This presentation describes tracheostomy -definition, indication, contraindication, types, tubes, procedure, complications, sequelae

1. Dr Ashly Alexander
ENT PG Resident
GMC,Bhopal

2. Definition
 It is an operation in which an opening is made in
cervical part of trachea to bye pass the upper
respiratory tract

4.  Acute emergencies for short duration
Endotracheal intubation
Laryngotomy
 Later shift to Tracheostomy

5. Intubation
• Rapid procedure  Non invasive
• No need of equipped OT
Drawbacks
• Tube may be blocked
• pressure necrosis if kept for longer period 48hrs

6. Types of tracheostomy
Based on:
• Circumstances Emergency
Elective
• Duration Temporary
Permanent
• Site High
Mid
Low

7. Temporary tracheostomy
Can be elective or emergency
 Elective : as a part of planned procedure as in major
head & neck surgery or for prolonged respiratory
support for ventilated patients
 Emergency : severe trauma to head & neck, acute
upper airway obstruction

8. Permanent tracheostomy
 Elective procedure
 In operations involving removal of larynx-
laryngectomy, laryngopharyngectomy, diversion
procedures for aspiration problems
 Trachea is permanently disconnected from the
pharynx & proximal end of trachea sutured to the skin

10. Effects ??
 Laryngeal bypass- unable to cough & phonate
 Reduction in respiratory dead space
 Redundant area between larynx & tracheal opening
where mucous tends to accumulate
 Filtration & humifification effect of nasal mucosa lost
 Increased risk for infection
 Tracheostomy tube acts as FB producing local
inflammation & abrasions

11. Indications
 Upper Airway Obstruction
 Removal of retained secretions
 Prolonged ventilation
 As a part of another procedure

12. 1 .Upper airway obstruction
A Intrinsic
 Congenital - web, laryngeal stenosis, tracheo esophageal fistula,
 Traumatic - Fumes, corrosives, Sharp object FB, Instrumentation
 Infective - Ac laryngitis, Ac epiglottitis, diphtheria
Chr granulomatous lesions
 Neurological- B/L abd vc palsy, myasthenia gravis ,Tetanus,
poliomyelitis
 Neoplastic -Benign-Papilloma, chondroma
Malignant- Ca Larynx& laryngopharynx
 Miscellaneous - FB, Angioneurotic edema

13. B Extrinsic
• Traumatic - Cut throat, Crush injuries of Larynx,
Strangulation
• Infective - Ludwig’angina, RP Abscess, PP Abscess
• Neurological - Rec Laryngeal N Palsy, ca esophagus,
ca thyroid, metastatic mediastinal LN,
thyroidectomy
• Malignant - Pressure due to Ca Thyroid& other
neck tumors

14. Removal of retained secretions
 CCF
 Infection
 Pulmonary oedema
 Bulbar palsy
 Here secretions can be aspirated with minimal
upset to the patient & reduction in respiratory
dead space makes it easier for patient to breathe.

15. Prolonged ventilation
• Unconscious pt- Coma( Head Injuries, CVA, encephalitis)
• Depressed Resp Center- Bulbar palsy, barbiturate
poisoning
• Lesion of ant horn cells & Nerves - Polyneuritis,
Poliomyelitis, Myasthenia gravis
• Myoneural lesions - Tetanus
• Chest Injuries - Flail chest, multiple # ribs
• Lung Pathology -Fibrosis, collapse, Emphysema
As its more secure than nasotracheal / orotracheal tube
& reduced dead space facilitates weaning

16. As a part of another procedure
 Prior to major H&N surgery
Laryngofissure , Laryngectomy,
hemiglossectomy, mandibulectomy
RP Abscess, maxillofacial operations
It prevents aspiration of blood & helps easy
administration of anaesthetic drugs
Contraindications- NIL

17. Types of Tracheostomy tubes
 Metallic
Chevalier Jackson
Fuller’s bivalve
size 8 to 44 with ↑of 2
 Portex
Cuffed -size 5.5-10(↑0.5)
Non Cuffed -size 3 -10 (↑0.5)

18.  Salpekar’s double cuffed
 Durhams tube
Adjustable shield for short neck
 Redcliff tube - right angled for short neck

19. Features of tracheostomy tube
 Cuff- prevents aspiration
forms air tight seal to prevent anaesthetic gas
leakage
S/E- subglottic stenosis
 Inner tube- projects 2-3mm beyond the outer tube
helps in cleaning
 Fenestration – helps in phonation
sited at the point of max curvature
single/multiple holes

20.  Flexibility –conforms more accurately to pts anatomy
cause less abrasions
 Adjustable flange – allows length of the tube to be
varied

21. Tracheostomy Procedure
 Anaesthesia Local / General
 Position Supine with
extended neck& fixed head
Incision
 Vertical in emergency
 Transverse in elective surgery

25. Post operative Care
 Humidification
 Frequent suctioning
 Deflation of tube every 4 hrs for 15 mins for first 24
hrs
 Never remove outer tube in first 48 hrs
 Change of dressing
 Ambulation and physiotherapy
 Supportive treatment

26. Sequelae of Tracheostomy
 Inability to speak
 Can not swim
 Inability to lift heavy wt and heavy work
 Difficulty in micturition , defecation and parturition
 Anosmia

27. Tracheostomy complications
A Immediate
 Hemorrhage
Injury to thyroid isthmus, ant Jugular vein,
Innominate art, Inf Thyroid art, Carotid
vessels
 Injury to
Oesophagus, Dome of Pleura,
RLN, Cricoid cartilage
 Apnoea d/t release of CO2
 Vasovagal attack
 Aspiration and Lung collapse

28. B Intermediate
 Extubation /tube obstruction
 Subcutaneous emphysema - tracheal opening is large
 Mediastenal emphysema - Pretracheal fascia is not incised
 Tracheo esophageal fistula /tracheoarterial fistula
pressure necrosis
 Infection- Perichondritis ,Tracheo bronchitis
 Dysphagia -  glottic pressure

29. C Late
• Tracheo malacia
• Laryngeal stenosis
• Tracheal stenosis
• Tracheo cutaneous fistula
• Difficult decannulation-
psychological dependence,
persistant pathology
Granuloma formation

30. DECANNULATION
CUFFED TUBE
UNCUFFED FENESTRATED TUBE
DOWNSIZE
TUBE BLOCKED DURING DAY TIME
TUBE BLOCKED FOR 24 HRS
DECANNULATE
AIRTIGHT DRESSING

31. Thank you