Tracheostomy is a surgical procedure that creates an opening in the trachea to allow direct access to the breathing tube. It has several indications including bypassing upper airway obstruction, removing secretions from the lungs, and facilitating prolonged mechanical ventilation. There are different types of tracheostomies based on location and whether they are temporary or permanent. Potential complications include bleeding, infection, and tracheal stenosis. Proper care including suctioning, humidification, and dressing changes can help prevent complications. Percutaneous dilational tracheostomy is a minimally invasive technique to perform tracheostomy at the bedside using guidewires and dilation. Decannulation involves gradually removing the tracheostomy tube when the original condition improves

1. Tracheostomy
Dr. Mohammad Ashrafuzzaman Sajib
Consultant (ICU)
Department of Anesthesia, Analgesia &
Intensive Care Medicine
Bangabandhu Sheikh Mujib Medical University

2. Definition Tracheotomy
Greek origin: ‘tom’- ‘to cut’ the trachea
Surgical opening of the trachea
Tracheostomy
Greek origin: ‘stom’- ‘mouth’
Creation of a stoma between trachea and
cervical skin

3. Definition……..
An operative procedure that creates a surgical
airway in the cervical trachea
A Surgical fistula created between the anterior wall
of the trachea and the skin outside, which can be
maintained with or without a tube.

4. History
The first known depiction of tracheostomy is from 3600 BC, on Egyptian
tablets
The first scientific reliable description of successful tracheostomy by the
surgeon who performed it was by Antonio Musa Brasavola in 1546, for relief
of airway obstruction from enlarged tonsils.
Another reference found in - rig veda dated 2000 BC.
Ebers papyrus (dated 1550 BC)- Egyptian medical papyrus mentions
tracheotomy
Alexander the Great
Antyllus (2 AD), Greek surgeon performed tracheostomies in oral surgeries
Tracheotomy well documented in Indian and Arabian literature in middle
ages.

5. History….Cont.
• Tracheostomy gained popularity in 1800s
• Two methods:
a. High- by dividing cricoid
b. Low- trachea entered directly
• Significant problems associated with
high method
• Till the end of 19th century, tracheostomy
was considered hazardous.
• Chevalier Jackson in 1923 established
principles of tracheostomy.

6. Indications
A. To bypass obstruction of Upper airway
• Congenital Laryngeal web/cysts, B/L choanal atresia,
Tracheoesophageal fistula, Craniofacial anomalies,
• Subglottic/tracheal stenosis
• Infective Acute epiglottitis, Diphtheria, Acute
• layngotracheobronchitis, Ludwig’s angina
• Trauma External injury to larynx/trachea, maxillofacial
• injury, corrosive injury, inhalational injury
• Neoplasm Tumours of larynx, pharynx, tongue, upper trachea
• Foreign Body Foreign body lodged in larynx
• Vocal cords B/L abductor paralysis, Bulbar palsy
• Post operative : Surgery of the base of the tongue, Hypopharynx.

7. Indications…….
B. Removal of secretions and protection of
Tracheobronchial tree from aspiration
Neurological diseases- GBS, MS, Bulbar palsy
Coma- head injury, poisoning, tumour
In such situations- laryngeal/pharyngeal incompetence
Cuffed tube--- useful

8. Indications……..
C. Respiratory failure
• Tracheostomy- dead space, effort of
breathing, alveolar ventilation improved.
• Ease of removal of secretions
• Pulmonary diseases- exacerbation of chronic
bronchitis, emphysema, severe pneumonia
• Neurological diseases- MS, Motor neuron
disease
• Severe chest injury- flail chest

9. Indications
D. Prolonged ventilation
• T-tube more secure than ET tube; easier to wean off ventilator
support
• Duration : >3 wks of intubation
E. As a part of another procedure
• Temporary tracheostomy in head and neck surgeries

11. Types
A. TEMPORARY/PERMANENT:
• Temporary tracheostomy- elective or emergency
• Permanent tracheostomy-as part of operation involving
removal of larynx
B. HIGH/MID/LOW:
• High- above isthmus via 1st tracheal ring
• Mid- through 2nd-3rd tracheal ring, preferred
• Low- below the level of isthmus

12. Clinical Types
Surgical tracheostomy
Minitracheostomy
Paediatric tracheostomy
Percutaneous dilatational
tracheostomy

13. Timing of Tracheostomy
• Older recommendation advised to perform tracheostomy within 3 days
after translaryngeal intubation to more than 21 days.
• Heffner recommendation---more up to date about the timing.
i. We can consider tracheostomy if the patient remain ventilator
dependent after 1 week
ii. Decision should be based on anticipated duration of MV
support & the expected benefit .
• Early Vs Late Tracheostomy concept :
Early : Performed within 7 days of ETT
Late : Performed after 7 days of ETT

14. Preoperative assessment
• Informed consent
• Coagulation profile adequate,
• platelet count >50000/cumm
• Neck examination- to anticipate difficulties in
procedure as in enlarged thyroid, limited neck
extension.
• T-tube arranged, checked and prepared to perform
the procedure.

18. Advantage & Disadvantages
• A. Advantages include
• Avoid direct Laryngeal injury
• Facilitates nursing care
• Enhance patient mobility
• More secure airway
• Improved patient comfort
• Permits speech
• Provide psychological benefit
• More rapid weaning from mechanical ventilation
• Better oral hygiene
• Reduced need for sedation
• Decreased risk for nosocomial infection

19. • B. Disadvantages include :
• Complication can occur
• Bacterial airway colonization
• Costly procedure
• Surgical scar
• Tracheal and stomal stenosis

20. Complications…….Immediate (0-24 hrs)
Haemorrhage
Local injury-cricoid
cartilage, 1st
tracheal ring,
carotid artery
Recurrent
laryngeal nerve
Air embolism Apnoea Cardiac arrest

21. Complications…….
Intermediate
(From Day 1 to Day
7)
Secondary haemorrhage
Tube displacement
Tube blockage
Subcutaneous emphysema
Pneumothorax
Infection
Tracheal necrosis

22. Complications…
Late ( After Day 7)
• Haemorrhage
• Granuloma formation
• Tracheo-oesophageal fistula —whom
to suspect ?
• Tracheo-cutaneous fistula
• Laryngotracheal stenosis
• Tracheomalacia
• Difficult decannulation
• Tracheostomy scar

23. Minitracheostomy or Cricothyrotomy/ Cricothyroidotomy
Procedure for opening airway through cricothyroid membrane
Minitracheostomy kits commercially available

24. Minitracheostomy or
Cricothyrotomy/
Cricothyroidotomy………….
Initially it was taken as a negative
approach due to high complication
rates specially Subglottic Stenosis.
Later on, further studies showed its
effectiveness with low
complication rates.
It provides both Elective &
Emergency airway access.

25. Minitracheostomy
or Cricothyrotomy/
Cricothyroidotomy
………..
 Provides more advantages than OST such as
i. Technical simplicity
ii. Speed of performance
iii. Low complications rate
iv. Suitable for bedside procedure
v. Airway remains isolated from Median Sternotomy,
Radical neck dissection.
vi. Smaller scar
vii.Less Esophageal injury
viii.No chance of Pneumothorax or tracheal arterial
fistula
****Despite these advantages, many authorities
recommends this procedure as an elective long term
method of airway access in highly selective patients.

26. Minitracheostomy or
Cricothyrotomy/
Cricothyroidotomy………..
Indications :
• Emergency Cricothyrotomy is useful because it requires
smaller number of instruments and less training than
tracheostomy.
• Emergency access for securing airway where Oral/Naso
tracheal intubation is unsuccessful or contra indicated.
• More useful in Trauma management, Axial/ cervical
spine injury, severe facial trauma.
Contra indications :
• Not for airway obstruction management which occurs
just after endotracheal exubation.
• Primary Laryngeal trauma or infection.
• Absolutely contraindicated in Infants & children
younger than 10-12 yrs.

27. Minitracheostomy or Cricothyrotomy/
Cricothyroidotomy…………
• Short & long term complications
ranges from 6.1%.
• Subglottic stenosis: (2-3) %
• Location—mainly at cricothyrotomy
site, not at the cuff site.
• It should usually be replaced with
standard Tracheostomy within 48-72
hrs.
Complications
:

28. Tracheostomy Care
A. Suctioning :
i. Tracheotomized patients have increased secretions with decreased
ability to clear them.
ii. Proper suctioning decreases lung infection & airway plugging.
iii. Frequent suctioning is needed if ineffective cough present
iv. Technique---Should remove maximum secretion with minimum
airway trauma.
v. The tube itself may be the reason for increased amount of
secretion.

29. Tracheostomy care………
B. Humidification
Upper respiratory tract by passed, conditioning of inspired gas lost. So warm,
humidified air should be provided. Failure to humidification of inspired air leads to
inspissated secretion, impaired mucocilliary clearance, decreased cough.
D. Types: -Cold water humidifiers
Hot water humidifiers
Heat and moisture exchangers (HME)
Stoma protector
E. Nebulization

30. Tracheostomy Care……
F. Wound & dressing Care :
i. Daily stomal examination---Infection, excoriation of skin identification.
ii. Wound needs to be cleaned & free of blood/secretion.
iii. Dressing change---Twice a day & when the dressing is soiled.
iv. Stomal cleaning with 1:1 mixture of H2O2 & Saline.
v. Special care is needed while changing dressing & tapes—Dislodge issue.
vi. Malodorous tracheal Stomatitis should be treated with topical
antimicrobial dressing---0.25% Dakin’s solution to facilitate resolution.

31. Tracheostomy
Tube Change
Tracheostomy Tract is
formed in 7days
1st tube change- 5-7 days
Frequency of tube change-
no standard interval

32. Types of Tracheostomy
Tube
• cuffed or uncuffed

33. Types of
Tracheostomy
Tube
2. Single or double lumen
tubes

34. 3. Adjustable flange long tube
4. Suction aid tracheostomy tube

35. Types of
Tracheostomy Tube
5. Tracheostomy with speaking valve

36. Types of
tubes
based on
Tube
Material
PVC Silicone
Siliconed
PVC
Silastic
Silver Armoured
Fullers
tube

37. Percutaneous Dilational Tracheostomy (PDT)
 1st described by Shelden & Pudenz (1957)
 Several modification technique was described by Ciaglia et al. in 1988.
 Basic method is to place a guidewire through the anterior Tracheal wall,
followed by dilation over this guidewire to create a Tracheal stoma.
 Can be done in ICU or OT room.
 Adequate monitoring ( O2 saturation , Cardiac Rhythm and BP) is needed.
 No significant differences in Mortality or major complications found between
PDT or OST in several meta analysis.

38. PDT……
PDT is taken as minimally invasive
procedure, done at bedside in ICU.
It avoids the risk of transporting critically ill
patients & the cost of OT room.
During procedure----Continuous Patient
monitoring in needed.
Direct Bronchoscopic Visualization----often
required.
Several techniques are available but the
Ciaglia technique is the most common.

39. PDT….Cont..
Advantages of PDT includes
• Easier access for timing of the
procedure
• Reduced OT room & manpower
utilization
• No need to transport critically ill
patient to OT room.
• Better cosmetic result
• Possibly reduced Stomal infection,
Bleeding & Reduced Tracheal
secretion in parastomal area.
Special recommendation for OST over PDT :
• Patient with more severe Respiratory distress
(FiO2 >0.6, PEEP > 10, Complicated ET
intubation, Nonpalpable Cricoid cartilage,
Cricoid cartilage <3 cm above the sternal
notch).
• Obese patients with abundant pretracheal S/C
fat
• Large Goiter
• Abnormal airway due to congenital acquired
conditions
• Bleeding disorders which cannot be corrected
by coagulation factors.

40. PDT..Cont..
• Contraindications:
a. Absolute:
i. cervical injury
ii. Coagulopathy
iii. Not an Emergency airway
iv. Infected insertion site
v. Uncorrected coagulopathy
b. Relative :
i. Short fat neck/obesity
ii. Enlarged thyroid
iii. Inability to extend neck (cervical injury/prior tracheostomy)

41. Percutaneous
Dilational
Tracheostomy
set

42. Decannulation
Considered when
original condition
requiring
tracheostomy has
improved
Approached in a
step-wise manner
In paediatric group
endoscopic
assessment prior
to decannulation
essential
Sequence :
Fenestrated tube>
occlusion cap>
occlusion cap for
12 hrs > 24 hrs>
decannulation

43. Thank You