2. • Definition:
− Surgical procedure to create an opening through the neck
into the trachea
− Synonymous with tracheotomy
• History of Tracheostomy
– Period of legend (2000 BC – 1546 AD )
– Period of fear (1546 – 1833 )
– Period of drama (1833 – 1932 )
– Period of enthusiasm (1932 – 1965 )
– Period of rationalization (1965 …)
3. INDICATIONS
1. Upper airway obstruction
− Congenital : laryngeal web, cyst, choanal atresia
− Infection / inflammation : epiglottitis, croup, deep neck space
abscess, edema due to irritation, irradiation, allergy
− Trauma to airway : external, endoscopic
− Neoplasm : laryngo-tracheal, pharyngeal
− Foreign body in airway
− Paralysis of larynx : B/L abductor palsy
4. 2. Respiratory insufficiency
• Chronic bronchitis, bronchiectasis, atelectasis,
retained airway secretions
3. Retained secretions in the airway
• Inability to cough out the sputum : coma,
respiratory muscle palsy or spasm, laryngectomy
• Painful cough : chest injuries, pneumonia
• Excessive secretions : pulmonary edema
6. TYPES OF TRACHEOSTOMY
• Emergency / Elective
• Temporary / Permanent
• Therapeutic /Prophylactic
• High : (1st ring - above thyroid isthmus)
• Mid : (2nd – 4th ring - behind thyroid isthmus)
• Low : (below 4th ring - below thyroid isthmus )
7. • Mid tracheostomy is commonly preferred because
• High tracheostomy leads to subglottic stenosis
• Low tracheostomy is avoided as
• Trachea is deeper
• Displacement of tracheostomy tube is common
• Proximity to great vessels
• Surgical emphysema is common
• Tracheostomy stoma is close to tracheal bifurcation
9. JACKSON’S METALLIC TUBE
• Made of German silver
• Has obturator , inner tube and outer tube
• Inner tube is longer than outer tube for its removal and cleaning
• Outer tube maintains patency
• Pilot is inserted into outer tube for smooth & non-traumatic insertion of tube
• Outer tube has a lock mechanism for the inner tube and used for protection
of the inner tube during coughing
11. FULLER’S BIVALVED METALLIC TUBE
• Outer tube is bivalved. The 2 blades
when pressed together, help in smooth
entry of tube
• Inner tube is longer and has a vent for
phonation
• Patient phonates by closing main tube
opening
• Vent also helps in decannulation of tube
12. PORTEX CUFFED TUBE
• Made of siliconized Poly Vinyl Chloride
• Thermolabile and prevents crusting
• Low-pressure high-volume cuff maintains an air-tight seal
required for
• Prevention of aspiration of secretions
• Positive pressure ventilation
21. Metallic Tubes Plastic Tubes
Easily cleaned without suction Cleaning requires suction
Cuff is absent Cuff is present
Cannot be connected to
ventilator
Can be connected
Rigid , less comfortable to
patient
Soft, more comfortable
Concomitant radiotherapy is to
be avoided
Can be given
24. 1. POSITIONING
• Supine position with
extension of neck
• Antiseptic dressing and
draping
• Local anesthesia or General
anesthesia with
endotracheal intubation
25. 2. INFILTRATION
• Cricoid palpated and 5 cm
horizontal incision line
marked 2 cm below it
• 2 % lignocaine with
1:200000 adrenaline
injected in incision line
26. 3. INCISION
• A 5 cm horizontal incision made with
# 15 blade and deepened below
subcutaneous tissue
• A 5 cm midline vertical incision made
below cricoid in emergency to avoid
injury to blood vessels
27. 4. EXPOSURE OF STRAP MUSCLES
• Investing layer of deep
cervical fascia opened
vertically with artery forceps
• Palpation for tracheal rings
done regularly during the
dissection
28. 5. EXPOSURE OF THYROID ISTHMUS
Strap muscles retracted
laterally with Langenbeck
retractors to expose the
trachea & thyroid isthmus
29. 6. ISTHMUS SEPARATION FROM TRACHEA
Thyroid isthmus detached from tracheal surface and
retracted with blunt tracheal hook
30. 7. DIVISION OF THYROID ISTHMUS
• If required, thyroid isthmus is
divided between clamps and
transfixion sutures applied at
the ends
31. 8. CONFIRMATION OF TRACHEA
• 5 ml syringe containing 4 % Lignocaine taken, its
needle inserted into trachea and aspirated
• Air bubbles confirm presence of needle in trachea
• 2 ml of solution injected into trachea and needle
removed quickly to avoid breaking of needle during
violent cough movements
32. 9. CREATION OF TRACHEAL WINDOW
• Cricoid hook inserted below the cricoid to
steady trachea
• Tracheal window created by excising anterior
1/3rd of 2nd & 3rd tracheal ring with No. 11
blade and held with Allis tissue forceps
34. 10. INSERTION OF TRACHEOSTOMY
TUBE
• Endotracheal tube withdrawn into
larynx
• Lubricated tracheostomy tube
inserted into trachea
• Confirm presence of tube in
trachea with help of ambu bag and
auscultation
35. 11. SUTURING OF FLANGES
• Cuff inflated with 5 ml of air and
anesthetic circuit connected to
the tube
• Neck extension released and
flanges of tube sutured to skin
to avoid tube movement
36. TYING THE TAPES
• Tapes of tracheostomy tube
tied around the neck keeping
a space for 1 finger and neck
kept flexed
• Skin incision closed loosely to
avoid surgical emphysema.
37. INSERTION OF MEDICATED GAUZE
Betadine soaked gauze or Sofratulle put around the
tracheostomy opening
38. COMPLICATIONS OF TRACHEOSTOMY
• Immediate Complications (occur during operation)
• Primary Hemorrhage
• Air embolism
• Cardiac arrest
• Aspiration of blood
• CO2 withdrawal apnoea
• Injury to apical pleura (pneumothorax), recurrent laryngeal
nerve, esophagus
39. INTERMEDIATE COMPLICATIONS
• Occurs within first few days
• Reactionary & secondary hemorrhage
• Blocking or displacement of tube
• Subcutaneous emphysema, pneumothorax
• Tracheitis and crusting
• Atelectasis & lung abscess
• Wound infection
40. LATE COMPLICATIONS
Occur after weeks / months
• Subglottic stenosis, tracheal stenosis
• Tracheo-arterial or Tracheo-venous fistula
• Tracheo-esophageal fistula
• Persistent tracheo- cutaneous fistula
• Decannulation difficulty
• Tracheostomy wound scar / keloid
• Metallic tube corrosion and fragment aspiration
42. TRACHEOSTOMY SUCTION
• Pt given 100 % oxygen and cuff deflated
• Suction catheter with the diameter < 1/3rd of internal diameter of
tracheostomy tube to be used
• Catheter introduced beyond the inner tube and not more inside to
avoid tracheal/bronchial irritation (Multiple-eyed catheters preferred as
they produce less trauma than whistle tip catheters)
• Lubricated catheter tip inserted with suction off
• At the end of inspiration, suction put on and catheter withdrawn in
rotating motion
43. TRACHEOSTOMY SUCTION CONTD…
• Each suction procedure should last for 10-15 seconds. Instill 0.5 ml
NaHCO3 to liquefy crusts
• Chest auscultated for confirmation of adequate suctioning
• Cuff re-inflated to a pressure of 25 mmHg and patient oxygenated
again
• Tracheostomy wound dressing done BID, a Moist gauze piece placed
over tracheostomy stoma
• Steam inhalation TID
• Chest physiotherapy, expectorants and mucolytics continued
44.
45.
46.
47. CHANGING OF TRACHEOSTOMY TUBE
• Inner tube is removed and cleaned when blocked
• Outer tube not removed before 72 hrs to allow formation
of tracheo-cutaneous tract
• Cuff of Portex tube deflated for 10 minutes every 2 hours
to prevent pressure necrosis and dilatation of trachea
48. DECANNULATION
• Adult: plug or seal tube opening and if tolerated for 24 hrs,
remove tube
• Children : Sequentially reduce the size of tube
• After tube removal close wound
− Healing occurs within 1 week
− Secondary closure after freshening the wound margin is
required rarely
49. DIFFICULTY IN DECANNULATION
Organic causes:
• Persistence of cause
requiring tracheostomy
• Obstructing tracheal
granulations
• Tracheal edema
• Subglottic stenosis
• Collapse of tracheal wall
(tracheomalacia)
Non-organic causes:
• Emotional dependence in children
• Inability to tolerate upper airway
resistance
• In-coordination of laryngeal
opening reflex
• Long-standing tube leads to
impaired laryngeal development
51. DISADVANTAGES OF TRACHEOSTOMY
• Anosmia : no nasal air entry
• Aphonia : avoided by phonatory vent
• Aspiration : avoided by cuffed tube
• Inability to lift heavy weight
• Inability to perform strenuous exercise
• Inability to swim
52. PERCUTANEOUS TRACHEOSTOMY
• Trachea punctured with needle and cannula
• Needle removed and a guide wire passed into trachea
via cannula
• Cannula removed and graded dilators passed over the
guide wire till the opening can admit a tracheostomy
tube
54. CRICOTHYROIDOTOMY (MINITRACHEOSTOMY)
• Midline vertical skin incision made to identify cricothyroid notch
• Cricothyroid membrane incised horizontally, with # 11 blade, close
to cricoid
• Knife handle inserted and rotated by 900, to widen the horizontal
opening and tracheostomy tube is inserted
• Elective tracheostomy done as soon as possible to avoid subglottic
stenosis
