2. Etymology and terminology
tracheotomy comes from two Greek words
the root tom- (from Greek τομή) meaning "to cut“
the word trachea (Greek τραχεία)
Tracheostomy meaning "mouth," refers to the making of
a semi-permanent or permanent opening, and to the
opening itself
Definition: surgical procedure to bypass the airway in
the patient with upper airway obstruction, to make
tracheobronchial toliet easier in the patient with
decreased consciousness or for need of ventilator
installation
3. Indicaton: General
to bypass an obstructed upper
airway;
2. to clean and remove secretions from
the airway;
3. to more easily, and usually more
safely, deliver oxygen to the lungs.
1.
4. Indications: Spesific
Airway Bypass
• Severe inflammation of face, neck and larynx
• Tracheal injury
• Upper airway tumor
• Thyroid operation with complication of bleeding or bilateral recurrent nerve paralysis
• Neck radiotherapy
• Severe head and neck operating procedures
• Facial injury with multiple fracture
Bronchial Toilet
• Head trauma with consciousness disturbances, uneffective cough
• Tracheobronchitis with an edema and a lot of secretes
• Thoracic trauma with uneffective cough
• Post surgical procedure wtih inadequate cough
Easier Ventilation
• Prolonged ventilator after intubation > 48 hours
8. Anatomy of the Neck
lies between the lower margin
of the mandible above and the
suprasternal notch and the
upper border of the clavicle
below.
In the central region of the neck
the respiratory system (the
larynx and the trachea), and
behind the alimentary system
(the pharynx and the
esophagus)
At the sides of these structures
are the vertically running carotid
arteries, internal jugular
veins, the vagus nerve, and the
deep cervical lymph nodes
9. Cont’d
Superficial Fascia
thin layer that encloses the platysma
muscle
embedded in it are the cutaneous
nerves, the superficial veins, and the
superficial lymph nodes
Platysma
a thin but clinically important
muscular sheet embedded in the
superficial fascia
Superficial Veins
External Jugular Vein
Tributaries
Anterior Jugular Vein
10. Cont’d
Deep Cervical Fascia
Investing Layer
Pretracheal Layer
thin layer that is attached above to the laryngeal cartilages surrounds the thyroid
and the parathyroid glands and encloses the infrahyoid muscles
Prevertebral Layer
thick layer that encircles the neck, splits to enclose the trapezius and the
sternocleidomastoid muscles
thick layer that passes like a septum across the neck behind the pharynx and the
esophagus and in front of the prevertebral muscles and the vertebral column
Carotid Sheath
local condensation of the prevertebral, the pretracheal, and the investing layers
of the deep fascia that surround the common and internal carotid arteries, the
internal jugular vein, the vagus nerve, and the deep cervical lymph nodes
14. Pre Operative
Informed consent explain about:
Operating procedures
Loss of voices when tracheostomy canule still in the trachea
Complication of operation
Should be done in the operating theatre as much as
possible
Adequate lightning
One assistant required
Tracheostomy set
15. Cont’d
Plastic or metal canule preparation
Prophylactic antibiotic: Cefazolin or combination of
Clindamycin and Garamycin
Anaesthetic preparation:
Local or general anasthesia local anasthesia with lidocain
(max dose 7 mg/kgBW)
Patient’s position is supine with hyperextension of the
head give a cushion below the shoulder trachea
will be exposed to the anterior
Give the head a “doughnut” cushion
16.
17.
18. Types of Tracheostomy Tubes
Cuffed Tube with
Disposable Inner
Cannula
Cuffed Tube with
Reusable Inner
Cannula
Cuffless Tube with
Disposable Inner
Cannula
Used to obtain a closed circuit
for ventilation
Used to obtain a closed circuit
for ventilation
Used for patients with tracheal
problems
Used for patients who are
ready for decannulation
19. Cont’d
Cuffed Tube with
Reusable Inner
Cannula
Used for patients with tracheal
problems
Used for patients who are
ready for decannulation
Fenestrated
Cuffed
Tracheostomy
Tube
Fenestrated
Cuffless
Tracheostomy
Tube
Used for patients who are on
the ventilator but are not able
to tolerate a speaking valve to
speak
Used for patients who have
difficulty using a speaking valve
20. Cont’d
Metal
Tracheostomy
Tube
Not used as frequently
anymore. Many of the patients
who received a tracheostomy
years ago still choose to
continue using the metal
tracheostomy tubes.
21. Steps of Procedures
1.
Desinfection with povidone - iodine 10% or with Hibitane – alcohol
70% at operating area (from lower lips – chin – neck until ICS 2, left
and right until the anterior border of trapezius muscle)
2.
Operation area is narrowed by sterile linen
3.
Identification of trachea with palpation, starting from thyroid
cartilage to jugular notch
4.
Perform a local anasthesia with lidocain 1% or 2% injection
subcutaneously
5.
Vertical incision 3-4 cm (emergency case) or horizontal or collar
incision (elective case), incision is deepened by cutting subcutis,
fascia of neck superficial at the midline on the incision site
22.
23. Cont’d
6.
Hemostasis
7.
Put Langenbeck to the left and the right, balanced traction to
mantain trachea in the midline. If theisthmus of the thyroid gland
stand in the way, set aside the isthmus to the caudal and hold it
with blunt hook. Identification of trachea, put sharp-one-tooth
hook between cricoid and 1st tracheal ring
8.
Tracheal ring was cut vertically using No. 11 knife blade with a
sharp edge facing up and direction of the incision to the cranial
(2nd – 3rd ring for high tracheostomy; 4th – 5th ring for low
tracheostomy)
24.
25. Cont’d
9.
Trachea maintained open with a blunt tooth hooks on the right
and left side, clean the existing secretions by using a suction
cannula and alternating with oxygenation
10.
secretions were taken for culture and sensitivity test (for diphteria
patients)
11.
Insert the cannula tracheostomy carefully, at the time of inserting
the tip, position of the axis perpendicular to the tracheal
cannula, after entering surely turn the direction parallel to the axis
of the trachea, proceed to thrust according the curve of cannula
tracheostomy into the lumen of the trachea.
26. Cont’d
12.
check cannula into the lumen of the trachea, feel the breath of
the hole cannula tracheostomy, or use the end of the string that
vibrates at the blast of breath
13.
the whole latch is released, assistant hold the cannula, cannula is
fixed with sutures at the right and left lobes of cannula to the skin of
the neck and installing a ribbon strap around the neck.
14.
If the incision is too wide, skin is sutured loosely (don’t be too tight:
can cause skin emphysem)
15.
Between cannula lobes and skin, put a sterile gauze cushion
30. Complication
Post Operative
Early
Bleeding,
Infection at operation site,
Impaired swallowing function because of tracheostomy cuff
Subcutaneous emphysema,
Late
Granuloma
Tracheoesophageal fistula
Tracheocutaneous fistula
Laryngotracheal stenosis
31. Post Operative Management
Observation for the first 24 hours
Treatment for primary disease
Tracheostomy cannula management:
Suction of the secrete / hour
Cleanse the smaller cannula / 6 hours
Nebulizer with warm air for 15 minutes /6 hours
Treat tracheostomy wound with gauze replacement every treatment
32.
33. References
Boldenham A, Whiteley S. Respiratory Emergencies. In Ellis BW, Brown
SP eds. Hamilton Bailey’s Emergency Surgery 13th ed. Varghese Co.
2000, 43 – 45.
Shires GT, Thal ER, Jones RC. Trauma in Principle of Surgery Schwartz
8th ed. McGraw Hill Inc. 2005, 338 – 339
Cobb JP. Critical care: a system – oriented approach. In Norton ed.
Surgery Basic Science and Clinical Evidence. Springer, 2001, 282
Zollinger, J.R., Ellison, E., 2010. Zollinger’s Atlas of Surgical
Operations, Ninth Edition, 9th ed. McGraw Hill Professional.