Here are the key anatomical considerations between pediatric and adult tracheostomy: - The pediatric trachea is shorter, more vertical and closer to the skin surface compared to adults. This makes pediatric tracheostomy more prone to complications like surgical emphysema. - The subglottic region in children is narrower and more prone to stenosis on irritation or injury. Decannulation is more difficult in children because: - Their larynx is higher in the neck which makes tolerance of an artificial airway removal challenging. - The larynx and trachea are still developing in children. Long-term intubation can impair this development, resulting in incoordination of laryngeal reflexes and inability to tolerate

1. Tracheostomy
Dr. Krishna Koirala
2020-04-24 @2:00 PM

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

5. 4. Anesthesia administration in:
– Laryngo-pharyngeal growths
– Maxillofacial trauma
– Trismus
– Severe Ludwig’s angina
– Positive pressure ventilation for > 72 hrs

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

8. Commonly used Tracheostomy
tubes

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

10. Jackson’s metallic tube

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

13. Portex cuffed tube

14. Cuffed double lumen tube

15. Cuffed fenestrated tube

16. Portex uncuffed tube
For tracheostomy patient receiving radiation and in children

17. Uncuffed double lumen fenestrated tube

18. Hands free speaking valve

19. Tube with adjustable flange
Used in obese neck, edematous neck

20. Salpekar double cuff tube
Prevents ischemic necrosis of tracheal cartilage

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

22. Age of pt Tracheostomy tube size
Portex (I.D. in
mm)
Metallic (Fg)
1 – 3 yrs 4.0 – 4.5 16
4 – 6 yrs 5.0 18
7 – 9 yrs 5.5 20, 22
10 – 12 yrs 6.0 24, 26
13 – 18 yrs 7.0 – 7.5 28, 30
Adult 8.0 – 9.0 32, 34, 36

23. Steps of Tracheostomy

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

33. Bjork flap
Alternately an inferiorly based tracheal flap is made
and sutured to lower skin edge

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 Haemorrhage
– 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

41. Surgical emphysema

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

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

50. Tracheostomy Intubation
Invasive Non-invasive
Complications are more Less
Can be kept for > 7 days Should not be kept
Pt can speak Cannot speak
Tracheo-bronchial toilet is easy Difficult
Decreases dead space by 30-50% Does not

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

53. Percutaneous Tracheostomy

54. Cricothyroidotomy (Minitracheostomy)
1. Midline vertical skin incision made to identify cricothyroid
notch
2. Cricothyroid membrane incised horizontally, with # 11 blade,
close to cricoid
3. Knife handle inserted and rotated by 900, to widen the
horizontal opening and tracheostomy tube is inserted
4. Elective tracheostomy done as soon as possible to avoid
subglottic stenosis

57. Cricothyroidotomy

58. PG Question : Describe the anatomical considerations between pediatric and adult
tracheostomy. Why is decannulation difficult in children?