Tracheostomy Indication Contraindcations

1. TRACHEOSTOMY
Dr.HIMANSHU SONI
Fellow in Head and Neck Oncology - FHNO
Fellow in Craniomaxillofacial Trauma – AOMSI
Oral and Maxillofacial Surgeon

2. Contents
 Introduction
 History
 Indications & contraindications for Tracheostomy
 Armamentarium & Surgical anatomy
 Surgical/open tracheostomy
 Tracheostomy care & maintenance
 Complications
 Percutaneous tracheostomy
 References

3. Introduction
 Trachea is a conduit b/w the upper airway and the lungs, It
delivers moist warm air, expels CO2 & secretions from the R S.
 Blockage at any point along this conduit can be fatal, surgical
creation of an opening into the trachea is the principle way of
securing the airway.

4. ⚫ TRACHEOTOMY
Surgical procedure in which an opening is made in the anterior
wall of the trachea to establish an airway.
Often temporary and reversible.
- Hiester 1718
⚫ TRACHEOSTOMY(tomos= cut , stoma=mouth)
Surgical creation of an opening into the trachea through the neck
with the trachea being brought into continuity with the skin.
Most often, not always permanent.
- Negus 1938

5. History
 2000 BC :Rig Veda
 400 BC: Hippocrates condemned tracheostomy,
citing threat to carotid arteries.
 Hierronymus, Fabricus and Habicot provided the
first technical descriptions of surgical procedure.
 1546 : first successful tracheostomy Antonius
Mvsa Brasavola,

6.  1921:Jackson defined and refined surgical airway management
technique
 1955: Percutaneous tracheostomy was described by Shelden,
 1969:Toy and Weinstein described a PT using the guide wire
approach of Seldinger.
 1985 Ciaglia et al described PDT.

7. Functions of tracheostomy
1. Alternative pathway for breathing: circumvents obstruction in
upper airway
2. Improves alveolar ventilation:↓ses dead space & resistance to
airflow
3. Protects airway: against aspiration
4. Permits removal of tracheobronchial secreations
5. Intermittent positive pressure respiration: if >72hrs better than
intubation

8. Indications
1.Acute upper airway obstruction
2. Potential upper airway obstruction
3. Protection of the lower airway
4. Patients requiring artificial respiration.
Bailey &Love’s short practice of surgery

9.  Absolute indications for Tracheostomy, for conditions other
than impending respiratory obstruction, include (IPPV):
1. When injuries are severe enough to cause hypercarbia and/or
hypoxemia from the outset- flail chest, lung contusion or
aspiration.
2. Control of cerebral oedema (by controlling blood gases) in
severe head injuries
Rowe & Williams
Indications

10. Indications
 Major laryngeal trauma
 Inability to intubate or perform needle cricothyrotomy in
pediatric pt
 Facilitation of management of cervical spine injury or oncologic
ressection of head & neck.
 Laryngeal foreign body or pathology (e.g., tumor) prohibiting
cricothyrotomy
 Prolonged ventillation
Fonseca trauma

12. TYPE of Trachesotomies

13. Evolution in indications tracheostomy in children
⚫ Acute epiglottitis and laryngotracheobronchitis no longer represent an
indication for tracheostomy.
⚫ Acc to retrospective study conducted by Froelich et al in 46 children
undergoing tracheostomy b/w 1996-2001, there was decrease in
frequency of tracheostomy due to upper airway obstructions & An
increasing indications were noted for chronic disorders requiring
prolonged ventilator dependence.
Int J of Pediatric Otorhinolaryngo (2006) 70,
115—119

14. CONTRAINDICATIONS
 Emergency tracheostomy is contraindicated if the patient’s
airway can be secured by other means (needle/open
cricothyrotomy)
 In an expanding hematoma.

15. SURGICAL ANATOMY

18. JACKSON’S SAFETYTRIANGLE
Triangular space in neck
• Base: Lower end of thyroid cartilage
• Apex: Suprasternal notch
• Sides: Inner edges of sternocleidomastoid muscle
So named as this marks the area through which safe dissection can
be done for tracheostomy
Also represents the area into which infiltration anesthesia is
given during tracheostomy under local anesthesia

19. ⚫‘Tracheal-tug’
⚫The intimate relationship between the arch of the
aorta and the trachea and
⚫left bronchus is responsible for the physical sign
known as ‘tracheal-tug’,
⚫characteristic of aneurysms of the aortic arch.

20. Types of tracheostomy
⚫Emergency
⚫Elective / tranquil
 Therapeutic : to relieve respiratory obstruction
 Prophylactic : to guard against anticipated respiratory
obstruction or aspiration
⚫Permanent
⚫Percutaneous dialational
⚫Mini tracheostomy (Cricothyrotomy)

21. ⚫The golden rule of tracheostomy—based entirely
on anatomical considerations
⚫is ‘stick exactly to the midline’. If this is not done,
major vessels are in jeopardy and it is possible,
although the student may not credit it, to miss the
trachea entirely.

22. Armamentarium

23. Various type of the tubes
1. Silver/Metal tubes- outdated.
E.g.Alder-Hey and Sheffield.
2. Plastic tubes -most commonly used. flexible, comfortable & less traumatic.
 Silicon tubes-
E.g.- Romsons tubes, Portex tubes, Shiley tubes.
 Polyvinylchloride (PVC) tubes
 Silastic tubes

25. Tube selection
⚫ The length - The standard tube lengths are 60–90 mm (adult), 39–
45 mm (pediatric) and 30–36 mm (neo-natal).
⚫ The diameter - largest tube that fits comfortably should be used.
(this is approx 3/4th diameter of the trachea.)
woman- No.6 or No.7
man- No.7 or No.8.
⚫ Cuff tube- necessary when aspiration is a problem or when a
positive pressure ventilation is required.
Cuff should be deflated at regular intervals atleast 5mins/hr.

26. TRACHEOSTOMY SURGICAL STEPS

27. STEPS
1.Airway control
endotracheal intubation/ventilation and
oxygenation by means of a bag and mask.
If the airway is under control, a more orderly
& less traumatic tracheostomy can be
performed.
2.Patient position-supine position,
place shoulder pad & head ring for to allow
maximum extension of neck.

29. The incision is made through the
Subcutaneous tissue and platysma,
down to the deep cervical fascia.
The anterior jugular veins will be
Encountered superficial to the deep
cervical fascia on either side of the
midline.
Note that the trachea is deeper than one imagines.

30. A self-retaining retractor can now be inserted and the
dissection continued until the strap muscles are encountered.
These should be separated in the midline. The assistant can
do this using a pair of Langenbeck retractors.
The dissection is continued with blunt ended dissecting
scissors. If one stays in the midline, it is a relatively bloodless
field and one continues deeper until the thyroid isthmus is
identified.

31. 2 PRINCIPLES OF ENTERING TRACHEA
⚫ Cricoid cartilage or 1st tracheal ring must not be cut or
injured
⚫ Incision in trachea must not extend below 4th tracheal ring
⚫ Tracheostomy hook between 1st & 2nd tracheal ring,
superior traction to elevate trachea
⚫ V
arious entrance incisions like U, INVERTED U, TAND
CRUCIFORM, or a window may be created.

32. ⚫ A traction suture with 2-0 silk
from tip of flap to inferior margin
of skin
⚫
⚫
Trousseau dialator or kelly
hemostat inserted and spread
vertically
Tracheal lumen should be
visualised an inferiorlv hinged
tracheal flap Bjork’s flap is made
which is sutured to the skin.

33. If the trachea is low in the neck and one is having
difficulty accessing the upper trachea, then there are two
strategies to bring the trachea further up into the neck.
Firstly a Cricoid hook can be used. The hook is inserted
into the trachea just under the cricoid cartilage and the
trachea is gently pulled upwards into the incision. This
usually works well.
An alternative strategy is to insert a deep Travis retractor
and place the upper arm against the lower edge of the
thyroid cartilage and the lower, against the upper edge of
the sternum. When the retractor is opened the trachea is
drawn upwards by the pull on the more robust thyroid
cartilage.

34. DEALING WITH THYROID ISTHMUS
There are different opinions regarding this
1. Dividing the Isthmus between two clamps and ligating it.
2. Pulling thyroid Isthmus up.
3. Pulling thyroid isthmus down.
Once the isthmus is divided or pulled up or down the trachea will be
exposed and the rings should be counted.

35. TRACHEOSTOMY TUBE INSERTION
⚫ Tracheal dilators will be needed to
enable the tube to be inserted into the
tracheal lumen.
⚫ The assistant should now hold the tube
in situ until it is secured. Use a flexible
suction catheter down the tube to
suction any blood or mucus out of the
trachea and connect the catheter mount
to the tracheostomy tube and the
anaesthetic tubing

36. TYPES OF TRACHEOSTOMY TUBES
⚫CUFLESS TUBES
⚫CUFFED TUBES

37. Types of Tracheostomy Tubes
Parts of a Tracheostomy
Tube Tube with inner
Cannula

38. Metal tube with inner
cannula and obturator
Single Cannular Shiley
Pediatric Tracheostomy Tube
Obturator at Right

42. Skin closure
 incision should not be sutured or dressed
tightly. (subcutaneous emphysema,
pneumomediastinum & pneumothorax.)
 Asmall gauze pad may be placed b/w
the flange of the tube and the skin

43. Tracheostomy: Pediatric Anatomical consideraions
⚫ Dome of pleura extends in to neck and is this vulnerable to injury
⚫ The hyoid bone, thyroid cartilage and the cricoid cartilage lie higher in the neck.
 Trachea is pliable and difficult to palpate
⚫ Recurrent laryngeal nerve
Neck is short so less working space
⚫ Cricoid can be injured

44. VARIATION
⚫ In children short neck: left brachiocephalic vein may come up above the
suprasternal notch so that dissection is rather more difficult and dangerous.
⚫ Also, child’s trachea is softer and more mobile than the adult’s and therefore
not so readily identified and isolated.
⚫ Its softness means that care must be taken, in incising the child’s trachea, not to
let the scalpel plunge through and damage the underlying oesophagus.
⚫ In contrast, the trachea may be ossified in the elderly and small bone shears
required to open into it.

45. Tracheostomy: Pediatric
1.Bronchoscope/ETT inserted to provide, an
airway and rigidity to the trachea.
2. Do not to insert the knife too deeply
3. A vertical skin incision is used. Before the
anterior tracheal wall is incised, silk retraction
sutures are placed in either side of the midline.
4. Tape the silk retraction sutures to the chest wall
5. Silastic tubes are preferable
Routine Post-op R/G of the neck and chest.

46. Tracheostomy care
Fixation of tube
Positioning
Suctioning
Humidification
Changing of tube
Care of inflatable cuff
Dressing
Decannulation
Breathing exercises and nutrition

47. Bedside equipment
• Spare tubes of Same / smaller size.
• Tracheal dilator.
• Suctioning equipment
-Ensure everyday equipment is assembled and working.
• Humidification unit
-Ensure everyday equipment is working properly.
• Container to hold speaking valve, occlusive cap/button or spare inner cannula.

49. Fixation of tube

50. Positioning

51. Suctioning

52. Humidification
Aims:
 To prevent drying of pulmonary secretions (tracheitis & crust
formation).
 To preserve muco-ciliary function.
Various methods of humidification
A) HEATED HUMIDIFIERS.
B) HEAT MOISTURE EXCHANGE FILTERS.
C) NEBULIZERS.
-In addition to atmospheric humidification,
-Instill 3 -4 drops of hypotonic saline/ sodium bicarbonate 1-2ml/h
-Thick, copious secretions use mucolytic agents.

53. Dressing

54.  Fresh tracheostomyCshaorueldob
e
fl
e
tf
hti
en tube
place for 3 - 5 days for the
permanent tract to form.
 loss of the tracheal opening into the
neck wound, disastrous
consequences.
 A tube in an infant should not be
changed for the first time without a
bronchoscope on hand.

55. CARE OF CUFFED TRACHEOSTOMY TUBE
Inflate:
• Immediately post-op
• during mechanical ventilation
Deflate:
• Cuff should be deflated atleast 5mins every hr.
• First suction the oropharynx.

56. SPIROMETER
Recommended cuff pressure is <25cm
⚫ Using a cuff pressure
manometer, check the
pressure of the tracheostomy
cuff. Should be less than 25
cm of H2O. If more chances
of tracheal injury. If more
pressure is needed, then
change the tube.As a simple
rule, air in cc about half the
size of tracheostomy tube is
sufficient for adequate volume
and pressure of the cuff.
⚫ .

57. Breathing exercises and nutrition

58. 1. It is recommended that endotracheal suctioning should be performed only when
secretions are present, and not routinely;
2. It is suggested that pre-oxygenation be considered if the patient has a clinically
important reduction in oxygen saturation with suctioning;
3. Performing suctioning without disconnecting the patient from the ventilator is
suggested;
4. Use of shallow suction is suggested instead of deep suction, based on evidence
from infant and pediatric studies;
5. It is suggested that routine use of normal saline instillation prior to
endotracheal suction should not be performed;
American Association for Respiratory Care (AARC)
Guidelines- Recommendations
AARC Clinical Practice Guidelines: Restrepo RD, Brown JM II, Hughes JM Endotracheal Suctioning of Mechanically Ventilated
Patients With Artificial Airways 2010 Respir Care 2010;55(6):758–764. © 2010 Daedalus Enterprises

59. 5. The use of closed suction is suggested for adults with high FIO2, or PEEP,or at
risk for lung derecruitment, and for neonates;
American Association for Respiratory Care (AARC)
Guidelines- Recommendations
6. Endotracheal suctioning without disconnection (closed system) is suggested in
neonates;
7. Avoidance of disconnection and use of lung recruitment maneuvers are
suggested if suctioning-induced lung derecruitment occurs in patients with
acute lung injury;
8. It is suggested that a suction catheter is used that occludes less than 50% the
lumen of the endotracheal tube in children and adults, and less than 70% in
infants;
9. It is suggested that the duration of the suctioning event be limited to less than
15 seconds
AARC Clinical Practice Guidelines: Restrepo RD, Brown JM II, Hughes JM Endotracheal Suctioning of Mechanically Ventilated
Patients With Artificial Airways 2010 Respir Care 2010;55(6):758–764. © 2010 Daedalus Enterprises

60. Complications of tracheostomy
⚫Immediate Intermediate Late

61. Immediate
⚫Hemorrhage
⚫Air embolism
⚫Apnoea
⚫Cardiac arrest
⚫Local damage

62. Hemorrhage
⚫Anterior jugular veins
⚫ Inferior thyroid veins
⚫Thyroid gland

63. Air embolism
⚫Inadvertent opening of large neck veins
⚫Air sucked in and passing rapidly into right atrium
⚫Tamponade and death

64. Apnoea
⚫Sudden discharge of carbon dioxide
⚫Allow the patient to breath a mixture of 95% oxygen
and 5% carbon dioxide during the procedure

65. Cardiac arrest
⚫Exessive adrenaline production
⚫Rapid rise of ph
⚫Hyperkalemia

66. Local damage

67. Intermediate
⚫Dislodgement
⚫Surgical emphysema
⚫Pneumothorax/pneumomediastinum
⚫Scabs and crusts
⚫Infection
⚫Tracheal necrosis
⚫Tracheoarterial fistula
⚫Tracheo-oesophageal fistula
⚫Dysphagia

68. Dislodgement
⚫Post operative oedema, hematoma and emhysema
⚫Prevention:
⚫Suturing flanges in early period and tapes in later
period

69. Surgical emphysema
⚫ Subcutaneous
emphysema is alarming
but it is not fatal
⚫ Too large incision
⚫ Tube partially
obstructed/diverts air
into soft tissues
⚫ Too tight closure of
subcutaneous tissues
⚫ Excessive coughing

70. Pnuemothorax/pneumomedistinum
⚫Direct puncturing of
pleura
⚫Tube is inserted
between the anterior
wall of trachea and soft
tissues of anterior
mediastinum

71. Scabs and cysts
⚫Tracheostomy alters the basic physiology

72. Infection
Pseudomonas,
stahphylococcus, hemolytic
streptococci and candida

73. Tracheal necrosis
⚫ Over sized tracheostomy
tubes,
⚫ Improper curve of the
tube,
⚫ Impingement of tip of
the tube
⚫ Pressure of cuff

74. Tracheoarterial fistula
⚫ Occurs in 0.1-1%
⚫ Mortality 80-90%
⚫ Hemmorrhage occurring 3days to
6wks after tracheostomy should be
thought of as a result of TIF
⚫ Low tracheal incision
⚫ Improper position of tube against the
vessel
⚫ Improper curve or length of tube
⚫ Secondary to pressure

76. Traheo-oesophagial fistula
⚫Over inflated or improperly fitting cuffed tube
⚫Positive pressure ventilation

77. Dysphagia
Managed by feeding through ryles tube

78. Late
⚫Stenosis
⚫Difficulty with decannulation
⚫Tracheo cutaneous fistula

79. Stenosis
⚫3 distinct levels
⚫1)stoma
⚫2)cuff site
⚫3) tip of tube
⚫Caused by
⚫Inflatable cuff
⚫Scar contracture

80. Difficulty in decannulation
In long standing cases
Granulations
Fibrous masses
Tracheal strictures

81. Tracheocutaneous fistula and scars
⚫Due to migration of squamous epithelium from skin
into trachea

82. ⚫Patients with
respiratory failure who
cannot be weaned
within 7-10 days
⚫Most severely injured
trauma patients who
require air way support
more than 5 days

84. Percutaneous tracheotomy
(history)
1955, Shelden et al - first
attempt with cutting
trocar into the trachea.
⚫ 1985, Ciaglia et al -
percutaneous dilational
tracheostomy (PDT)
⚫ 1989, Schachner et al -
Rapitrach
⚫ 1990, Griggs et al - the
guidewire dilating forceps
(GWDF)

85. Surgical techniques
Percutaneous procedure
Introduction of tracheal
needle
Placement of guide wire

86. Surgical techniques
Percutaneous procedure
Insertion of guiding
catheter
Serial dilation

87. Placement of tracheostomy tube

88. Ciaglia Blue Rhino kit containing needle, guide wire, and serial dilators
Percutaneous Dilational Tracheostomy-
Commercial Kits & Techniques

90. Tracheal lumen entered below 2nd ring with
introducer needle

93. ⚫ Griggs guidewire dilating forceps (GWDF) technique
⚫ 2002 Percu Twist technique

94. Griggs and Rapitrach systems

95. Griggs and Rapitrach Technique

96. The Percutwist system
Note the dilatation of the tract with a semi-sharp screw over a guide wire

98. Complications of Percutaneous Tracheostomy
Complications of Percutaneous technique are not common
1. false passage of the tracheostomy tube,
2. pneumothorax,
3. delayed bleeding,
4. puncture of the posterior tracheal wall,
5. premature extubation during the procedure and loss of the
airway.

99. Intensive Care Med (1991) 17:261-263
•A prospectivenon-randomised study
•The safety and utility of surgical and PCT techniques performedin ICU
•Standard indications for tracheostomy of prolongedmechanical ventilation (> 10 days)

100. •RCT of 30 PCT vs 30 Surgical Cases
•median time for insertion of the tracheostomy tube was 11.5 min (range 7–24 min) vs 15
min (range 5–47 min) (P<0.01).
•Minor bleeding was encountered in 6 cases in the PDT group as opposed to 24 cases in
the TR group (P<0.01),
•Major bleeding in none versus 2 cases, respectively.
Post-tracheostomy period,
•minor bleeding in 2 cases in the PDT vs 9 cases in the TR group (P<0.05), and major
bleeding was encountered in 1 case in each group.
•Minor infections were encountered in 3 cases in the PDT group as opposed to 11 cases in
the TR group (P<0.01). Major infection was encountered in none versus 8 cases,
respectively (P<0.01).

101. Prospective, randomized trial.
30 patients underwent PDT and 26 patients had ST.In one patient, PDT was converted to ST.
Mean time 11 mins (SD, 6; range, 2-40), vs 14 mins (SD, 6; range, 3-39).
In the PDT group, five patients had moderate bleeding during the procedure. In three
patients, the bleeding was resolved with compression; in one patient, it was resolved
with ligation of the vessel; and in one patient, it was resolved with electrocoagulation.
Bleeding did not cause any complications afterward.
In the PDT group, one patient had minimal oozing from the wound edge on the first
postoperative day and it was resolved spontaneously.

102. •368 abstracts, 15 prospective, randomized-controlled trials involving nearly 1,000 patients
•complications, case length, and cost-effectiveness.
•meta-analysis illustrates there is no clear difference but a trend toward fewer complications
in percutaneous techniques.
•Percutaneous tracheotomies are more cost-effective and provide greater feasibility in
terms of bedside capability and nonsurgical operation.

104. References
1. Rowe &William’s Maxillofacial injuries 2nd edition-vol I
2. Oral & maxillofacial trauma :Fonseca-3rd edition-vol I
3. Bailey & love’s short practice of surgery 23rd edition.
4. Scott and Brown’s Otolaryngology 6th edition vol I ,vol II
5. Operative otolaryngology Head and Neck –Eugene N Myers vol I
6. Diseaes of Nose ,Throat , Ear – Logen Turner
7. Text book of Otolaryngology and head and neck surgery -Byron &Bailey
8. Clinically oriented Anatomy -5th edition –Keith L Moore
9. An atlas of head & neck surgery-Lore’ 3rd edition
10. Internet sources

106. ???????????
⚫HORIZONTAL VS VERTICAL INCISION
⚫KNIFE VS CAUTERY
⚫NO. OF SUTUIRES
⚫TYPE OF FLAP