Tracheostomy is an ancient surgical procedure where an opening is created in the trachea to allow for breathing. It has been performed since 3600 BC in Egypt. Modern indications include prolonged intubation, airway obstruction, difficulty managing secretions, and as an adjunct to head and neck or chest surgery where ventilation may be problematic. Potential complications range from minor bleeding or infection to serious issues like tracheal stenosis, tracheoesophageal fistula, or erosion into major blood vessels. Careful surgical technique and postoperative management can help reduce risks.

1. TRACHEOSTOMY www.hi-dentfinishingschool.blogspot.com

2. History Tracheostomy is one of the oldest surgical procedures. A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC. Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC. The first successful tracheostomy was performed by Brasovala in the 15th century.

3. Tracheostomy History and indications 1932 prevent pulmonary infection in neurologically impair patients secondary to infections (poliomyelitis). 1943 remove bronchial secretions in cases of myasthenia gravis and tetanus. 1951 reduce the volume of dead space, use in COPD and severe penumonia. 1950 positive pressure through tracheostomy for patients with poliomyelitis. 1955 obstruction secondary to infection: diphteria, Ludwig’s angina. 1961 Obstructions secondary to tumour, infectious disease and trauma.

4. INDICATIONS FOR TRACHEOSTOMY Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005. Goldenberg D, et al Tracheotomy: changing indications and a review of 1,130 cases, J Otolaryngol 31:211–215, 2002 Adjunct to management of major head and neck trauma Adjunct to major head and neck surgery Inability to intubate Upper airway obstruction Inability of patient to manage secretions Facilitation of ventilation support Prolonged intubation

5. INDICATIONS FOR TRACHEOSTOMY The Lindholm Scale of Laryngotracheal Damage Grade I erythema and edema without ulceration Grade II superficial ulceration of the mucosa <1/3 airway circumference Grade III continuous deep ulceration <1/3 airway circumference or superficial ulceration >1/3 airway circumference Grade IV deep ulceration with exposed cartilage.

6. TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATION Increased patient mobility More secure airway Increased comfort Improved airway suctioning Early transfer of ventilator-dependent patients from the intensive care unit (ICU) Less direct endolaryngeal injury Enhanced oral nutrition Enhanced phonation and communication Decreased airway resistance for promoting weaning from mechanical ventilation Decreased risk for nosocomial pneumonia in patient subgroups Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

7. Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch. Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally

8. The thyroid isthmus lies in the field of the dissection. Typically, the isthmus is 5 to 10 mm in its vertical dimension, mobilize it away from the trachea and retract it, then place the tracheal incision in the second or third tracheal interspace

9. Shiley tracheostomy tube: #6 Shiley tracheostomy tube: #8 for bronchoscopy.

10. TRACHEOSTOMY TUBE CARE Securing tracheostomy around patient’s neck. Use of this content is subject to the Terms and Conditions of the MD Consult web site. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. , Copyright © 2005 Mosby, Inc. INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 TABLE 106-2 -- RELATIVE CONTRAINDICATIONS TO PERFORM PERCUTANEOUS DILATIONAL TRACHEOTOMY tracheotomy was upper airway obstruction because of infectious disease including diphtheria, polio, Ludwig's angina, tetanus, and laryngotracheobronchitis. [ 29 ] [ 41 ] [ 49 ] Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation. [ 21 ] Surgical Technique Tracheotomy is optimally performed under general anesthesia in the operating room. If necessary, the procedure may be performed under local anesthesia or in an intensive care setting. [ 29 ] In case a tracheotomy is being performed under local anesthesia, the surgeon and the anesthetist have to work in tandem to keep the patient maximally reassured. On most occasions the anesthetist may use minimal sedation to achieve patient comfort without compromising the ability to breathe spontaneously. Another critical precaution to keep in mind is to avoid the use of Bovie cautery. The surgical field may be getting the oxygenrich gas mixture from the nasal cannula or the ventilating mask. This simple precautionary measure will avert the risk of igniting fire in the surgical field. The basic technique consists of either a vertical incision from the cricoid cartilage, 1.5 inches inferiorly or a horizontal incision midway between the sternal notch and the cricoid cartilage ( Figure 106-1 ). The incision is carried down through the skin, subcutaneous tissue, and platysma to reveal the strap muscles. If the patient is obese and the adipose tissue obtrusive, a minimal cervical lipectomy may be performed. [ 23 ] At this level, the dissection should be in a vertical plane regardless of the skin incision chosen. The strap muscles are separated by a vertical incision through the bloodless midline raphe (linea Alba) and retracted from one another revealing the thyroid isthmus which typically lies over the third and fourth tracheal ring ( Figure 106-2 ). The isthmus may be dealt with in a number of ways. This decision is based on the position of the isthmus relative to the wound and the surgeon's personal preference. It may be superiorly retracted, transected, and suture-ligated ( Figure 106-3 ), transected slowly using a monopolar cautery (Bovie) [ 10 ] [ 28 ] ( Figure 106-4 ), or inferiorly retracted (least commonly used method). [ 28 ] The trachea is revealed and the third and fourth tracheal rings are identified using the cricoid as a landmark. As with the skin incision, there are equally reasonable choices for the entrance into the trachea. An inferiorly based trap door flap (Bjork flap) can be created using a Mayo scissor and sutured to the subcutaneous tissue using 3-0 chromic suture. Alternatively the anterior section of a single tracheal ring can be resected or a round or vertical oval window spanning two tracheal rings be excised [ 15 ] [ 29 ] [ 47 ] using a scalpel, curved Mayo scissor, or a tracheotomy punch ( Figure 106-5 and Figure 106-6 ). The endotracheal tube cuff is deflated and the tube slowly withdrawn by the anesthesiologist until the inferior tip of the tube is lined up with the superior border of the newly formed tracheal opening. A tracheotomy tube is then inserted through the tracheotomy into the airway and the patient is ventilated. Tracheotomy Complications The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication and are thus divided into intraoperative, early, and late postoperative. It should be noted that there may be an overlap in the timeframe in which early, intermediate, and late complications present. It is important to note that specific patient populations, such as the pediatric, post head trauma, obese, burn patient, or seriously debilitated are more susceptible to complications related to tracheotomy. [ 20 ] 2445 Figure 106-1 A, Surface anatomy of the neck with skin incision for the tracheotomy ( left ) and cricothyrotomy ( right ). B, A vertical skin incision is made between the cricoid and second tracheal ring as assessed by palpation through the skin. Tracheotomy holds a complication rate of between 5% to 40% depending on study design, patient follow-up, and the definition of the different complications. [ 46 ] In a recent study of 1130 surgical tracheotomies, the major complication rate for surgical tracheotomy was found to be as low as 4.3%, with a mortality rate of 0.7%. [ 20 ] Death from tracheotomy is caused most often by hemorrhage or tube displacement. It is important to note that the incidence of complications in emergency tracheotomy is 2 to 5 times that found in an elective procedure. The most common complication has classically been hemorrhage (3.7%), followed by tube obstruction (2.7%), and tube displacement (1.5%) The incidence 2446 Figure 106-2 The strap muscles are separated through the bloodless midline raphe to reveal the underlying thyroid isthmus. Figure 106-3 The thyroid isthmus may be retracted or suture ligated. of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is less than 1%. Immediate Complications Immediate complications of tracheotomy include those present during or at the termination of the operation. Although these complications are usually caused during surgery, they may appear hours or days after the tracheotomy is performed. Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Frequent sites of bleeding are the anterior jugular veins, the thyroid isthmus, and vascular variants such as the thyroid ima artery. [ 36 ] Other immediate complications include insertion of the tracheotomy tube into a false route, electrocautery-induced intraoperative fire, [ 1 ] and surgical injury to adjacent structures. Intermediate Complications Intermediate complications develop during the first hours to days after surgery. Again, hemorrhage may be a frequent postoperative complication of tracheotomy. 2447 Figure 106-4 The thyroid isthmus may be safely transected slowly using a monopolar cautery (Bovie) when it obscures the proposed entrance site into the trachea. Figure 106-5 A horizontal incision can be made in the intracartilaginous space. Because many of these patients are hypotensive, bleeding does not occur until arterial blood pressure is restored or venous pressure is increased by coughing associated with canula placement. Minor oozing may be managed by light packing with oxidized cellulose, microfibrillar collagen, or tranexamic acid-soaked gauze packs. [ 27 ] Transient tracheitis and stomal cellulitis may occur, and all fresh tracheotomies should be attended to with strict local hygiene. Severe infection such as mediastinitis, clavicular osteomyelitis, and necrotizing fasciitis are rare, but have been reported after tracheostomy and must be treated aggressively. [ 48 ] Other known early postoperative complications include subcutaneous emphysema, pneumomediastinum, Figure 106-6 A tracheotomy punch is then used to make a circular window in the anterior wall of the trachea. and pneumothorax. All of these may result from excessive dissection of tissue planes at the time of tracheostomy , blockage of the cannula, or assisted ventilation with excessive pressure, causing dissection of air along the pretracheal fascia. The incidence of subcutaneous emphysema is 0% to 9% and the incidence of pneumothorax is 0% to 4% in adults. [ 43 ] Obstruction of the tracheotomy tube on the first few postoperative days is likely to result from blood clot, partial displacement, or tube impingement on the posterior tracheal wall. The incidence of tube obstruction is 2.5%. [ 43 ] Routine postoperative care including observation, humidification, and frequent gentle suctioning prevents tube obstruction. Dislodgment of the tracheotomy tube may be a fatal complication in the first few days after tracheotomy. Several factors that play a role in tube dislodgment are the length of the tube, thickness of the neck, site of tracheostomy , postoperative swelling, and method of securing the tube. As a general rule, the ties should be secured snugly, yet allow passage one finger between the ties and the neck to prevent neck constriction. We suture the flanges to the skin with monofilament suture in addition to the ties. In an emergent situation of accidental decannulation during the initial 48 hours after the tube placement, one failed attempt at replacement must be followed with orotracheal intubation. This often-neglected intervention can save many unnecessary mishaps. Late Complications A late complication such as delayed hemorrhage may be a result of traction on granulation tissue or from innominate artery erosion. Immediate investigation 2448 into the cause of bleeding is thus mandatory. Trachea-innominate fistula with massive hemorrhage occurs in 0.4% of tracheotomies. [ 14 ] Long-term tracheal intubation and ventilation with a cuffed tracheotomy tube may result in cartilage necrosis of the tracheal wall. Erosion may also occur with a cuffless tube if the tip of the tube is lodged anteriorly, the innominate artery is high in the neck, or the tracheostomy is placed too low. This complication may be heralded by a &quot;sentinel&quot; bleed that may occur 3 days to 3 weeks before massive hemorrhage and should prompt an immediate fiberoptic tracheal examination. [ 26 ] If there is evidence of erosion or necrosis, the patient must be immediately evaluated in the operating room under general anesthesia, with the patient prepared for mediastinal exploration and thoracotomy. In instances of massive hemorrhage, direct digital pressure on the anterior wall of the stoma tract (posterior wall of the vessel) has been effective in controlling bleeding. Tracheal-innominate artery blowout carries a mortality rate of 85% to 90%. [ 7 ] [ 8 ] [ 37 ] Tracheoesophageal fistula is rare, with a reported incidence of 0.01% to 1%. [ 51 ] Tracheoesophageal fistula is thought to result from incidental damage to the posterior tracheal wall at the time of surgery or to be the product of two factors: an over inflated and improperly fitted cuffed tube, which places pressure on the posterior tracheal wall, together with an indwelling nasogastric tube in the esophagus. The diagnosis should be suspected clinically by coughing during eating, chronic cough on swallowing saliva, recurrent aspiration, and pneumonia. Barium swallow or methylene blue instilled into the esophagus and flexible fiberoptic evaluation may be diagnostic; however, generally a combination of these studies, with endoscopic evaluation, is often necessary. Once the diagnosis is confirmed, definitive surgical repair is undertaken. [ 22 ] [ 40 ] Tracheal stenosis and subglottic stenosis are complications predisposed by previous endotracheal tube intubation, high tracheostomy or cricothyroidotomy, and trauma to the airway. Patients at increased risk for tracheal stenosis include children and patients tracheotomized for closed head trauma. Meticulous surgical technique, aggressive treatment of postoperative infections, and the use of the high-volume, low-pressure cuffed tube help minimize the risk of tracheal stenosis. Tracheocutaneous fistula is a late complication, which is more common as the stomal tract is epithelialized with long-term cannulation. A persistent fistula causes continual tracheal secretions with skin irritation, disturbed phonation, and frequent infections. Infection and granulation tissue may play a role in persistent stomal fistulas. Persistent fistulas require excision of the fistula tract. Contraindications No absolute contraindications exist to open surgical tracheostomy . Bookmark URL: /das/book/view/59514421-2/1263/983.html/top History of difficult intubation Limited ability to extend the cervical spine Prothrombin time or partial thromboplastin time >1.5 times control Bleeding time >10 min Platelet count <40,000/mm 3 Positive end-expiratory pressure >15 cm H 2 O Short or obese neck Occluding thyroid mass or goiter over the tracheotomy site Active infection over the tracheotomy site Pulsating palpable blood vessel over the tracheotomy site Anatomic abnormality of the trachea Children younger than 12 years of age About MD Consult | Contact Us | Terms and Conditions | Privacy Policy | Registered User Agreement www.mdconsult.com Copyright © 2006 Elsevier Inc . All rights reserved.

11. TRACHEOSTOMY TUBE CARE Tube changes: Indications: soiled, cuff rupture. Complications: insertion into a false passage bleeding, and patient discomfort. Avoid within 1 st week. First tube change by surgeon. Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation. Use of this content is subject to the Terms and Conditions of the MD Consult web site. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. , Copyright © 2005 Mosby, Inc. INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 TABLE 106-2 -- RELATIVE CONTRAINDICATIONS TO PERFORM PERCUTANEOUS DILATIONAL TRACHEOTOMY tracheotomy was upper airway obstruction because of infectious disease including diphtheria, polio, Ludwig's angina, tetanus, and laryngotracheobronchitis. [ 29 ] [ 41 ] [ 49 ] Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation. [ 21 ] Surgical Technique Tracheotomy is optimally performed under general anesthesia in the operating room. If necessary, the procedure may be performed under local anesthesia or in an intensive care setting. [ 29 ] In case a tracheotomy is being performed under local anesthesia, the surgeon and the anesthetist have to work in tandem to keep the patient maximally reassured. On most occasions the anesthetist may use minimal sedation to achieve patient comfort without compromising the ability to breathe spontaneously. Another critical precaution to keep in mind is to avoid the use of Bovie cautery. The surgical field may be getting the oxygenrich gas mixture from the nasal cannula or the ventilating mask. This simple precautionary measure will avert the risk of igniting fire in the surgical field. The basic technique consists of either a vertical incision from the cricoid cartilage, 1.5 inches inferiorly or a horizontal incision midway between the sternal notch and the cricoid cartilage ( Figure 106-1 ). The incision is carried down through the skin, subcutaneous tissue, and platysma to reveal the strap muscles. If the patient is obese and the adipose tissue obtrusive, a minimal cervical lipectomy may be performed. [ 23 ] At this level, the dissection should be in a vertical plane regardless of the skin incision chosen. The strap muscles are separated by a vertical incision through the bloodless midline raphe (linea Alba) and retracted from one another revealing the thyroid isthmus which typically lies over the third and fourth tracheal ring ( Figure 106-2 ). The isthmus may be dealt with in a number of ways. This decision is based on the position of the isthmus relative to the wound and the surgeon's personal preference. It may be superiorly retracted, transected, and suture-ligated ( Figure 106-3 ), transected slowly using a monopolar cautery (Bovie) [ 10 ] [ 28 ] ( Figure 106-4 ), or inferiorly retracted (least commonly used method). [ 28 ] The trachea is revealed and the third and fourth tracheal rings are identified using the cricoid as a landmark. As with the skin incision, there are equally reasonable choices for the entrance into the trachea. An inferiorly based trap door flap (Bjork flap) can be created using a Mayo scissor and sutured to the subcutaneous tissue using 3-0 chromic suture. Alternatively the anterior section of a single tracheal ring can be resected or a round or vertical oval window spanning two tracheal rings be excised [ 15 ] [ 29 ] [ 47 ] using a scalpel, curved Mayo scissor, or a tracheotomy punch ( Figure 106-5 and Figure 106-6 ). The endotracheal tube cuff is deflated and the tube slowly withdrawn by the anesthesiologist until the inferior tip of the tube is lined up with the superior border of the newly formed tracheal opening. A tracheotomy tube is then inserted through the tracheotomy into the airway and the patient is ventilated. Tracheotomy Complications The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication and are thus divided into intraoperative, early, and late postoperative. It should be noted that there may be an overlap in the timeframe in which early, intermediate, and late complications present. It is important to note that specific patient populations, such as the pediatric, post head trauma, obese, burn patient, or seriously debilitated are more susceptible to complications related to tracheotomy. [ 20 ] 2445 Figure 106-1 A, Surface anatomy of the neck with skin incision for the tracheotomy ( left ) and cricothyrotomy ( right ). B, A vertical skin incision is made between the cricoid and second tracheal ring as assessed by palpation through the skin. Tracheotomy holds a complication rate of between 5% to 40% depending on study design, patient follow-up, and the definition of the different complications. [ 46 ] In a recent study of 1130 surgical tracheotomies, the major complication rate for surgical tracheotomy was found to be as low as 4.3%, with a mortality rate of 0.7%. [ 20 ] Death from tracheotomy is caused most often by hemorrhage or tube displacement. It is important to note that the incidence of complications in emergency tracheotomy is 2 to 5 times that found in an elective procedure. The most common complication has classically been hemorrhage (3.7%), followed by tube obstruction (2.7%), and tube displacement (1.5%) The incidence 2446 Figure 106-2 The strap muscles are separated through the bloodless midline raphe to reveal the underlying thyroid isthmus. Figure 106-3 The thyroid isthmus may be retracted or suture ligated. of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is less than 1%. Immediate Complications Immediate complications of tracheotomy include those present during or at the termination of the operation. Although these complications are usually caused during surgery, they may appear hours or days after the tracheotomy is performed. Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Frequent sites of bleeding are the anterior jugular veins, the thyroid isthmus, and vascular variants such as the thyroid ima artery. [ 36 ] Other immediate complications include insertion of the tracheotomy tube into a false route, electrocautery-induced intraoperative fire, [ 1 ] and surgical injury to adjacent structures. Intermediate Complications Intermediate complications develop during the first hours to days after surgery. Again, hemorrhage may be a frequent postoperative complication of tracheotomy. 2447 Figure 106-4 The thyroid isthmus may be safely transected slowly using a monopolar cautery (Bovie) when it obscures the proposed entrance site into the trachea. Figure 106-5 A horizontal incision can be made in the intracartilaginous space. Because many of these patients are hypotensive, bleeding does not occur until arterial blood pressure is restored or venous pressure is increased by coughing associated with canula placement. Minor oozing may be managed by light packing with oxidized cellulose, microfibrillar collagen, or tranexamic acid-soaked gauze packs. [ 27 ] Transient tracheitis and stomal cellulitis may occur, and all fresh tracheotomies should be attended to with strict local hygiene. Severe infection such as mediastinitis, clavicular osteomyelitis, and necrotizing fasciitis are rare, but have been reported after tracheostomy and must be treated aggressively. [ 48 ] Other known early postoperative complications include subcutaneous emphysema, pneumomediastinum, Figure 106-6 A tracheotomy punch is then used to make a circular window in the anterior wall of the trachea. and pneumothorax. All of these may result from excessive dissection of tissue planes at the time of tracheostomy , blockage of the cannula, or assisted ventilation with excessive pressure, causing dissection of air along the pretracheal fascia. The incidence of subcutaneous emphysema is 0% to 9% and the incidence of pneumothorax is 0% to 4% in adults. [ 43 ] Obstruction of the tracheotomy tube on the first few postoperative days is likely to result from blood clot, partial displacement, or tube impingement on the posterior tracheal wall. The incidence of tube obstruction is 2.5%. [ 43 ] Routine postoperative care including observation, humidification, and frequent gentle suctioning prevents tube obstruction. Dislodgment of the tracheotomy tube may be a fatal complication in the first few days after tracheotomy. Several factors that play a role in tube dislodgment are the length of the tube, thickness of the neck, site of tracheostomy , postoperative swelling, and method of securing the tube. As a general rule, the ties should be secured snugly, yet allow passage one finger between the ties and the neck to prevent neck constriction. We suture the flanges to the skin with monofilament suture in addition to the ties. In an emergent situation of accidental decannulation during the initial 48 hours after the tube placement, one failed attempt at replacement must be followed with orotracheal intubation. This often-neglected intervention can save many unnecessary mishaps. Late Complications A late complication such as delayed hemorrhage may be a result of traction on granulation tissue or from innominate artery erosion. Immediate investigation 2448 into the cause of bleeding is thus mandatory. Trachea-innominate fistula with massive hemorrhage occurs in 0.4% of tracheotomies. [ 14 ] Long-term tracheal intubation and ventilation with a cuffed tracheotomy tube may result in cartilage necrosis of the tracheal wall. Erosion may also occur with a cuffless tube if the tip of the tube is lodged anteriorly, the innominate artery is high in the neck, or the tracheostomy is placed too low. This complication may be heralded by a &quot;sentinel&quot; bleed that may occur 3 days to 3 weeks before massive hemorrhage and should prompt an immediate fiberoptic tracheal examination. [ 26 ] If there is evidence of erosion or necrosis, the patient must be immediately evaluated in the operating room under general anesthesia, with the patient prepared for mediastinal exploration and thoracotomy. In instances of massive hemorrhage, direct digital pressure on the anterior wall of the stoma tract (posterior wall of the vessel) has been effective in controlling bleeding. Tracheal-innominate artery blowout carries a mortality rate of 85% to 90%. [ 7 ] [ 8 ] [ 37 ] Tracheoesophageal fistula is rare, with a reported incidence of 0.01% to 1%. [ 51 ] Tracheoesophageal fistula is thought to result from incidental damage to the posterior tracheal wall at the time of surgery or to be the product of two factors: an over inflated and improperly fitted cuffed tube, which places pressure on the posterior tracheal wall, together with an indwelling nasogastric tube in the esophagus. The diagnosis should be suspected clinically by coughing during eating, chronic cough on swallowing saliva, recurrent aspiration, and pneumonia. Barium swallow or methylene blue instilled into the esophagus and flexible fiberoptic evaluation may be diagnostic; however, generally a combination of these studies, with endoscopic evaluation, is often necessary. Once the diagnosis is confirmed, definitive surgical repair is undertaken. [ 22 ] [ 40 ] Tracheal stenosis and subglottic stenosis are complications predisposed by previous endotracheal tube intubation, high tracheostomy or cricothyroidotomy, and trauma to the airway. Patients at increased risk for tracheal stenosis include children and patients tracheotomized for closed head trauma. Meticulous surgical technique, aggressive treatment of postoperative infections, and the use of the high-volume, low-pressure cuffed tube help minimize the risk of tracheal stenosis. Tracheocutaneous fistula is a late complication, which is more common as the stomal tract is epithelialized with long-term cannulation. A persistent fistula causes continual tracheal secretions with skin irritation, disturbed phonation, and frequent infections. Infection and granulation tissue may play a role in persistent stomal fistulas. Persistent fistulas require excision of the fistula tract. Contraindications No absolute contraindications exist to open surgical tracheostomy . Bookmark URL: /das/book/view/59514421-2/1263/983.html/top History of difficult intubation Limited ability to extend the cervical spine Prothrombin time or partial thromboplastin time >1.5 times control Bleeding time >10 min Platelet count <40,000/mm 3 Positive end-expiratory pressure >15 cm H 2 O Short or obese neck Occluding thyroid mass or goiter over the tracheotomy site Active infection over the tracheotomy site Pulsating palpable blood vessel over the tracheotomy site Anatomic abnormality of the trachea Children younger than 12 years of age About MD Consult | Contact Us | Terms and Conditions | Privacy Policy | Registered User Agreement www.mdconsult.com Copyright © 2006 Elsevier Inc . All rights reserved.

12. TRACHEOSTOMY TUBE CARE Tracheostomy tube cuff pressures in a range of 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.

13. TRACHEOSTOMY TUBE CARE Chest Xray: cuff has a width greater than the caliber of the trachea, which suggests the presence of a hyperinflated cuff and tracheal overdistention Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

14. TRACHEOSTOMY TUBE CARE Humidification of the inspired gas is a standard of care for tracheostomized patients. Thermovent

15. • Secretions in the trach • Suspected aspiration of gastric or upper airway secretions • 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 Indications For Suctioning

16. Tracheostomies should be suctioned whenever physical examination reveals the presence of secretions CLEARANCE OF SECRETIONS

17. SPEECH

18. SPEECH Tracheostomy Speaking Valve Passy-Muir 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

19. NUTRITION Tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic closure. Between 20% and 70% of patients with a chronic tracheostomy experience at least one episode of aspiration every 48 hours Evaluation by speech therapist Keep head elevated to 45° during periods of tube feeding Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

20. WEANING FROM TRACHEOSTOMY Demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation. Tracheostomy stomas can narrow markedly or close within 48 to 72 hours after tube removal. Deflating the tracheostomy cuff and capping the tube.

21. WEANING FROM TRACHEOTOMY The ability to breath and clear airway secretions around a small, capped tube signifies readiness for decannulation Patients who fail breathing trials with capped tracheostomy tubes should be evaluated by flexible fiberoptic endoscopy for evidence of airway lesions and adequacy of airway function.

22. Complications of Tracheostomy Complications 5-40% Mortality <2% Complications are more frequent in emergency situations, severely ill patients and small children.

23. Complications of Tracheostomy Stoma Stoma site infection Stomal hemorrhage Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula

24. Complications of Tracheostomy Trachea Granuloma Tracheoesophageal fistula fewer than 1% of patients as a result of pressure necrosis of the tracheal and esophageal mucosa from the tube cuff risks: high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus

25. Complications of Tracheostomy Tracheoinnominate fistula: 0.4% with mortality rate of 85% to 90%. Major airway hemorrhage may occur first within several days or as long as 7 months after performance of a tracheostomy. Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy Tracheal stenosis: can develop from 1 to 6 months after decannulation risk for tracheal stenosis ranges between 0% and 16% Tracheomalacia

26. CONCLUSION The most common indications for tracheostomy is mechanical ventilation with prolonged tracheal intubation. Tracheostomy: emergency and elective, improve quality of life. Meticulous surgical technique. Appropriate postoperative tracheostomy care to reduce complications.

28. Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin.[ Guidewire introduction, with removal of sheath PERCUTANEOUS DILATIONAL TRACHEOTOMY

29. PERCUTANEOUS DILATIONAL TRACHEOTOMY Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark

30. PERCUTANEOUS DILATIONAL TRACHEOTOMY 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 trachea

31. PERCUTANEOUS DILATIONAL TRACHEOTOMY Cook Ciaglia percutaneous dilatational tracheostomy kit

36. TRACHEOSTOMY TUBE CARE Securing tracheostomy around patient’s neck. Tube changes: Indications: soiled, cuff rupture. Complications: insertion into a false passage bleeding, and patient discomfort. Avoid within 1 st week. First tube change by surgeon. Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation. Use of this content is subject to the Terms and Conditions of the MD Consult web site. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. , Copyright © 2005 Mosby, Inc. INDICATIONS FOR TRACHEOTOMY Current indications for tracheotomy are: prolonged intubation and mechanical ventilation, bypass of an upper airway obstruction, easier management of secretions, as an adjunct to chest or head and neck surgery in which ventilation problems or prolonged intubation are anticipated ( Table 106-2 ). The earliest indication for the procedure was upper airway obstruction resulting from trauma or infection. As late as the 1950s, the major indication for 2444 TABLE 106-2 -- RELATIVE CONTRAINDICATIONS TO PERFORM PERCUTANEOUS DILATIONAL TRACHEOTOMY tracheotomy was upper airway obstruction because of infectious disease including diphtheria, polio, Ludwig's angina, tetanus, and laryngotracheobronchitis. [ 29 ] [ 41 ] [ 49 ] Other causes of upper airway obstruction necessitating tracheotomy include obstruction due to neoplastic processes, or functional obstruction such as bilateral vocal cord paralysis or edema secondary to smoke inhalation or caustic agent ingestion. In such cases, patients are usually stabilized by tracheal intubation or with a cricothyrotomy and tracheotomy later. Although facial fractures in and of them selves are not an indication for tracheotomy, in cases of severe maxillo-facial trauma, tracheotomy is sometimes used to secure an airway where intubation would be difficult or damaging. Today, the most common indication for tracheotomy is prolonged tracheal intubation, usually with mechanical ventilation. A recent review of more than 1000 consecutive tracheotomies found that 76% were performed to facilitate mechanical ventilation. [ 21 ] Surgical Technique Tracheotomy is optimally performed under general anesthesia in the operating room. If necessary, the procedure may be performed under local anesthesia or in an intensive care setting. [ 29 ] In case a tracheotomy is being performed under local anesthesia, the surgeon and the anesthetist have to work in tandem to keep the patient maximally reassured. On most occasions the anesthetist may use minimal sedation to achieve patient comfort without compromising the ability to breathe spontaneously. Another critical precaution to keep in mind is to avoid the use of Bovie cautery. The surgical field may be getting the oxygenrich gas mixture from the nasal cannula or the ventilating mask. This simple precautionary measure will avert the risk of igniting fire in the surgical field. The basic technique consists of either a vertical incision from the cricoid cartilage, 1.5 inches inferiorly or a horizontal incision midway between the sternal notch and the cricoid cartilage ( Figure 106-1 ). The incision is carried down through the skin, subcutaneous tissue, and platysma to reveal the strap muscles. If the patient is obese and the adipose tissue obtrusive, a minimal cervical lipectomy may be performed. [ 23 ] At this level, the dissection should be in a vertical plane regardless of the skin incision chosen. The strap muscles are separated by a vertical incision through the bloodless midline raphe (linea Alba) and retracted from one another revealing the thyroid isthmus which typically lies over the third and fourth tracheal ring ( Figure 106-2 ). The isthmus may be dealt with in a number of ways. This decision is based on the position of the isthmus relative to the wound and the surgeon's personal preference. It may be superiorly retracted, transected, and suture-ligated ( Figure 106-3 ), transected slowly using a monopolar cautery (Bovie) [ 10 ] [ 28 ] ( Figure 106-4 ), or inferiorly retracted (least commonly used method). [ 28 ] The trachea is revealed and the third and fourth tracheal rings are identified using the cricoid as a landmark. As with the skin incision, there are equally reasonable choices for the entrance into the trachea. An inferiorly based trap door flap (Bjork flap) can be created using a Mayo scissor and sutured to the subcutaneous tissue using 3-0 chromic suture. Alternatively the anterior section of a single tracheal ring can be resected or a round or vertical oval window spanning two tracheal rings be excised [ 15 ] [ 29 ] [ 47 ] using a scalpel, curved Mayo scissor, or a tracheotomy punch ( Figure 106-5 and Figure 106-6 ). The endotracheal tube cuff is deflated and the tube slowly withdrawn by the anesthesiologist until the inferior tip of the tube is lined up with the superior border of the newly formed tracheal opening. A tracheotomy tube is then inserted through the tracheotomy into the airway and the patient is ventilated. Tracheotomy Complications The complications of tracheotomy may be categorized by the interval from the procedure to the onset of the complication and are thus divided into intraoperative, early, and late postoperative. It should be noted that there may be an overlap in the timeframe in which early, intermediate, and late complications present. It is important to note that specific patient populations, such as the pediatric, post head trauma, obese, burn patient, or seriously debilitated are more susceptible to complications related to tracheotomy. [ 20 ] 2445 Figure 106-1 A, Surface anatomy of the neck with skin incision for the tracheotomy ( left ) and cricothyrotomy ( right ). B, A vertical skin incision is made between the cricoid and second tracheal ring as assessed by palpation through the skin. Tracheotomy holds a complication rate of between 5% to 40% depending on study design, patient follow-up, and the definition of the different complications. [ 46 ] In a recent study of 1130 surgical tracheotomies, the major complication rate for surgical tracheotomy was found to be as low as 4.3%, with a mortality rate of 0.7%. [ 20 ] Death from tracheotomy is caused most often by hemorrhage or tube displacement. It is important to note that the incidence of complications in emergency tracheotomy is 2 to 5 times that found in an elective procedure. The most common complication has classically been hemorrhage (3.7%), followed by tube obstruction (2.7%), and tube displacement (1.5%) The incidence 2446 Figure 106-2 The strap muscles are separated through the bloodless midline raphe to reveal the underlying thyroid isthmus. Figure 106-3 The thyroid isthmus may be retracted or suture ligated. of pneumothorax, tracheal stenosis, and tracheoesophageal fistula is less than 1%. Immediate Complications Immediate complications of tracheotomy include those present during or at the termination of the operation. Although these complications are usually caused during surgery, they may appear hours or days after the tracheotomy is performed. Bleeding during the performance of a tracheotomy is most commonly the result of errors in surgical technique. Frequent sites of bleeding are the anterior jugular veins, the thyroid isthmus, and vascular variants such as the thyroid ima artery. [ 36 ] Other immediate complications include insertion of the tracheotomy tube into a false route, electrocautery-induced intraoperative fire, [ 1 ] and surgical injury to adjacent structures. Intermediate Complications Intermediate complications develop during the first hours to days after surgery. Again, hemorrhage may be a frequent postoperative complication of tracheotomy. 2447 Figure 106-4 The thyroid isthmus may be safely transected slowly using a monopolar cautery (Bovie) when it obscures the proposed entrance site into the trachea. Figure 106-5 A horizontal incision can be made in the intracartilaginous space. Because many of these patients are hypotensive, bleeding does not occur until arterial blood pressure is restored or venous pressure is increased by coughing associated with canula placement. Minor oozing may be managed by light packing with oxidized cellulose, microfibrillar collagen, or tranexamic acid-soaked gauze packs. [ 27 ] Transient tracheitis and stomal cellulitis may occur, and all fresh tracheotomies should be attended to with strict local hygiene. Severe infection such as mediastinitis, clavicular osteomyelitis, and necrotizing fasciitis are rare, but have been reported after tracheostomy and must be treated aggressively. [ 48 ] Other known early postoperative complications include subcutaneous emphysema, pneumomediastinum, Figure 106-6 A tracheotomy punch is then used to make a circular window in the anterior wall of the trachea. and pneumothorax. All of these may result from excessive dissection of tissue planes at the time of tracheostomy , blockage of the cannula, or assisted ventilation with excessive pressure, causing dissection of air along the pretracheal fascia. The incidence of subcutaneous emphysema is 0% to 9% and the incidence of pneumothorax is 0% to 4% in adults. [ 43 ] Obstruction of the tracheotomy tube on the first few postoperative days is likely to result from blood clot, partial displacement, or tube impingement on the posterior tracheal wall. The incidence of tube obstruction is 2.5%. [ 43 ] Routine postoperative care including observation, humidification, and frequent gentle suctioning prevents tube obstruction. Dislodgment of the tracheotomy tube may be a fatal complication in the first few days after tracheotomy. Several factors that play a role in tube dislodgment are the length of the tube, thickness of the neck, site of tracheostomy , postoperative swelling, and method of securing the tube. As a general rule, the ties should be secured snugly, yet allow passage one finger between the ties and the neck to prevent neck constriction. We suture the flanges to the skin with monofilament suture in addition to the ties. In an emergent situation of accidental decannulation during the initial 48 hours after the tube placement, one failed attempt at replacement must be followed with orotracheal intubation. This often-neglected intervention can save many unnecessary mishaps. Late Complications A late complication such as delayed hemorrhage may be a result of traction on granulation tissue or from innominate artery erosion. Immediate investigation 2448 into the cause of bleeding is thus mandatory. Trachea-innominate fistula with massive hemorrhage occurs in 0.4% of tracheotomies. [ 14 ] Long-term tracheal intubation and ventilation with a cuffed tracheotomy tube may result in cartilage necrosis of the tracheal wall. Erosion may also occur with a cuffless tube if the tip of the tube is lodged anteriorly, the innominate artery is high in the neck, or the tracheostomy is placed too low. This complication may be heralded by a &quot;sentinel&quot; bleed that may occur 3 days to 3 weeks before massive hemorrhage and should prompt an immediate fiberoptic tracheal examination. [ 26 ] If there is evidence of erosion or necrosis, the patient must be immediately evaluated in the operating room under general anesthesia, with the patient prepared for mediastinal exploration and thoracotomy. In instances of massive hemorrhage, direct digital pressure on the anterior wall of the stoma tract (posterior wall of the vessel) has been effective in controlling bleeding. Tracheal-innominate artery blowout carries a mortality rate of 85% to 90%. [ 7 ] [ 8 ] [ 37 ] Tracheoesophageal fistula is rare, with a reported incidence of 0.01% to 1%. [ 51 ] Tracheoesophageal fistula is thought to result from incidental damage to the posterior tracheal wall at the time of surgery or to be the product of two factors: an over inflated and improperly fitted cuffed tube, which places pressure on the posterior tracheal wall, together with an indwelling nasogastric tube in the esophagus. The diagnosis should be suspected clinically by coughing during eating, chronic cough on swallowing saliva, recurrent aspiration, and pneumonia. Barium swallow or methylene blue instilled into the esophagus and flexible fiberoptic evaluation may be diagnostic; however, generally a combination of these studies, with endoscopic evaluation, is often necessary. Once the diagnosis is confirmed, definitive surgical repair is undertaken. [ 22 ] [ 40 ] Tracheal stenosis and subglottic stenosis are complications predisposed by previous endotracheal tube intubation, high tracheostomy or cricothyroidotomy, and trauma to the airway. Patients at increased risk for tracheal stenosis include children and patients tracheotomized for closed head trauma. Meticulous surgical technique, aggressive treatment of postoperative infections, and the use of the high-volume, low-pressure cuffed tube help minimize the risk of tracheal stenosis. Tracheocutaneous fistula is a late complication, which is more common as the stomal tract is epithelialized with long-term cannulation. A persistent fistula causes continual tracheal secretions with skin irritation, disturbed phonation, and frequent infections. Infection and granulation tissue may play a role in persistent stomal fistulas. Persistent fistulas require excision of the fistula tract. Contraindications No absolute contraindications exist to open surgical tracheostomy . Bookmark URL: /das/book/view/59514421-2/1263/983.html/top History of difficult intubation Limited ability to extend the cervical spine Prothrombin time or partial thromboplastin time >1.5 times control Bleeding time >10 min Platelet count <40,000/mm 3 Positive end-expiratory pressure >15 cm H 2 O Short or obese neck Occluding thyroid mass or goiter over the tracheotomy site Active infection over the tracheotomy site Pulsating palpable blood vessel over the tracheotomy site Anatomic abnormality of the trachea Children younger than 12 years of age About MD Consult | Contact Us | Terms and Conditions | Privacy Policy | Registered User Agreement www.mdconsult.com Copyright © 2006 Elsevier Inc . All rights reserved.

38. TRACHEOTOMY