAL OF TRACHEO BRONCHEAL SECRETIONS:

Coma , head injuries , cough is painful

INTERMITTENT POSITIVE PRESSURE VENTILATION: > 72 hrs TO ADMINISTER ANESTHESIA:

Difficult intubation or impossible as in laryngopharyngeal growths , trismus.

INDICATIONS
RESPIRATORY OBSTRUCTION:
INFECTIONS

Acute laryngo tracheo bronchitis , ac epiglottitis , diphtheria Ludwigs angina , peritonsillar , retropharyngeal or parapharyngeal abscess , tongue abscess
TRAUMA

External injury of larynx and trachea Trauma due to endoscopies Fracture of mandible or maxillofacial injuries
NEOPLASMS

Benign and malignant neoplasm of larynx , pharynx , trachea and thyroid

Foreign body larynx Edema of larynx due to irritant fumes , gases , allergy , radiation Bilateral abductor palsy CONGENITAL ANOMALES

Laryngeal web ,cysts , TOF ,b/l choanal atresia

INDICATIONS
RETAINED SECRETIONS:
INABILITY TO COUGH: coma of any cause eg :head injuries ,
CVA , narcotic overdose
Paralysis of respiratory muscles eg:spinal injuries , polio , GB

syndrome ,myasthenia gravis

Spasm of respiratory muscles , tetanus , eclampsia , strychnine

poisoning

PAINFUL COUGH - chest injuries , multiple rib fractures ,

pneumonia

ASPIRATION OF PHARYNGEAL SECRETIONS:

Bulbar polio ,polyneuritis ,bil laryngeal paralysis

Contraindications

1. Performance of the procedure in children as cartilage is soft. 2. Unstable cervical spine 3. Uncorrected coagulopathy 4. Presence of neck mass or pervious neck surgery 5. History of mediastinal irradiation due to intrathoracic fibrosis 6. Previous history of surgical tracheostomy 7. Increased intracranial pressure

Advantages of Tracheostomy
Increased patient mobility More secure airway Increased comfort Improved airway suctioning Early transfer of ventilator-dependent patients

from the intensive care unit (ICU)

Less endo-laryngeal injury Enhanced oral nutrition Enhanced phonation and communication Decreased airway resistance for promoting

weaning from mechanical ventilation

Decreased risk for nosocomial pneumonia

How To Create a Tracheostomy

Cricothyroidotomy
For Urgent Procedures

Surgical Tracheostomy Percutaneous Tracheostomy

Can be done in the ICU at the bedside

Anatomy

The trachea is a fibromuscular tube supported by 20 hyaline cartilages which are opened posteriorly. The posterior wall is in contact with the oesophagus. Trachea lies in midline of the neck extending from cricoid cartilage (C6) superiorly to the tracheal bifurcation at the level of sternal angle (T5). In adults it is 12-16 cm long and 13-16 mm wide in women and 16-20 mm wide in men The blood supply is primarily supported by the bracheocephalic artery and through the inferior thyroid and bronchial arteries. The nerve supply is by parasympathetic and sympathetic fibres. The parasympathetic supply to the trachea is by the recurrent laryngeal nerve a branch of the vagus nerve

TYPES

EMERGENCY TRACHEOSTOMY: When airway obstruction

is complete & urgent need to establish airway. Inubation either not possible or feasible

ELECTIVE TRACHEOSTOMY: Planned , unhurried

endotracheal tube can be put and local or general anesthesia can be given . It is of 2 types THERAPEUTIC: To relieve obstruction , remove tracheobronchial secretions , or give assisted ventilation. PROPHYLACTIC :To guard against anticipated respiratory obst , or aspiration of blood or pharyngeal secretions such as in extensive surgery of tongue , floor of mouth mondibular resection or laryngofissure

TYPES
PERMANENT TRACHEOSTOMY: Required for

cases of bilateral abductor paralysis

Laryngeal stenosis Laryngectomy or laryngo pharyngectomy Lower tracheal stump is brought to surface

and stitched to the skin

TYPES
HIGH TRACHEAOSTOMY: done above the level of thyroid
isthmus lies against the 2 ,3 , 4 tracheal rings tracheastomy at this site can cause perichondritis of the cricoid cartilage and subglottic stenosis and is always avoided , only indication is carcinoma of larynx

MID TR ACHEAOSTOMY: Preferred one , done through the 2 or 3

rd tracheal rings.

LOW TRACHEASTOMY: Done below the level of isthmus . Trachea

is deep at this level and close to the several large vessels , also difficulty with tracheastomy tube which impinges on suprasternal notch

Tracheostomy Tubes
Tracheostomy tubes are available in a variety of sizes and styles,

from several manufacturers.

Dimensions of tracheostomy tubes are given by their inner

diameter (ID), outer diameter (OD), length, and curvature.

Tracheostomy tubes can be angled or curved, a feature that can be

used to improve the fit of the tube in the trachea.

Cuffs on tracheostomy tubes include high-volume low-pressure

cuffs, tight-to shaft cuffs, and foam cuffs.

Tracheostomy tubes which have an inner cannula are called dual

cannula tracheostomy tubes.

Metal versus Plastic tracheostomy tubes

Tracheostomy tubes can be of either metal or plastic. Metal tubes are constructed of silver or stainless steel.

Metal tubes are not used commonly because they are

expenseive, rigid construction uncuffed lack a 15 mm connector for attachment to a ventillator

Plastic tubes are most commonly used and are

made from polyvinyl chloride or silicone.

Polyvinyl chloride softens at body temperature

(thermolabile), conforming to patients tracheal anatomy and centering the distal tip in the trachea

Tracheostomy tube selection

While selecting a tracheostomy tube, the ID and OD, its curvature and

proximal and distal length must be considered .

If the ID is too small, it will

increase the resistance through the tube, make airway clearance difficult, increase the cuff pressure required to create a seal
If the OD is too large,

Difficulty in speech difficult to pass through the stoma. may not conform to the shape of the trachea, compression of the membranous trachea,

Tracheostomy tubes are available in standard length

or extra length.
Extra length tubes are constructed with either extra

proximal length (horizontal extra length) or with extra distal length (vertical extra length)
Extra proximal length facilitates tracheostomy tube

placement in patients with a large neck (eg, obese patients).

Extra distal length facilitates placement in patients

with tracheaomalacia or tracheal anomalies.

Care must be taken to avoid inappropriate use of

these tubes, which may induce distal obstruction of the tube

Cuffed Tracheostomy tube

Cuffed tracheostomy tubes

allow airway clearance, protection from aspiration positive pressure ventilation

It is recommended that cuff pressure

be maintained at 2025 mmHg (2535 cm H2O) to minimize the risks for both tracheal wall injury and aspiration.

Fenestrated tracheostomy tubes

The fenestrated tracheostomy

tube is similar in construction to standard tracheostomy tubes, with the addition of an opening in the posterior portion of the tube above the cuff.
With the inner cannula removed,

the cuff is deflated, and the tracheostomy air passage occluded, the patient can inhale and exhale through the fenestration and around the tube.

This allows for assessment of the patients ability

to breathe through the normal oral/nasal route preparing the patient for decannulation allowing phonation
Supplemental oxygen administration to the upper

airway (eg, nasal cannula) may be necessary if the tube is capped.

Surgical Tracheostomy
Surgical tracheostomy (ST) is usually performed in the

operating room on a patient under general anesthesia, but it may be performed at the bedside in the intensive care unit.
The patients shoulders are elevated with head extension

(unless cervical disease or injury is present), elevating the larynx and exposing more of the upper trachea.
Local anesthesia with a vasoconstrictor is usually infiltrated

into the skin and deeper tissues

The skin of the neck over the

2nd tracheal ring is identified, and a vertical incision about 23 cm in length is created extending from cricoid cartilage to just above sternal notch.
Sharp dissection following the

skin incision is used to cut across the platysma muscle, and bleeding controlled by hemostats and ties or electocautery. Strap muscles are separated in the midline and retracted laterally

Blunt dissection parallel to the long

axis of the trachea is then used to spread the submuscular tissues until the thyroid isthmus is identified
Thyroid isthmus is displaced upwards

or divided between the clamps , and sutures ligated.

If the gland lies superior to the 3rd

tracheal ring, it can be bluntly undermined and retracted superiorly to gain access to the trachea

Trachea is fixed and open with a

vertical incision in the region of 3rd and 4th or 3rd and 2nd rings .this is then converted in to a cirular opening.
Tracheastomy tube of appr size

is inserted and secured by tapes.

Skin incision should not be

sutured or packed tightly as it may lead to development of subcutaneous emphysema

Gauge dressing is placed

between skin and flange of the tube around stoma.

Percutaneous tracheostomy
1955, Shelden et al - first attempted PCT with cutting trocar into

the trachea.
The wire-guided technique for percutaneous tracheostomy was

developed and reported in 1986 by the American surgeon, Ciaglia.

1990, Griggs et al - the guidewire dilating forceps (GWDF) Several variants of the percutaneous tracheostomy technique

have been developed.

Using a wire guided sharp forceps(Griggs technique) using a single tapered dilator (BlueRhino) passing the dilator from inside the trachea to the outside (Fantonis technique); using a screw like device to open the trachea wall (PercTwist).

Technique
As an alterative to ST , percutaneous dilational tracheostomy

(PDT) has become a very common method of placing a tracheostomy in critically ill patients in the intensive care unit.
It is rapid, simple, easy to learn, and cost effective.

The procedure should be deferred in patients having an

INR>1.4, Activated partial thromboplastin time >45 seconds Platelet count of < 75,000 ml.

To prevent inadvertent injury of the membranous posterior

tracheal wall or too lateral a location of the tracheostomy, a technique of observing and directing the needle and wire placement, using fiberoptic bronchoscopy is recommended
In order to visualize the upper rings of the trachea with the

bronchoscope, the endotracheal tube must be withdrawn until the its tip is just in the larynx.
Patients requiring a tracheostomy only for airway access or

protection often can have a laryngeal mask airway replace the endotracheal tube to provide the route for bronchoscopic visualization.

PDT is usually performed in an anesthetized patient, and can be

done in the intensive care unit or operating room.

The patient should be monitored by SpO2, EtCO2 and ECG.

The patient is positioned as for the surgical tracheostomy A pillow is placed under the shoulders, the neck is moderately

extended, and the first three tracheal rings are identified

The anterior neck is prepared with povidine iodine and draped with

sterile sheets.
The skin overlying first and second tracheal rings is infiltrated

subcutaneously with 3-5 ml of 1% xylocaine with epinephrine (1:200,000), and a 1.5 cm vertical incision is made and blunt dissection is performed to expose the pretracheal fascia.

The anterior trachea is

palpated and the intended site is punctured with a 14G intravenous cannula in a postero-caudal direction.
The entry of the IV

cannula in trachea is confirmed by aspiration of air into a saline filled syringe.

A guide wire is inserted through the cannula, and the cannula is withdrawn, The tracheal opening is dilated over the guide wire until a stoma of sufficient size to accommodate the desired tracheostomy tube is created. The method of dilating the tracheal opening over the guide wire varies with various methods

Ciaglia technique
With Ciaglia

technique, the tracheal opening is dilated by using a series of plastic dilators inserted over the guide wire

Griggs Technique
Using a tracheal spreader

modified to thread over the wire; this technique involves forceps dilation to create the skin path and tracheal stoma.
The trachea is entered between

the appropriate tracheal rings with an intravenous catheter.

The guide wire is threaded

through the catheter.

The sharp-tipped dilating forceps

are passed over the wire, spread in the skin and soft tissues of the neck and into the trachea, and spread again

A tracheostomy tube is placed over the guide wire

and through the passage created.

Tracheal injury may be higher with this technique

(especially if performed without bronchoscopy) than the other PDT techniques.

Blue Rhino dilator

Blue Rhino dilator is a single,

tapered dilator that is used instead of the sequential dilators of Ciaglia.

It has a slippery coating that makes

insertion very easy.

It is softer and therefore (probably)

less likely to damage the membranous tracheal wall.

Since there is only a single dilator to

pass, insertion is more rapid.

A substantial amount of force is

needed to insert the dilators and tracheostomy tube, which often collapses the trachea and fractures a tracheal ring

Fantoni technique
In an attempt to prevent

membranous tracheal (posterior) wall injury and protect the anterior rings from fracture, Fantoni devised a special dilating tube that is placed translaryngeally through the trachea and pulled out rather than forced in.

After the guide wire is placed, a fiberoptic scope is used

to direct the retrieval of the wire and bring it out of the endotracheal tube in Fantonis technique.
The special tube is pulled from the inside through the

trachea and dilates its own path

After placement, the dilating tip is removed, the upper

part of the tube reversed in the trachea and the cuff inflated.
During placement, a small-diameter cuffed endotracheal

tube can be used to support gas exchange while dilation is being performed

Perc Twist technique

Perc Twist , a screw

action dilator that was designed to allow dilation with twisting while lifting the trachea rather than pushing down.

Choosing a Technique ST vs PCT

Coagulation abnormalities favor ST over PDT, since

bleeding vessels are more easily controlled under direct vision.

High levels of need for oxygenation would favor ST over

PDT (ie, Fio2> 0.7 and positive end-expiratory pressure > 10 mm Hg

Patients with unstable or fragile cervical spines would favor

ST over PDT.
Patients having recent surgical repair of neck injuries may

benefit from PDT because of its lower wound-infection rate.

Patients with unfavorable neck anatomy would favor ST

over PDT (ie, previous surgery, neck masses, poor neck mobility, or obesity)

IMMEDIATE COMPLICATIONS
Haemorrhage Apnoea Pneumothorax due to injury to apical pleura Injury to recurrent laryngeal nerve Aspiration of blood Injury to esophagus -TOF

INTERMEDIATE COMPLICATIONS
Bleeding reactionary or secondary Displacement of tube Blocking of tube Subcutaneous emphysema Tracheitis and tracheobronchitis with crusting

in trachea
Atelectesis and lung abscess Local wound infection and granulations

LATE COMPLICATIONS
Hemorrhage due to erosion of major vessel Laryngeal stenosis perichondritis of cricoid cartilage Tracheal stenosis tracheal ulceration and infection Tracheo esophageal fistula prolonged use of cuffed tube or

erosion of trachea by the tip of tracheastomy tube

Persistent tracheocutaneous fistula Problems of tracheastomy scar keloid or unsightly scar Corrosion of tracheastomy tube and aspiration of its

fragments in to the tracheobroncheal tree

POST OPERATIVE CARE

CONSTANT SUPERVISION: Look for bleeding , displacement or blocking

of tube and removal of secretions is essential

A nurse or Pt relative should be in

attendance
Pt is given a bell or a paper pad and pencil

to communicate

SUCTION
Depending on the amount of secretion

suction my be required every half an hour or so.

Use sterile catheters , suction injuries to

tracheal mucosa should be avoided .

PREVENTION OF CRUSTING AND TRACHEITIS

Proper humidification by use of humidifier ,

steam tent , ultrasonic nebulizer or keeping boiling kettle in the room

If crusting occurs a few drops of normal or

hypotonic saline or ringer lactate are instilled in to trachea every 2-3 hours to loosen crusts
A mucolytic agent such as acetyl cystein

solution can be instilled to liquify tenacious secretions or toloosen crusts

CARE OF TRACHEOSTOMY TUBE

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 become easy.
After 3-4 days , outer tube can be removed and cleaned

every day.
If cuffed tube is used, it should be periodically deflated to

prevent pressure necrosis or dilation of trachea.

Decannulation.
Tracheostomy tube should not be kept longer than necessary . Prolonged use of tube leads to tracheobronchial infection,tracheal

ulceration,granulation,stenosis and unsightly scars.

To decannulate a patient, tracheostomy tube is plugged and the patient closely

observed.
If the patient can tolerate it for 24 hours , tube can be safely removed. In children, the above procedure is done using a smaller tube. After tube removal wound is taped and closely observed Healing will take place with in a few days or a week ,rarely a secondary

closure of wound may be required

PRINCIPLES FOR DECANNULATING AN INFANT CHILD: 1.Decannulate in the operation theatre where services of a trained nurse or an anaesthetist are available.

2.Equipment for re-intubation should be available immediately , it consists of a good headlight laryngoscope , proper-sized endotrachacheal tube and a tracheostomy tray.

3.after decannualtion watch the child for several hours for respiratory distress,tachycardia and color Oxymetry is very useful to moniter oxygen saturation , may require blood gas determination.

Tracheostomy and weaning

A lot of research is being done on the optimal timing of

performing a tracheostomy.
For patients requiring prolonged mechanical ventilation,

performing an early tracheostomy (within 2 days) is considered to facilitate early weaning.

Advantages of early tracheostomy

reduced dead space decreased airway resistance, decreased work of breathing, better secretion clearance by suctioning, reduced requirements of sedatives and MR better glottic function with reduced risk of aspiration, atelectasis,pneumonia shortened ICU stay

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