A VERY GOOD AND RESOURCEFUL PRESENTATION FOR PRIMARY CARE PHYSICIANS

1. DR JOSHUA TACKIE OFOLI
MBBS (Jos), MSc (Liverpool), FWACP, FMCFM

2.  Robust slide content to facilitate self study
 Review of only significant slides
 Apologies for some crowded slides

3.  An operative
procedure that creates
a surgical airway in the
cervical trachea

4.  The first known depiction of tracheostomy is from 3600 BC, on Egyptian tablets
 The first scientific reliable description of successful tracheostomy by the surgeon
who performed it was by Antonio Musa Brasavola in 1546, for relief of airway
obstruction from enlarged tonsils.
 In the early 20th century, tracheostomy was made much safer, technical aspects of
the procedure were refined and described in detail by the famous surgeon
Chevalier Jackson
 At present, tracheostomy is more commonly used for prolonged mechanical
ventilation rather than for upper airway obstruction.
 Tracheotomy has often been advocated as part of the long-term ventilator weaning
process and has also found its way into evidence-based guidelines for weaning

6.  Improved oral hygiene for the intubated patient
 Decreased requirement for sedation in the intubated
patient
 Oral movement for communication, nutrition and
hydration (with manipulation)
 Reduction in damage to the larynx, mouth or nose from
prolonged endotracheal intubation
 Vocalisation (with manipulation)
 Improved patient comfort

7.  It is D-shaped, with incomplete cartilaginous rings anteriorly and
laterally, and a straight membranous wall posteriorly
 starts from the inferior part of the larynx (cricoid cartilage) in
the neck, opposite the 6th cervical vertebra, to the
intervertebral disc between T4-5 vertebrae in the thorax
 The thyroid isthmus is located between second and third
tracheal rings,
 the innominate artery most often crosses the anterior trachea
in an oblique fashion distal or inferior to the third tracheal
ring
 the aortic arch crosses above the carina.
 The coronal and sagittal tracheal dimensions vary in males
and females.
 The upper limits of the coronal and sagittal diameters in men
are 25 and 27 mm, respectively.
 In women, they are 21 and 23 mm, respectively.

8.  The recurrent laryngeal nerves lie in
close proximity to the trachea within
the tracheoesophageal groove.
 The blood supply to the cervical
trachea enters posteriolaterally from
the inferior thyroid artery
 ultrasound probe in the intended area
of dissection to confirm the absence
of any significant vasculature

9.  Endoluminal Intubation
 Emergent cricothyrotomy
 should be considered only when the patient is in a very
difficult life threatening situation and thus the need to use
extreme measures
 No conscientious physician should perform any procedure
known (even colloquially) as a slash
 Percutaneous transtracheal jet ventilation (PTJV)

10.  may replace or precede tracheostomy
 intraoperative control provided by an endotracheal tube facilitates
tracheostomy
 comparably easy
 more rapidly performed
 well tolerated for short periods (generally 1-3 weeks).
 Contraindications
 C-spine instability,
 Mid face fractures,
 laryngeal disruption,
 obstruction of the laryngotracheal lumen.
 Supplements
 nasal airway trumpet:
 provides dramatic relief of airway obstruction caused by soft tissue
redundancy, collapse, or enlargement in the nasopharynx.
 oral airway :
 prevents the tongue from collapsing against the back wall of the
oropharynx
 Intubation can be performed orally or nasally, depending on local
trauma and the logistics of planned operative intervention.

11.  Advantage:
 cricothyroid membrane is superficial and readily accessible,
with minimal dissection required.
 Disadvantage:
 cricothyroid membrane is small and adjacent structures (eg,
conus elasticus, cricothyroid muscles, central cricothyroid
arteries) are jeopardized;
 the cannula may not fit.
 Damage to the cricoid cartilage from the scalpel or pressure
necrosis leads to perichondritis and possibly stenosis
 overall complication rate:
 32%, which is 5 times that of tracheostomy under controlled
circumstances

12.  patient's neck is extended and stabilized
 Palpate for the cricoid cartilage approximately 2-3 cm below the
thyroid notch
 A 1-cm horizontal incision is made just above the superior border
of the cricoid (this avoids the vessels that run under the inferior
border, in the same manner as the intercostal neurovascular
bundles) to expose the cricothyroid membrane, which is then
punctured in the midline
 The blade must be directed inferiorly to avoid trauma to the true
vocal cords.
 Care is taken not to extend this puncture through the back wall of
the larynx and into the esophagus
 Insert a blunt instrument (eg, knife handle) into the incision and
rotate it perpendicularly to widen the incision to accommodate a
small cannula.

13.  catheter is placed through the skin and into
the trachea.
 performed under local anaesthesia
 once PTJV is in place, the patient can be
oxygenated with jet ventilation
manoeuvres.
 most commonly used in the management
of the difficult airway (supraglottic and
glottic obstruction) before the induction of
general anaesthesia

14.  Patients in acute respiratory distress may need acute
surgical intervention
 Urgent tracheostomy can be performed in a controlled
environment (eg, operating room) with the patient under
local anaesthesia.

15.  Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
 Upper airway foreign body that cannot be dislodged with Heimlich and basic cardiac life support
manoeuvres
 Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral vocal cord paralysis)
 Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid bone, or great
vessels
 Subcutaneous emphysema
 Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the mid
face and mandible)
 Upper airway edema from trauma, burns, infection, or anaphylaxis
 Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent
period)
 Severe sleep apnea not amendable to continuous positive airway pressure devices or other less
invasive surgery

16.  Most are performed in patients who are already
intubated and who are undergoing a tracheostomy for
prolonged intubation
 patients undergoing extensive head and neck procedures
may receive a tracheostomy during the operative
procedure to facilitate airway control during
convalescence
 A smaller population of patients with chronic pulmonary
problems (eg, sleep apnea) elects to undergo
tracheostomy

17.  Initial decision for tracheostomy by attending physician
 Attending physician to discuss procedure with patient
and/or family
 Referral to general or ENT surgeon
 Informed consent by Surgeon (risks, benefits, and
alternatives)
 Pre op: CBC, Coagulation profile, Group and screen
 NPO after midnight

18.  Percutaneous
 Open

19.  Enhancement of patient comfort during prolonged
weaning efforts
 Mechanical ventilation estimated or anticipated to be
longer than 7 days
 Failed extubation
 Relief of upper airway obstruction
 Secretion management
 Need for bedside procedure secondary to increased risk
of patient transfer to operating room

20.  Absolute
 Absence of informed consent
 Active site infection
 Uncorrectable bleeding diathesis
 Operator inexperience
 Relative
 Difficult airway
 Morbid obesity
 High ventilatory/positive end-expiratory pressure (PEEP) requirements
 abnormal or poorly palpable midline neck anatomy
 Coagulopathy
 Pediatric patients
 enlarged thyroids
 History of neck surgery
 Emergent procedure

21.  single graded dilator technique is optimal.
 Advantages
 time required for bedside PDT is shorter than for open
tracheostomy,
 elimination of scheduling difficulty associated with operating
room and anaesthesiology for ICU patients,
 PDT expedites performance of the procedure because critically
ill patients who would require intensive monitoring to and
from the operating room need not be transported;
 cost of performing PDT is roughly half that of open surgical
tracheostomy due to the savings in operating room charges
and anaesthesiology fees
 Reducing complications
 Bronchoscopy
 visualize the anterior entry site of the needle,
 avoid posterior tracheal injury
 ensure that the guide wire and dilator are advanced
distally
 Bedside ultrasound

22. • Best performed in an operating room with adequate
equipment and assistance
• Position the unconscious or anesthetized patient
supine with the neck extended and the shoulders
elevated on a small roll.
• can also be done at the bedside in the intensive care
unit
• Overextension of the neck should be avoided because
it further narrows the airway
• overextension can lead to placement of the
tracheostomy too low (toward the carina) and too
close to the innominate artery (especially in the very
mobile paediatric trachea).

23.  Unless the patient is comatose, and generally even if comatose, some sort
of anesthesia is preferable.
 local anesthesia prefered
 Lidocaine or lidocaine 1% with 1:150,000 parts epinephrine (help minimize
bleeding)
 standard recommended doses are 3-4 mL/kg of lidocaine alone or 5-7
mL/kg of lidocaine in combination with epinephrine.
 conscious sedation for patients in ICU on sedatives and analgesics
 Some patients require deeper sedation
 In addition to sedatives and analgesics, most patients are also given a
short-acting paralytic

24.  Palpate the landmarks (eg, thyroid notch, sternal
notch, cricoid cartilage) and mark them with a pen
 Apply anaesthesia
 3-cm vertical skin incision initiated below the
inferior cricoid cartilage.
 Many advocate the horizontal skin incision, which
is made along relaxed skin tension lines and gives
better cosmesis but a horizontal incision may trap
more secretions.
 Subcutaneous fat may be removed with
electrocautery to aid in exposure and to prevent later
fat necrosis
 Meticulous hemostasis throughout the procedure

25.  Dissection proceeds through the platysma until the midline raphe between the
strap muscles is identified
 Palpate the inferior limit of the field to assess the proximity of the innominate
artery
 Cauterize or ligate aberrant anterior jugular veins and smaller vessels.
 Midline dissection is essential for hemostasis and avoidance of paratracheal
structures
 The strap muscles are separated and retracted laterally, exposing the
pretracheal fascia and the thyroid isthmus.
 The lateral retraction also serves to stabilize the trachea in the midline
 the thyroid isthmus, typically lies anteriorly over the first 2-3 tracheal rings
 A retracted isthmus may be irritated if it rubs against the tracheostomy tube in
the postoperative period, causing bleeding
 Thus although it may be retracted out of the field, it must often be divided in
some cases.
 Elevate the isthmus off the trachea with a hemostat and divide it
 Division is performed sharply or with electrocautery and suture ligature
 Dry the field

26.  Clean the remaining fascia off of the anterior face
of the trachea
 warn the anaesthesiologist of impending airway
entry
 Complete preparations for Deflate endotracheal
tube balloon
 Injection of topical anaesthesia can stem the
cough reflex of an awake patient
 Make tracheal opening
 Simple horizontal (bedside)
 T-Shape
 U-shape
 H-shape
 silk stay suture can be placed through the
tracheal wall on each side and taped to the neck
skin on either side.
 Marking the tape that holds these sutures to the
skin with "Do not change or remove" is prudent
 These sutures are removed after the first
tracheostomy tube change 5-7 days
postoperatively

27.  Suction secretions and blood
 Slowly withdraw endotracheal tube
 Secure the cricoid with a hook and elevate it superiorly to facilitate
control of the tracheal entry
 Replace lateral retractors into trachea
 Enter trachea
 airway is confirmed intact based on carbon dioxide return and
bilateral breath sounds
 secure the tracheostomy tube to the skin with 4-0 permanent sutures.
 Attach a tracheostomy collar with the head flexed to avoid
unnecessary slack in the collar
 To avoid the risk of subcutaneous emphysema and subsequent
pneumomediastinum, the skin is not closed
 Place a sponge soaked with iodine or petrolatum gauze between the
skin and the flange for 24 hours to deflect infection and anxiety
about minor oozing of the skin edge.
 https://img.medscape.com/pi/meds/ckb/68/27068.mp4

29.  Ideal tube size
 maximizes the functional internal diameter while
limiting the outer diameter to approximately three
quarters of the internal diameter of the trachea
 reduces airway resistance and the work of breathing
while facilitating airflow around the tube
 Most women no. 6 Shiley cuffed tracheostomy tube
 Most men no. 8 Shiley cuffed tracheostomy
 Ideally, the end of the tracheostomy tube should be 2-3 cm
from the carina to avoid the potential for the tube to enter
the mainstem bronchus with neck flexion
 A tube that is too short abuts the posterior tracheal wall,
causing obstruction and ulceration.
 A tube that is too long curves forward and erodes the
anterior tracheal wall, which can be perilously close to the
innominate artery.

30. 1. single-cannula tubes:
a. Uncuffed (A)
b. cuffed (B):
2. Double-cannula
• Removable inner tubes
• fenestrated and non
fenestrated inner cannulae
• Obturator for insertion

31. Allow positive pressure ventilation and prevent aspiration
Indications :
 Risk of aspiration
 Newly formed stoma in adult
 Positive-pressure ventilation
 Bleeding (eg, in a multiple-trauma patient)
 Unstable condition
Contraindications :
 Child younger than 12 years
 Significant risk of tracheal tissue damage from cuff
irritates the trachea and provokes and trap secretions, even when deflated
Use only when necessary
Even modern low-pressure cuffs should be deflated regularly (four times a day) to prevent pressure
necrosis
cuff pressures should be checked regularly in patients on mechanical ventilation

32.  Indications :
 Stable stoma
 Paediatric and neonatal patients
 Upper-airway obstruction due to tumours
or neuromuscular disorders causing vocal
cord palsy
 Contraindications:
 Dependent on positive-pressure ventilation
 Significant risk of aspiration
 Newly formed tracheostomy

33.  permit airflow, which, in addition to air leaking around the tube,
allows the patient to phonate and cough more effectively
 single or multiple fenestrations on the superior curvature of the
shaft
 Both Outer and /or inner
 Cuffed fenestrated tubes are particularly used in patients who are
being weaned off their tracheostomy when a period of cuff
inflation and deflation is required
 Uncuffed fenestrated tubes are used in patients who no longer
depend on a cuffed tube.
 contraindicated in patients who require positive-pressure
ventilation, as some of the air will leak out of the fenestrations.
 Standard fenestrations are rarely in the right place; if flush with
the tracheal wall, they instead cause irritation and granulation
and should not be used.
Fenestrated cuffed and
uncuffed tubes.

34.  attached to the proximal end of the tube prevents
the tube from descending into the trachea
 allows for securing the tube with tapes, ties, or
sutures
 tube size and type is often imprinted on the neck
plate for easy identification
 Certain tubes have a swivel neck plate that rotates
on two planes and facilitates dressing and wound
care
 These also allow distal tracheal obstructions to be
bypassed through a conventional tracheostomy
Adult swivel, neonatal, and
pediatric neck flanges.

35.  Certain tubes have an adjustable
flange that allows variable tube
length and may be useful in
patients with larger necks.
 These also allow distal tracheal
obstructions to be bypassed
through a conventional
tracheostomy Bivona and Portex adjustable-
neck-flange tubes.

36.  Manage in intensive care for first 24 hours
 Keep spare tube by patients bedside
 If tube becomes dislodged ( unable to ventilate through the tracheostomy or prominent subcutaneous air
seen)
 Surgical review POD1 + follow up instructions
 First trach change + suture removal POD7
 Observe in hospital for stoma maturity then discharge
 If the patient is stable for 24 - 48 hours with the trach cuff deflated or with a cuffless tube in place, the
patient may be discharged at the attending physicians discretion.
 For awake patients who are tolerating a cuffless trach or a deflated trach cuff, a Passey-Muir (speaking)
valve may be ordered by the attending physician or pulmonologist
 A qualified respiratory therapist can apply the speaking valve and instruct the patient in it's use.
 When necessary, speech therapy should be consulted to help the patient phonate correctly with the
speaking valve

41.  Tracheostomy risks include blocking of the tube by debris, and
dislocation of the tracheostomy cannula
 use of a multidisciplinary team and a tracheostomy-care protocol
can improve outcomes
 Role of ICU nurses, ENT surgeons and intensivist
 Dependent on available technology, teaching activities, and
personnel involved in the decision to remove the tracheostomy
 Cleaning the inner cannula might prevent infection, and although
the inner cannula increases the imposed work of breathing, it helps
keep a clear artificial airway.
 An important part of follow-up is the decision on when to
decannulate

42.  Patient and caregiver education/ training
 basic airway anatomy
 medical justification for the tracheostomy,
 tube description and operation,
 Appropriate tube selection
 signs and symptoms of respiratory and upper-airway distress,
 Airway management/ventilation
 signs and symptoms of aspiration,
 suctioning technique,
 tracheostomy tube-cleaning and maintenance,
 stoma-site assessment and cleaning,
 cardiopulmonary resuscitation,
 emergency decannulation and reinsertion procedures,
 tube-change procedure,
 Equipment supply, use and ordering procedures,
 Humidification needs
 Speech
 financial issues.
 scheduled follow-up plan with the attending physician

43.  Removal of tracheostomy cannula
 most important criteria regarding the decision to decannulate are ability to cough, frequency of
airway suctioning, and the patient’s condition
 If it is felt that trach is no longer needed and will not be needed in the foreseeable future, a trial of
breathing with the trach cuff deflated will be undertaken.
 If this is tolerated, the current trach tube may remain in place with the cuff deflated, or change the
trach to a cuffless smaller tube (#6 Shiley).
 The trach tube may then be plugged with the plug (with a red button) provided with the trach
tube.
 If the patient is stable for 24 - 48 h with the trach plugged, remove the trach, and the stoma will be
allowed to close.
 If upper airway pathology such as tracheal stenosis is suspected, the pulmonologist will perform a
flexible bronchoscopy prior to decannulation.
 Once the tube has been removed, occlude stoma with a tight dressing
 Change dressing when airleak becomes apparent to prevent tracheocutanous fistula

46.  Tracheostomy is an operative procedure that creates a
surgical airway in the cervical trachea.
 It is a viable alternative to prolonged endotracheal
intubation.
 It has several benefits to the patient, physician and
caregiver
 It could be emergent or elective
 It could be done through a percutaneous or open
approach
 Post operative and long term care are important

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48. THANK YOU