clinical skills

2. Surgical techniques
Percutaneous procedreOpen procedure

3. Open procedure
Midline incision from the lowr
border of the thyroid to the
manubrium sterni
Cut the skin, superficial fascia, platysma
and the deep fascia connecting the
pretracheal muscles of the two sides
Pretracheal muscles?

4. Separate the pretracheal muscles of both
sides by a retractor
The thyroid isthmus is divided by
2 kochers, transfixed by catgut to prevent
bleeding and leak of thyroxin and then
retracted.

5. Expose the trachea and inject 1/2 c.c surface
anaesthetic (pantrocaine 1%) in the trachea to
diminish the cough reflex Fix the trachea and elevate it by a cricoid hoo
7- Open the trachea by an incision or by
removal of a circular part of the 3rd and 4th
rings.

6. Surgical techniques
percutaneous procedure

7. Surgical techniques
percutaneous procedure

8. Surgical techniques
percutaneous procedure

9. Surgical techniques
percutaneous procedure
• Should be done in carefully
selected patients
• Under fiber optic control
• To be ready to switch to open
procedure

11. Types of Tubes
Cuffed tubes Un-cuffed Fenestrated
SilverInner cannulaAdjustable Flange

12. Cuffed Tubes
Allows ventilation and prevents aspiration
High cuff pressure can be damaging
Check pilot cuff
Don’t BLOCK THIS TUBE

13. Cuffed Tubes
• Tubes with inflatable cuffs
• Why the cuffs are needed?
• Any guesses about fixation?
• when the patient is unable to breathe on their own and requires artificial
respiration. Unless there is an air-tight seal around the tube, the air being
blown into the lungs by the respirator escapes around the sides of the
tubes.
or
• when an air-tight seal is necessary to prevent blood and other secretions
from running down the sides of the tracheostomy tube into the lungs.
During and following surgery to the head and neck, such complications are
a real danger and it is for this reason that a cuffed polythene tube is used
for the first couple of days post-operatively.

14. Un-cuffed Tubes
Maintains airway once aspiration risk has passed
Increase airflow to the larynx
Long term tracheostomy pts
Patients who do not require a seal
Paediatrics

16. Fenestrated Tube
Increases airflow to larynx/ vocalisation
Cuffed or un-cuffed
Enables phonation (speaking)
The fenestrated tube can be used as such if the patient is tolerating the cuff down
To suction always use the non fenestrated inner tube for suctioning
Fenestrated are the only tubes (when inner fenestrated tube insitu and cuff is down)
that can be intentionally occluded

17. Inner Cannula
Allows maintenance of tube patency
Aids tube hygiene
Close observation
Allows fenestrated tubes to be used earlier

18. Inner Cannula
Use of an inner cannula:
The inner cannula provides a vital safeguard against life-
threatening complications of tube obstruction in a cuffed tube and
must be present at all times.
Tracheostomy tubes without an inner cannula should be avoided
wherever possible particularly in the ward environment;

19. Adjustable Flange
Provide a longer tube – offer secure placement of tube in a deep-set
trachea
Essential for patients with difficult anatomy and on whom the insertion
will be complicated; insertion of this tube is usually via the surgical
technique (considered to be an unsuitable tube for the percutaneous
insertion technique)
These tubes are inserted in patients with very difficult anatomy and
therefore subsequent tube changes should be considered carefully.

20. Silver Negus
• Metal Tracheostomy Tubes
• These are made of silver because the metal is inert and does not irritate the
tissues. The most commonly used silver tube is the ‘Silver-Negus’. The sizes of the
tubes for adults vary from 28-36 FG. The letters FG stand for ‘French gauge’. The
number represents the circumference of the inner tube measured in millimetres.
As a rough guide, the FG size is 4 times the portex size.
• The tubes have a normal inner tube and a speaking tube with a small valve on.
• Speaking tubes should not be used to sleep in because of the danger of the valve
blocking and occluding the airway. Silver tubes cost approximately £200 each.
Each set is individual and pieces are not interchangeable. If a piece is lost it can
cost £100 at least to replace. The tubes also need repairing and maintaining
occasionally. Manufacturers of plastic tubes claim silver tubes are not as
comfortable as plastic but they have no evidence to support this.

21. Speech with tracheotomy