defined as a trachea with excessive transverse narrowing and widened sagittal diameter of the intrathoracic portion of the trachea. This is very different from the C-shaped trachea seen in about 49% of normal adults
ANATOMY OF TRACHEA & TRACHEOSTOMY
area of the male adult
trachea is approximately
diameter of 25 mm and
diameter of 27 mm are the
upper limits of normal
The lower limit of normal
for both transverse and
sagittal diameters is about
13 mm in men and 10 mm
Left Branchiocephalic Vein
vena cava anterolaterally on right side
Arch of Aorta
Lungs covered by
The left common
carotid and left
Duct on left side
Azygos vein on right
Venous plexuses situated around
trachea and oesophagus ultimately
drain into inferior thyroid venous
lymph nodes located around trachea,
the brachio-cephalic and right
common carotid arteries.
What is “Tracheostomy”
The word “tracheostomy” is
derived from the Latin “trachea”
and “tomein” (to make an
Tracheostomy is an operative
procedure that creates a surgical
airway in the cervical trachea .
What is this & what are its indications ???
Answer at the end of presentation
1932 to prevent pulmonary infection in
neurologically impair patients secondary
to infections (poliomyelitis).
1943 to remove bronchial secretions in
cases of myasthenia gravis and tetanus.
1951 to reduce the volume of dead space,
use in COPD and severe penumonia.
1950 positive pressure through
tracheostomy for patients with
1955 obstruction secondary to infection:
diphteria, Ludwig’s angina.
1961 Obstructions secondary to tumour,
infectious disease and trauma.
- Need for prolonged respiratory support, such as in
- To reduce anatomic dead space and increase the chance for
mechanical ventilation withdrawal
- To improve the patient`s quality of life (easier toilet,
ability to speak and eat, increase the mobility)
- Neuromuscular diseases paralyzing or weakening chest
muscles and diaphragm
PROTECTION of AIRWAY
Neurological Diseases(Polyneuritis, GBS)
Coma (GCS<8, risk of aspiration)
Elective Tracheostomy as Adjunct to H&N surgeries
<14 days on ETT(relative)
>21 days on ETT
-Congenital abnormalities. (Pierre Robin, Triecher Collins
- Obstructive Sleep Apnea Syndrome.
- Aspirations related to muscle or sensory problems.
-Prophylaxis (as preparation for extensive H&N
procedures, before radiotherapy for H&N CA)
-Cervical spinal cord injuries with respiratory muscles
No absolute contraindications exist to
it may lead to increased incidence of stomal
recurrence(a diffuse infiltrate of neoplastic tissue at the junction of the
amputated trachea and skin )
Physical assessment also surgical and
PT, PTT, INR
Types of Tracheostomy
1) Open procedure
a) High tracheostomy (Cricothyroidectomy)
b) Low tracheostomy
2) Percutaneous procedure
Emergency Cricothyrotomy Protocol
A patient that requires intubation and
Unable to intubate and
Unable to adequately ventilate
Patient 40 kg and 12 years old
Suspected fractured larynx
Inability to localize the cricothyroid membrane
Benefits include elimination of need for
operating room use or anesthesia, and
significant reduction in cost.
Should be done in carefully selected patients
Under fiber optic control
To be ready to switch to open procedure
PERCUTANEOUS DILATIONAL TRACHEOTOMY
Guidewire introduction, with
removal of sheath
Guidewire and catheter are advanced
together into the trachea as far as the
skin positioning marks on the guide
catheter to the skin.[
catheter, and dilator
unit are advanced
together into the
trachea to the skin
The tracheotomy tube is
loaded onto a dilator and
advanced into the trachea
over the guidewire and
catheter. The guidewire and
catheter are removed,
leaving only the
tracheostomy tube in the
PCV check(pressure controlled ventilation)
Repeat X-Ray soft tissue neck
IV fluid until able to tolerate orally
Risk factors for complications
Age: infants and adults over 75
Recent illness, especially an upper-respiratory infection
Apnea due to loss of hypoxic respiratory drive.
This is mainly important in the awake patient.
Ventilatory support must be available
Pneumothorax or pneumomediastinum
to the vocal cords (direct)
Injury to adjacent structures: recurrent
laryngeal nerves, the great vessels, and the
Early bleeding: This is usually the result of increased
blood pressure as the patient emerges from
anesthesia and begins to cough.
Plugging with mucus
Indications: soiled, cuff rupture.
Complications: insertion into a false passage bleeding,
and patient discomfort.
Avoid within 1st week.
First tube change by surgeon.
Difficult cases (obese, short and thick neck), be
prepared for endotracheal intubation.
Tracheostomy tube cuff pressures ---20 to 25 mm Hg.
Overly low cuff pressures < 18 mm Hg, may cause the cuff
to develop longitudinal folds, promote microaspiration of
secretions collected above the cuff, and increase the risk
for nosocomial pneumonia.
Excessively high cuff pressures above 25 to 35 mm Hg
exceed capillary perfusion pressure and can result in
compression of mucosal capillaries, which promotes
mucosal ischemia and tracheal stenosis.
Cuff pressure should be measured with calibrated devices
and recorded at least once every nursing shift and after
every manipulation of the tracheostomy tube.
Humidification of the inspired gas is a standard
of care for tracheostomized patients.
Indications For Suctioning
• Secretions in the trach
• Suspected aspiration of gastric or upper airway
• Increase in peak airway pressures when on ventilator
• Increase in respirations or sustained cough or both
• Gradual or sudden decrease in ABG
• Sudden onset of respiratory distress when airway
patency is questioned
After the track is formed – 4-5 days after the
Rate of exchange depends on clinical
situation of the specific patient – type of
discharge, type of tube, medical status, age..
Usually every 14 days.
Should be done by experienced staff.
Cuffed and uncuffed
Fenestrated and unfenestrated
Single and double lumen
To protect airway
To allow ventilation
Allow patient to
ventilate past tube via
Double lumen allows
Single lumen has a
Other Types of Tubes
Single Cannular Shiley
Tracheostomy Speaking Valve
A tracheostomy speaking valve is a one-way valve,
allows air in, but not out
forces air around the tracheostomy tube, through the
vocal cords and out the mouth upon expiration,
enabling the patient to vocalize
Tracheostomy tube prevents normal upward
movement of the larynx during swallowing and hinders
Between 20% and 70% of patients with a chronic
tracheostomy experience at least one episode of
aspiration every 48 hours
Keep head elevated to 45° during periods of tube
Resolution of pathology that necessitated the
tracheotomy (upper airway obstruction,
Normal protective laryngeal mechanisms (no
aspirations during normal swallowing, good
No planed further interventions (radiotherapy,
No mechanical ventilation