All you need to know about Tracheostomy including Indications, steps of tracheostomy and post operative care with self explanatory pictures

2. Dr Venkatesh Karthikeyan
CRRI
VMCH&RI
Mail : 4852012@gmail.com

3.  It is a procedure where
 an opening is made in the anterior wall of
the trachea
 And a channel is constructed between the
trachea and skin surface of neck by inserting
a tracheostomy tube

4. Indications
 Upper Airway obstructions
 Pulmonary toilet and airway protection
 Assisted Ventilation

5. Upper airway obstruction
 Causes may be intra – laryngeal or extra
– laryngeal
 Congenital
 Traumatic
 Infections
 Tumors
 Neurogenic

6. Congenital
 Pierre Robin Syndrome
 Subglottic stenosis
 Laryngeal web
 Laryngomalacia

7. Traumatic
 External trauma – maxillofacial injuries,
neck contusion, laryngeal fractures
 Foreign bodies
 Burns
 Instrumentation
 Prolonged intubation

8. Infections
 Acute epiglottitis
 ALTB
 Retropharygeal abscess
 Laryngeal diptheria

9. Tumors
 Laryngeal papillomatosis
 Hemangiomas
 Lymphangiomas
 Carcinoma
 Others

10. Neurogenic
 Bilateral vocal cord paralysis

11. Pulmonary toilet and airway
protection
 Head injury
 Drug intoxication
 Encephalitis
 Burns
 Shock lung
 Chest injury
 Cervical cord degeneration

12. Assisted Ventilation
 Aspiration
 Maxillofacial injuries
 Laryngeal cleft
 Neurogenic
 Tracheo – Esophageal fistula

13.  Flail chest
 Pneumothorax
 Pneumomediastinum
 Respiratory Distress syndrome
 Poliomyelitis
 Polyneuritis

14. Functions of Tracheostomy
 Relieves upper airway obstruction
 Decreases dead space
 Facilitates cleaning of Tracheobronchial
tree
 Protects against aspiration
 Reduces resistance of airflow
 Increases total compliance and alveolar
ventilation
 Helps in Intermittent positive pressure
ventilation
 Helps in induction of anaesthesia

15. Types of Tracheostomy
 According to Purpose
 Temporary
 Permanent
 According to timing of surgery
 Elective
 Emergency
 According to site of Stoma
 High (1st ring)
 Mid (2-4th rings)
 Low (below 4th ring)

16. Procedure

17.  Anesthesia
 General
 Local

18. Position
 Supine
 Pillow under the shoulders to allow
maximum extension of neck
 Head and neck must be held in midline
○ Symphysis menti and suprasternal notch must
be in one line

19. Incision
 5 cm long
 Two finger breath above the sternal notch

20. Horizontal incision
 In Elective procedures
 Cosmetically better scar

21. Vertical Incision
 In emergencies
 Easy access
 Minimal bleeding

23. Incision is deepened to expose
the strap muscles

30.  1% xylocaine is infiltrated into trachea to
prevent excessive irritation and cough
 This also ensures that the needle is
inside the trachea and we will be able to
aspirate air

31. First tracheal ring is always identified and avoided

32. An inferiorly based flap of tracheal ring
cartilage is made and sutured to the stomal
skin

41.  Metallic tube is preferred atleast for
initial 4-5 days till a permanent tract has
been formed
 Cuffed Portex tracheostomy tube can be
used
 Prevents aspiration of blood
 Used for post operative ventilation
*Cuff should be deflated periodically

42. Tracheostomy in Infants and
Children
 Trachea is soft and compressible
 Difficult identification
 Can easily be displaced laterally
 Risk of injury to nearby structures

43.  Perform tracheostomy with an
endotracheal tube or bronchoscope in
place

44.  Rose position Mediastinal structures
like apical pleura protrude into the neck
Injury  Pneumothorax

45.  Tracheotomy itself is suffice
 Suture placed on either side of the
incision on the trachea
 Tracheal lumen is narrow
 Deep incision
 Tracheo – esophageal fistula

46. Selection of Tracheostomy tube
 Large tube – Necrosis of tracheal rings
 Long tube – Impinges upon carina or
enter right bronchus
 Post of X ray
 Position of tube
 Rule out pneumothorax

47. Post op Management
 Cleaning and changing of inner tube
 Tracheobronchial toilet
 Humidification and prevention of crust
formation
 Nursing care to avoid infection
 Nasogastric feeding maybe needed
initially
 Physiotherapy

48. Decanulation
 By reduction of size of tube
 Closing the tube with a spigot

49. Complications
 Immediate
 Intermediate
 Late

50. Immediate Complications
 Primary hemorrhage
 Injury to blood vessels, jugular veins,
carotid artery
 Injury to RLN
 Pneumothorax / Pneumomediastinum
 Apnea due to sudden release of CO2
 Damage to cricoid and trachea
 Cardiac arrest
 Collapse of lung

51. Intermediate Complications
 False passage – Displacement of tube
 Crusting and Blocking of Inner tube
 Atelectasis and lung abscess
 Surgical emphysema
 Tracheo-oesophageal fistula
 Dysphagia
 Secondary infection

52. Late complications
 Hemorrhage
 Laryngo-tracheal stenosis
 Tracheo – cutaneous fistula
 Difficult decannulation
 Corrosion of tracheostomy tube
 Keloid formation over scar

53. Reference
 A Short Practice of Otorhinolaryngology
by Prof.K.K. Ramalingam
 Diseases of Ear, Nose and Throat by PL
Dhingra
 https://www.youtube.com/watch?v=77Wi
5Z3FOGk (Mayo Clinic)

54. Thank you