tracheostomy , tube

1. TRACHEOSTOMY
Dr. RAJENDRA SINGH LAKHAWAT

2. “Tracheostomy is making an opening
in the anterior wall of trachea &
converting it into a stoma on the
skin surface”

3. HISTORY
• Tracheostomy , which was performed in
ancient egypt, is one of the oldest surgical
procedures.
• It was described in the Rigveda, a Sanskrit
text, circa 2000 BC.
• Homerus of Byzantium is said to have
written of Alexander the Great, saving a
soldier from suffocation by making an
incision with the tip of his sword in the
man's trachea.

4. • Hippocrates condemned the practice of
tracheotomy as incurring an unacceptable risk of
damage to the carotid artery. Warning against
the possibility of death from inadvertent
laceration of the carotid artery during
tracheotomy, he instead advocated the practice
of tracheal intubation because surgical
instruments were not sterilized at that time,
infections following surgery also produced
numerous complications, including dyspnea,
often leading to death.

5. • The first successful tracheostomy was
performed by Brasovala in the 15th century.
• At the beginning of the twentieth century the
principles of the operation were described by
Chevalier Jackson & these remain the
principles of the operation to the present day.

6. Chevalier Jackson
(November 4, 1865 –
August 16, 1958)
He is also known as
father of endoscopy

7. Anatomy
•The trachea is a fibromuscular tube
supported by 20 hyaline cartilages which
are opened posteriorly.
•The soft tissue posterior wall is in
contact with the oesophagus.
•Trachea lies in midline of the neck
extending from cricoid cartilage (C6)
superiorly to the tracheal bifurcation at
the level of sternal angle (T5).
•In adults it is 12-16 cm long and 13-16
mm wide in women and 16-20 mm wide
in men.

8. • The blood supply is primarily supported by the
bracheocephalic artery and through the
inferior thyroid and bronchial arteries.
• The nerve supply is by parasympathetic and
sympathetic fibres.
• The parasympathetic supply to the trachea is
by the recurrent laryngeal nerve – a branch of
the vagus nerve

9. TYPES OF TRACHEOSTOMY
I. Temporary
1. Elective
2. Emergency
II. Permanent
Can also be classified as –
I. High tracheostomy.
II. Mid tracheostomy.
III. Low tracheostomy.

10. Temporary Tracheostomy
Elective Temporary tracheostomy-
It’s a planned, unhurried procedure. Almost all
operative surgical facilities are available.
Mainly done in :
a) Major head & neck operations, following which
postoperative swelling might result in upper
airways obstruction.
b) For respiratory support In a ventilated patient.

11. Emergency Temporary Tracheostomy-
It is employed when airway obstruction is
complete or almost complete & there is an
urgent need to establish the airway
it done in Patients with difficult airway include
those with conditions such as maxillo-facial
trauma, angioedema, obstructive upper
airway tumors

12. PERMANENT TRACHEOSTOMY
It is an elective pocedure in which trachea is
permanently disconnected from the pharynx
& the proximal end of the trachea is sutured
to the skin.
It is carried out as a part of an operation
involving removal of the larynx, such as a
laryngectomy or laryngopharyngectomy or as
a part of a diversion procedure for aspiration
problems.

13. High Tracheostomy-
It is done above the level of thyroid isthmus(
i.e, II, III, IV tracheal rings).
Tracheostomy at this site can cause
perichondritis of the cricoid cartilage &
subglottic stenosis so its generally avioded.
Only indication is Ca larynx because in such
cases, total larynx anyway would ultimately be
removed & a fresh tracheostome made in a
clear area lower down.

14. Mid Tracheostomy-
Is the most preferred one & is done through
the II & III rings & would entail division of the
thyroid isthmus or its retraction upwards or
downwards to expose this part of trachea.

15. Low Tracheostomy-
It is done below the level of isthmus. Trachea
is deep at this level & close to several large
vessels, also there are difficulties with
tracheostomy tube impringes on suprasternal
notch.

16. Effects of Tracheostomy
• Laryngeal Bypass- all of the normal laryngeal
functions are lost, the patient is unable to
cough or phonate.
• A reduction in respiratory dead space.
• A redundant area is created between the
tracheal opening & the larynx in which mucus
tends to accumulate & then fall back into the
lungs.

17. • The filtration of particulate matter &
humidification of inspired air by the nasal
mucosa is lost.
• An increased risk of infection.
• The tracheostomy tube will act as a foreign
body causing local inflamation, , and as it tends
to move during swallowing & with normal neck
movements, may cause abrasions along the
length of the track.

18. INDICATIONS
1) UPPER AIRWAY OBSTRUCTION-
This is no longer the most common indication
for tracheostomy. Owing to improvements in
the design of intubating laryngoscopes & the
development of alternative management
stratagies, such as the use of nasopharyngeal
airways or fibreoptic intubation, it is unusual to
be presented with a patient for whom
tracheostomy is first option.

19. LARYNGEAL INDICATION
A. Congenital
1.Laryngeal web or stenosis
2.Bilateral choanal atresia
3.Tracheo-oesophageal anomalies
B. Traumatic
1.External-gunshot,blow injuries,strangulation or cut throat
injuries of larynx.
2.internal-ihalation of hot fumes,foreign body.
C.Infective
1.Acute epiglotitis
2.Acute laryngotracheobronchitis
3.Diphtheria
4.ludwing’s angina

20. D.Neoplastic
1.Benign-multiple laryngeal papilloma
2.Malignant tumours of tongue,pharynx larynx,uper trachea and
thyroid.
E.Neurologic
1.Tetanus
2.Myasthenia gravis
3.Bilateral abductor palsy
4.Bulbar poliomyelitis
F.Allergic
1.Angio-neurotic oedema

21. 2) Removal of secretions-
As secretions accumulate in the lower respiratory
tract, gas diffusion within the alveoli deteriorates
resulting in respiratory failure. Once a tracheostomy
has been carried out secretions can be aspirated with
minimal upset to the patient.
In addition, the reduction in respiratory dead space
(upto 30-40%) makes it easier for the patient to
breathe.
1.Loss of cough reflex-bulber poliomyelitis
2.Unconsciousness-head injury,coma

22. 3) Prolonged Ventilation-
In cases where prolonged, continuous or
intermittent positive pressure required,
tracheostomy provides the safest means of
assisting ventilation. The tracheostomy tube is
more secure than a nasotracheal or orotracheal
tube & the reduction of respiratory dead space
facilitates the process of weaning the patient off
the ventilator.

23. 4) As a Part of another procedure –
As mentioned previously, temporary
tracheostomy is an integral part of many head &
neck procedures.
The tracheostomy is not only to guard against
airway obstruction due to swelling, but also
against aspiration of blood in the event of post op
haemorrhage, and facilitates the administration
of any further anaesthetic if required in event of
major complications.

24. TECHNIQUES
1. Open Surgical tracheostomy.
2. Percutaneous tracheostomy.
3. Cricothyrotomy.
4. Mini tracheostomy.

25. Open Surgical Tracheostomy
Whenever possible, endotracheal intubation
should be done before tracheostomy.
Position- The patient should be positioned supine
with a sandbag under the shoulders so that
neck is extended & this brings trachea forwards.
Anaesthesia- 1-2% of lignocaine with adrenaline
is infiltrated in the line of incision & area of
dissection. Sometimes general anesthesia with
intubation is used.

26. • The skin of the neck over
the lower border of cricoid
and suprasternal notch is
identified, and a horizontal
incision about 2–3 cm in
length is created.
• Sharp dissection following
the skin incision is used to
cut across the platysma
muscle, and bleeding
controlled by hemostats
and ties or electocautery.

27. • Blunt dissection parallel to the
long axis of the trachea is then
used to spread the submuscular
tissues until the thyroid isthmus
is identified
• If the gland lies superior to the
3rd tracheal ring, it can be
bluntly undermined and
retracted superiorly to gain
access to the trachea

28. • There are 2 basic approaches
to tracheal entry.
• the 2nd tracheal ring is divided
laterally and the anterior portion
removed.
• Lateral sutures are used to
provide counter traction during
tracheostomy-tube insertion.
• These are left uncut to provide
assistance if the tube is
accidentally dislodged later.

29. Percutaneous tracheostomy
• 1955, Shelden et al - first attempted PCT with cutting trocar into the
trachea.
• The wire-guided technique for percutaneous tracheostomy was
developed and reported in 1986 by the American surgeon, Ciaglia.
• 1990, Griggs et al - the guidewire dilating forceps (GWDF)
• Several variants of the percutaneous tracheostomy technique
have been developed.
 Using a wire guided sharp forceps(Griggs technique)
 using a single tapered dilator (BlueRhino)
 passing the dilator from inside the trachea to the
outside (Fantoni’s technique);
 using a screw like device to open the trachea wall
(PercTwist).

30. • percutaneous dilational tracheostomy (PDT) has become a very
common method of placing a tracheostomy in critically ill patients
in the intensive care unit.
• It is rapid, simple, easy to learn, and cost effective.
• The procedure should be deferred in patients having an
INR>1.4,
Activated partial thromboplastin time >45 seconds
Platelet count of < 75,000⁄ ml.

31. • To prevent inadvertent injury of the membranous posterior
tracheal wall or too lateral a location of the tracheostomy,
a technique of observing and directing the needle and wire
placement, using fiberoptic bronchoscopy is recommended
• In order to visualize the upper rings of the trachea with the
bronchoscope, the endotracheal tube (ET) must be withdrawn
until its tip is just in the larynx.
• Patients requiring a tracheostomy only for airway access or
protection often can have a laryngeal mask airway replace the
endotracheal tube to provide the route for bronchoscopic
visualization.

32. • PDT is usually performed in an anesthetized patient, and can be done
in the intensive care unit or operating room.
• The patient should be monitored by SpO2, EtCO2 and ECG.
• The patient is positioned as for the surgical tracheostomy
• A pillow is placed under the shoulders, the neck is moderately
extended, and the first three tracheal rings are identified
• The anterior neck is prepared with povidine iodine and draped with
sterile sheets.
• The skin overlying first and second tracheal rings is infiltrated
subcutaneously with 3-5 ml of 1% xylocaine with epinephrine
(1:200,000), and a 1.5 cm vertical incision is made and blunt
dissection is performed to expose the pretracheal fascia.

33. • The anterior trachea is
palpated and the intended
site is punctured with a 14G
intravenous cannula in a
postero-caudal direction.
• The entry of the IV cannula
in trachea is confirmed by
aspiration of air into a saline
filled syringe.

34. →A guide wire is inserted through the cannula, and the cannula
is withdrawn,
→The tracheal opening is dilated over the guide wire until a
stoma of sufficient size to accommodate the desired
tracheostomy tube is created.
→The method of dilating the tracheal opening over the guide
wire varies with various methods

35. Contraindications
Absolute-
1. Need for an emergency airway.
2. Performance of the procedure in children as cartilages is soft.
Relative-
1. High degree of ventillatory support–PEEP >8cm H2O, FiO2 > 50%.
2. Unstable cervical spine.
3. Uncorrected coagulopathy.
4. Presence of neck mass or pervious neck surgery.
5. History of mediastinal irradiation due to intrathoracic fibrosis.
6. Previous history of surgical tracheostomy.
7. Increased intracranial pressure.

36. Ciaglia technique
• With Ciaglia technique,
the tracheal opening is
dilated by using a
series of plastic dilators
inserted over the guide
wire

37. Griggs Technique
• Using a tracheal spreader
modified to thread over the
wire; this technique involves
forceps dilation to create the
skin path and tracheal stoma.
• The trachea is entered between
the appropriate tracheal rings
with an intravenous catheter.
• The guide wire is threaded
through the catheter.
• The sharp-tipped dilating
forceps are passed over the
wire, spread in the skin and soft
tissues of the neck and into the
trachea, and spread again

38. • A tracheostomy tube is placed over the guide
wire and through the passage created.
• Tracheal injury may be higher with this
technique (especially if performed without
bronchoscopy) than the other PDT techniques.

39. CRICOTHYROTOMY-
It is a horizontal incision in cricothyroid
membrane. It is done in dire emergency due
to non-availability of instruments for
tracheostomy or endotracheal intubation.
Mini Tracheostomy-
It is a vertical stab incision through
cricothyroid membrane. It allows ready
access, delivery of oxygen & removal of chest
secretions.

40. Post-operative Care
1. Constant supervision-
• After tracheostomy, constant supervision of
the patient for bleeding, displacement or
blocking of tube & removal of secretions is
essential.
• A nurse or patient’s relative should be in
attendance.
• Patient is given a bell or a paper pad & a pencil
to communicate.

41. 2. Suction-
• Depending on the amount of secretions,
suction may be required every half an hour
or so.
• Suction injuries to tracheal mucosa should be
avoided by applying suction to the catheter
only when withdrawing it.

43. 3. Prevention of crusting & tracheitis –
• Proper humidification, by use of humidifier,
steam tent, ultrasonic nebuliser or keeping a
boiling kettle in the room.
• If crusting occurs, a few drops of normal or
hypotonic saline or RL are instilled into the
trachea every 2-3 hours to loosen crusts.
• A mucolytic agent such as Acetylcysteine
solution, can be instilled to liquify tenaceous
secretions or to loosen the crusts.

44. 4. Care of tracheostomy tube-
• The tracheostomy tapes should be fastened
using a secure knot on both sides of neck, and
the neck should be in a neutral position.
• The cuff should only remain inflated for as long
as there is a risk of aspiration.
• Inspite of the introduction of low pressure
cuffs there is still a risk of perichondritis &
subsequent tracheal stenosis.

45. Difference between child tracheostomy & adult
tracheostomy
Anatomical Differences
Child Tracheostomy
1. The space available is
smaller.
2. Larynx lies higher in the
neck & is not easily
palpable.
3. Trachea is soft, smaller and
deep beneath the skin.
Adult Tracheostomy
1. The space available is not
that small.
2. It is not so high & is easily
palpable.
3. Trachea is more superficial.

46. Operative Difference
Child Tracheostomy
1. Should not remove section of
tracheal ring.
2. Cartilage is soft, springy and can
be distracted to allow
introduction of tracheostomy
tube ( There is no danger of
cartilage necrosis due to
pressure on vessels.)
3. 2nd, 3rd or 4th tracheal ring is
divided in midline for the
introduction of tube.
4. No space to use tracheal dilator
so tube is introduced with the
help of a curved artery forcep
without pilot.
Adult Tracheostomy
1. Section of tracheal ring is
removed.
2. It is not so.
3. A circular hole is made in
trachea.
4. Tracheal dilator is used to keep
tracheal ring apart and pilot is
used for the introduction.

47. COMPLICATIONS
• Complication rates following percutaneous
tracheostomy are 4 to 31 percent
• Following surgical tracheostomy are 6 to 66 %
• Complication rates are 2 to 5 times more
common in emergency cases

48. Immediate ( at the time of operation )-
A. Haemorrhage – It is the most common complication and
commonest fatal complication- Thyroid veins, juglular
veins, arteries
B. Air Embolism-life threatening but rare.
C. Pneumothorax – common in patients of emphysema.
D. Injury to recurrent laryngeal nerve.
E. Aspiration of blood.
F. Injury to oesophagus.
G. Apnoea.
H. Local demage- thyroid & cricoid cartilage

49. Intermediate ( during first few hours or days)-
1. Bleeding – reactionary or secondary.
2. Displacement of tube.
3. Blocking of tube.
4. Subcutaneous emphysema.
5. Tracheitis & tracheobronchitis with crusting in trachea.
6. Atelectasis & lung abscess.
7. Local wound infection & granulations.
8. Tracheo –oesophageal fistula.
9. Tracheal necrosis.
10. Dysphagia.

50. Late Complications(with prolonged use of
tube for weeks & months)-
1. Laryngeal & tracheal stenosis.
2. Tracheo-cutaneous fistula.
3. Decannulation problems.
4. Disfiguring scars.

51. DECANNULATION
• Tracheostomy tube should not be kept longer than
necessary. Prolonged use of tube leads to
tracheobronchial infections, tracheal ulcerations,
granulations, stenosis & unsightly scars.
• Decannulation should be approached in a stepwise
fashion.
• In most cases, particularly if the initial cuffed tube has
been changed for an uncuffed, fenestrated tube,
there should be enough airflow aound the tube to
allow the patient to breath easily with the tube
lumen occluded. In this case tube can be blocked off
with some form of obturator, during the day time
initially, & then for a full 24hrs, folowed by
decannulation.

52. • Once the tube has been removed the stoma
must be occluded with an airtight dressing. In
most of the case gauze swabs covered with an
oclussive dressing will be sufficient. It is
important to change the dressing whenever
air leak becomes apparent to avoid a
persistent tracheocutaneous fistula.

53. Sometimes attempts at decannulation are not successful. It
may be due to :
1. Persistance of the condition for which tracheostomy was
done.
2. Obstructing granulations around the stoma or below it
where tip of the tracheostomy tube had been impringing.
3. Tracheal oedema or subglottic stenosis.
4. Incurving of tracheal wall at the site of tracheostome.
5. Tracheomalacia.
6. Psychological dependence on tracheostomy & inability to
tolerate the resistance of the upper airway. In these cases
a much slower sequence of tube occlusion should be
followed with decannulation taking place over the course
of several days or a whole week.
A case of difficult decannulation may be required endoscopic
examination of the larynx, trachea & bronchi preferably
under mangification using telescopes or a flexible
endoscope.

54. Tracheostomy Tube
• A great no. of tracheostomy tubes is available.
They are made from a wide variety of
materials & there are many different designs
to overcome some of the problems associated
with tracheostomy.

55. CUFF
Cuff type tube can
be inflated to
prevent the
aspiration of blood
or saliva from above
& forms a seal to
prevent the leakage
of ventilating gases
during anaesthesia
or prolonged
mechanical
ventilation.

56. Indication-
• In patients requiring ventilation an inflated cuff
forms a seal to facilitate positive pressure ventilation.
• In patients with poor or absent swallowing reflexes
an inflated cuff will assist in minimising the risk of
gross aspiration.
Disadvantages-
• If a tracheostomy tube is occluded by a
decannulation cap or speaking valve when the cuff is
inflated the patient will be unable to breathe
adequately resulting in complete airway obstuction.
• The pressure of the cuff may cause damage to the
tracheal mucosa reducing perfusion, which may lead
to tracheal erosion, ulcerations, dilation or stenosis.

57. • It is important that the pressure in the cuff is
high enough to give an adequate seal without
occluding the circulation in mucus capillaries.
• For the most part, the use of modern high
volume low pressure cuffed tubes will achieve
this aim.
• Owing to the potential risk of subglottic stenosis
with cuffed tubes, Uncuffed tubes should be
used unless there is a risk of aspiration or the
need for supported ventilation

59. Indications-
• If a patient no longer requires a tracheostomy tube with the cuff
inflated consideration should be given to changing to an uncuffed
tube.
• An uncuffed tube is suitable for a patient in the recovery phase of
critical illness who has returned from intensive care and may still
require chest physiotherapy, suction via the trachea and airway
support.
• In the event of the tracheostomy becoming blocked the patient may
be able to breathe around the tube.
( The tube is easier to replace.
Suitable for long term use in patients
There is a lower incidence of tracheal mucosal damage)
Disadvantages-
Uncuffed tubes are NOT suitable for -
• Patients who require artificial ventilation.
• Patient requiring greater than 40% oxygen therapy (the patient will
partially inspire room air via the nose and mouth)

60. FENESTRATION-
A fenestrated tube has an
opening (fenestration)
which may be a single
large hole or multiple
small holes, in the back of
the outer cannula. The
front of the tube can be
blocked which allows the
air to flow upwards to the
upper part of the trachea
and larynx. A fenestrated
tube allows the patient to
breathe normally and top
speak or cough through
the mouth.

61. Indications-
• Fenestrated tracheostomy tubes are recommended to help
wean some patients from their temporary tracheostomy tube.
• They may be used to assist in directing air flow to pass through
the patients oral/nasopharynx (mouth, nose and vocal cords).
• In these patients if the fenestrated inner lumen is inserted
whilst the cuff is deflated, the work of breathing is reduced.
This allows the patient to breathe through the fenestration of
the tracheostomy tube as well as around it when the cuff is
deflated.
• May improve the patient’s ability to vocalise.
Disadvantages-
• May create an opportunity for oral and stomach contents to
enter the lungs through the fenestration increasing the risk of
aspiration in patients with an incompetent cough reflex.
• Patients requiring intermittent positive pressure ventilation
(IPPV) should have a non-fenestrated trachesotomy tube
inserted at the earliest opportunity, a non-fenestrated inner

62. INNER TUBE-
• An inner tube projects 2-3 mm beyond the end of
the outer tube so that the secretions or crusts,
which will inevitably collect, collect in the lumen of
the inner tube which can be removed for cleaning
without disturbing the main tracheostomy.
• The frequency with which the inner tube needs to
be cleaned will vary. In post-op period it may need
cleaning every couple of hours.
• If this need for frequent cleaning persists beyond
the first few days, attention should be given to
improving tracheobronchial toilet & humidification.

63. FLEXIBILITY-
• In many circumstances the anatomy of the
patient’s airway may preclude the use of rigid
tube, which will have a fixed curvature.
• The rigid tube may lie at an angle that tends to
cause an abrasion or may result in tube
obstruction as the lumen abuts the posterior
tracheal wall.
• A softer more flexible tube will tend to conform
more readily to the patient’s anatomy because
it is softer will cause less abrasion.

64. ADJUSTABLE
FLANGE-
An adjustable
flange allows the
length of the tube
to be varied to suit
the depth of the
stoma & can be
used to bypass
intratracheal
obstruction lying
distal to standard
length tubes.

65. Indications-
• Patients who have deep set tracheas are those,
for example, who are obese or have distorted
anatomy within the neck due to inflammation,
oedema or tumour. Patients with spinal
abnormalities such as kyphosis may also benefit
from this type of tube.
Disadvantages-
• Movement of the flange is not recommended as
a routine procedure because of the high risk of
accidental decannulation.

66. Size selection of tube in children
Endotrachial tube
Age/4 + 4
Tracheostomy tube
Upto 6 yrs = (age/3)+3.5
Over 6 yrs = (age/4)+4.5

67. Early versus late tracheostomy for
critically ill patients
• effectiveness and safety of early (≤ 10 days after tracheal
intubation) versus late tracheostomy (> 10 days after tracheal
intubation) in critically ill adults predicted to be on prolonged
mechanical ventilation with different clinical conditions.
• a longer duration of ventilation prior to tracheostomy is
associated with increased ICU morbidities and length of stay.
Early tracheostomy may have significant benefits without
adversely affecting mortality.

68. THANK YOU