This document discusses the anatomy of the trachea and provides details on tracheostomy procedures. It begins with the surgical anatomy of the trachea, including its length, diameter, cartilage structure, blood supply and inner lining. Indications for tracheostomy such as mechanical obstruction, respiratory failure and prolonged intubation are described. The document then provides details on the procedure, including incision types, tube selection and postoperative care considerations like tube changes, speaking abilities and weaning from the tracheostomy tube. Potential complications are also outlined.

1. SURGICAL ANATOMY OF
TRACHEA
&
TRACHEOSTOMY.
21 October 2020 1
Dr. Lamture Y.R.
Department of surgery
Datta Meghe medical college
Nagpur

2. Anatomy of the trachea.
Indications and contraindications of tracheostomy.
Procedure detail
Complications
Tracheostomy care
21 October 2020 2
Learning objectives

3. SURGICAL ANATOMY OF
TRACHEA.
21 October 2020 3

4. • Begins just below the larynx at approx. the 6th cervical vertebra(C6).
• In adults it is 12-16 cm long,
• 13-16 mm wide in women and 16-20 mm wide in men.*
• Outer diameter: 21-27 mm
• Internal diameter: 12-18 mm
• It is slightly to the right of the midline and divides at the carina into the right
and left bronchi.
• The carina lies under the junction of the sternum at the level of the 4th thoracic
vertebra.**
• *(Minsley and Wren 1996), **(Kumar and Clark, 1994 p 631)
21 October 2020 4
Anatomy of the trachea.

5. • A fibromuscular tube
supported by 20 hyaline
cartilages which are opened
posteriorly.
• The soft tissue posterior wall
is in contact with the
oesophagus.
• Three layers of tissue clothe
the cartilages:
• A fibrous elastic outer layer.
• A middle layer of cartilage &
bands of smooth muscle that
wind around the trachea.
• An inner lining consisting of
delicate ciliated columnar
epithelium containing mucous21 October 2020 5

6. • 18-22 cartilaginous rings
• There are 2.1 rings/cm
• Becomes intrathoracic at 6th cartilaginous ring
• Intrathoracic portion: 6-15 cm
21 October 2020 6

7. • 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 sympathetic system acts in the flight or fight
response stimulated by adrenaline. It causes an
increase in heart rate and relaxes the bronchi and
muscle of the gut wall.*
The parasympathetic supply to the trachea is by the
recurrent laryngeal nerve – a branch of the vagus
nerve – it can slow the heart rate, increase the acidity
to the stomach and constrict the bronchi. *
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8. Tracheal dimensions
• Average cross-sectional area of
the male adult trachea is
approximately 2.8 cm2.
• Transverse (lateral) diameter of 25
mm and sagittal (anteroposterior)
diameter of 27 mm are the upper
limits of normal (males) .
• The lower limit of normal for both
transverse and sagittal diameters is
about 13 mm in men and 10 mm in
women .
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9. Some facts about tracheal anatomy
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• The cervical segment (extrathoracic) ends at
the sternal manubrium and encompasses
about the first six tracheal rings.
• The C-shaped trachea is probably the most
frequent shape found.
• A man’s cross sectional tracheal area is
usually about 40 percent larger than a
woman’s.
• In women, the lower limit of normal for
transverse and sagittal diameters is about
10 mm.

10. Morphologic normal variants.
U-shaped trachea (27%)
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C-shaped trachea (49%)

11. TRACHEOSTOMY
A life saving procedure.
21 October 2020 11

12. 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.
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13. Terminology
• Tracheostomy:-
Surgical creation of permanent or temporary
opening in trachea.
• Tracheotomy:-
The term tracheotomy refers to an incision of the
trachea.
21 October 2020 13

14. Indications.*
1. Mechanical obstruction of the upper airways.
2. Protection of tracheobronchial tree in patients at risk
of aspiration.
3. Respiratory failure.
4. Retention of bronchial secretions.
5. Elective tracheostomy, e.g. during major head and neck
surgery a tracheostomy can provide/improve surgical
access and facilitate ventilation.
6. Prolonged intubation & Inability to intubate.
21 October 2020 14
* 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

15. Indications: Mechanical Obstruction.
21 October 2020 15

16. Indications: contd
 Protection of Airway:-
1. Neurological Diseases(Polyneuritis eg GBS, MN Diseases).
2. Coma (GCS<8, risk of aspiration).
 Respiratory Failure:-
1. Pulmonary Disease.
2. Flail Chest.
 Retention of Secretions:-
• In acute resp. infection, pulmonary disease etc.
 Elective Tracheostomy as Adjunct to H&N
surgeries
• <14 days on ETT(relative)
• >21 days on ETT21 October 2020 16

17. Contraindications
• NO Absolute.
• Relative-
• Laryngeal CA(strong)
21 October 2020 17

18. 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.
21 October 2020 18•Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

19. Pre-Op Preparations.
• History
• Physical Examination:-
• General
• Ear, Nose and Throat
• Head & Neck Examination
• Short neck, mass(thyroid mass, or skin lesion, previous scar, etc)
• Trachea( centrality, consistency, etc)
• Chest (RR, symmetry, breath sounds)
• Investigation
• Specific: x-ray soft tissue neck, CXR, CT Scan
• General: PCV, Platelet(>100 x 109 /L), PT/PTTK, U + Cr
21 October 2020 19

20. Pre-Op Preparation
• Explain the Procedure to patient (elective)
• Indication.
• Benefits.
• Risk/Possible complications.
• Interaction with Patient(s) with a tracheostomy.
• Informed Consent.
• Inform the anaesthetist and Theater nurse.
• Choice of Tracheostomy tube and instrument.
21 October 2020 20

21. Types of Tracheostomy Tubes.
21 October 2020 21
Bivona Fome-Cuff Tracheostomy Tube
Single Cannular Shiley Pediatric TT Single Cannular Shiley Pediatric TT
Metal Treacheostomy Tube.

22. Cuffed Tubes.
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23. Uncuffed Tubes.
21 October 2020 23

24. Classification.
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1. Timing:-
1. Elective.
2. Emergency.
2. Location:-
1. High.
2. Low.
3. Duration:-
1. Temporary.
2. Permanent.

25. Procedure.
• Anaesthesia:-
• Local Anesthesia.
• General Anesthesia.
• Incision:-
• Transverse.
• Longitudinal.
• Positioning
• Supine.
• Shoulder pad.
• Head ring.
21 October 2020 25

26. Special Instruments.
• Good functional suction machine.
• Good light source.
• Travis self-retaining retractor.
• Cricoid Hook.
• Negus Tracheal dilator.
21 October 2020 26

27. 21 October 2020 27

28. Procedure.
• General Anesthesia.
• Local Anesthesia.
21 October 2020 28

29. Procedure- cont’d
• The patient is
positioned with a
shoulder roll and a
foam pad (doughnut)
under the head.
• Skin Prep with povidine
iodine,
chlorohexidine(savlon).
• Draping.
• Good light source and
suction machine ready
& tested to be
functional.
21 October 2020 29

30. Procedure- cont’d
• Transverse Incision
• 2-4cm below cricoid cart/
2-4cm above suprasternal
notch
• Incision length=6cm/
anterior border of SCM
msc lateral
• Blunt dissection of subcut
21 October 2020 30
.

31. Procedure -cont’d
• Blunt dissection of
subcut tissue.
• Transversely.
• Retracted as shown.
21 October 2020 31

32. Procedure- cont’d
• Langerbeck retractor used to
retract laterally.
• 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 .
21 October 2020 32

33. 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 i
Procedure- cont’d
21 October 2020 33
Bjorke Flap.

34. Procedure- cont’d
• Thyroid ismuth is divided at midline by 2 haemostat
and cut edge secured by 2/0 vicryl
21 October 2020 34

35. Procedure- cont’d
• Depending on the size of Tracheostomy Tube about 4cm
longitudinal opening is made in trachea below 2nd ring.
21 October 2020 35

36. Procedure -cont’d
• Negus trachea dilator applied & Tracheostomy Tube
inserted in between.
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37. Procedure -cont’d
• Tube is anchored.
• Shiley tracheostomy tube: #6
• Shiley tracheostomy tube: #8 for bronchoscopy
21 October 2020 37

38. 21 October 2020 38

39. 1. Secretions in the trachea.
2. Suspected aspiration of gastric or upper airway
secretions.
3. Increase in peak airway pressures when on
ventilator.
4. Increase in respirations or sustained cough or
both.
5. Gradual or sudden decrease in ABG .
6. Sudden onset of respiratory distress when
airway patency is questioned .
Indications For Suctioning.
21 October 2020 39

40. Surgical Complications.
21 October 2020 40

41. Complications of Tracheostomy !!
• Stoma:-
• Stoma site infection.
• Stomal hemorrhage.
• Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous
fistula
21 October 2020 41

42. Complications of Tracheostomy !!
• Granuloma.
• Tracheoesophageal fistula:-
fewer than 1% of patients as a result of pressure necrosis of the tracheal and esophageal
mucosa from the tube cuff .
risk factors: high cuff pressures, presence of a nasogastric tube, excessive tube
movement, and underlying diabetes mellitus
21 October 2020 42

43. 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.
• **Goldenberg D, Ari EG, Golz A, et al: Tracheotomy complications: a retrospective study of 1130 cases. Otolaryngol Head Neck
Surg 123:495, 2000 .
21 October 2020 43

44. TRACHEOSTOMY TUBE CARE
• Securing tracheostomy around patient’s neck.
21 October 2020 44

45. TRACHEOSTOMY TUBE CARE.
• Tube changes:
1. Indications: soiled, cuff rupture.
2. Complications: insertion into a false
passage bleeding, and patient
discomfort.
3. Avoid within 1st week.
4. First tube change by surgeon.
5. Difficult cases (obese, short and thick
neck), be prepared for endotracheal
intubation.21 October 2020 45

46. 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.
21 October 2020 46

47. TRACHEOSTOMY TUBE CARE.
• Humidification of the inspired gas is a standard
of care for tracheostomized patients.
21 October 2020 47
Thermovent

48. SPEECH !!
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49. SPEECH.
21 October 2020 49
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 & out the mouth upon expiration, enabling
the patient to vocalize.

50. 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.
21 October 2020 50Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

51. 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 October 2020 51

52. 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.
21 October 2020 52

53. 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.
21 October 2020 53

54. References.
1. Bailey & Love’s Short Practise of surgery 25th edition.
2. ACS Surgery: Principles & Practice, 2007 Edition
3. Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
4. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005.
5. Goldenberg D, et al Tracheotomy: changing indications and a
review of 1,130 cases, J Otolaryngol 31:211–215, 2002
6. (Minsley and Wren 1996), **(Kumar and Clark, 1994 p 631).
7. Gysin C, Dugluerov P, Guyot JP, et al: Percutaneous versus
surgical tracheostomy: a double blind randomized trial. Ann Surg
230:708, 1999
21 October 2020 54

55. 8. Goldenberg D, Ari EG, Golz A, et al: Tracheotomy
complications: a retrospective study of 1130 cases. Otolaryngol
Head Neck Surg 123:495, 2000 .
9. Massick DD, Yao S, Powell DM, et al: Bedside tracheostomy in
the intensive care unit: a prospective randomized trial
comparing open surgical tracheostomy with endoscopically
guided percutaneous dilational tracheotomy. Laryngoscope
111:494, 2001.
10. Pryor JP, Reilly M, Shapiro MB: Surgical airway management in
the intensive care unit. Crit Care Clin 16:473, 2000 .
11. Walts PA, Murth C, DeCamp MM: Techniques of surgical
tracheostomy. Clin Chest Med 24:413, 2003 .
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