The document discusses tracheostomy, including: 1. Tracheostomy is a surgical procedure that creates an opening in the trachea to serve as an airway. 2. Complications include tracheal stenosis, swallowing difficulty, voice changes, breathing issues, and hemorrhage. 3. Post-op care involves having a spare tube available, communicating with patients and caregivers, and determining decannulation based on cough strength. The document provides information on the history, indications, anatomy, procedures, tube types, and complications of tracheostomy.

1. Tracheostomy
DR O. A. OPADOTUN
BABCOCK UNIVERSITY TEACHING
HOSPITAL

2. The following are emergency airways
except
 A. Cricothyroidotomy
 B. Tracheostomy
 C. Oropharyngeal airway
 D. Nasopharyngeal airway
 E. AMBU bag

3. Complications of Tracheostomy
 A. Tracheal Stenosis
 B. Swallowing difficulty
 C. Permanent voice change
 D. Breathing difficulty
 E. Hemorrhage

4. Concerning post op care
 A. always have a spare tube by the bedside
 B. Its important to carry patients & caregivers along
 C. Ability to cough determines time to decannulate
 D. No need to suction patient
 E. Tracheostomy Tract is formed in 7days

5. Concerning Tracheostomy
 A. Tracheostomy tube is usually changed monthly
 B. Patient with tracheostomy tube cannot speak
 C. Tracheostomy can be permanent or temporary
 D. It can be used to relieve upper airway obstruction

6. Outline
 Definition
 Historical background
 Indication
 Anatomy of the trachea
 Alternatives to tracheostomy
 Types of Tracheostomy
 Procedure
 Part & types of tracheostomy tube
 Post op care
 Complication
 summary

7. 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.

8. 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.
 In the early 20th century, tracheostomy was made much safer, technical
aspects of the procedure were refined and described in detail by the
famous surgeon Chevalier Jackson.

9. Major indications
 Upper airway obstruction
 Tracheobronchial toileting
 Adjunct to head and neck surgery( to allow for easy
manipulation & patient turning
 Respiratory Insufficiency

10. General indications

11. Benefits of tracheostomy
 Improved oral hygiene for the intubated patient
 Decreased requirement for sedation in the intubated patient
 Oral movement for communication, nutrition and hydration (with
manipulation)
 Reduction in damage to the larynx, mouth or nose from prolonged
endotracheal intubation
 Vocalisation (with manipulation)
 Improved patient comfort

12. Tracheal anatomy
 It is D-shaped, with incomplete
cartilaginous rings anteriorly and laterally,
and a straight membranous wall
posteriorly
 starts from the inferior part of the larynx
(cricoid cartilage) in the neck, opposite
the 6th cervical vertebra, to the
intervertebral disc between T4-5
vertebrae in the thorax
 The thyroid isthmus is located between
second and third tracheal rings,

13.  the innominate artery most often crosses the
anterior trachea in an oblique fashion distal or
inferior to the third tracheal ring
 the aortic arch crosses above the carina.
 The coronal and sagittal tracheal dimensions vary in
males and females.
 The upper limits of the coronal and sagittal
diameters in men are 25 and 27 mm, respectively.
 In women, they are 21 and 23 mm, respectively.

14. Innervation And Blood Supply
 The recurrent laryngeal nerves lie in close
proximity to the trachea within the
tracheoesophageal groove.
 The blood supply to the cervical trachea
enters posteriolaterally from the inferior
thyroid artery
 ultrasound probe in the intended area of
dissection to confirm the absence of any
significant vasculature

15. Alternatives to Tracheosotomy
 Endoluminal Intubation
 Emergent cricothyrotomy
 should be considered only when the patient is in a very difficult life threatening
situation and thus the need to use extreme measures
 No conscientious physician should perform any procedure known (even
colloquially) as a slash
 Percutaneous transtracheal jet ventilation (PTJV)

16. Emergent cricothyrotomy
 Advantage:
 cricothyroid membrane is superficial and readily accessible, with
minimal dissection required.
 Disadvantage:
 cricothyroid membrane is small and adjacent structures (eg,
conus elasticus, cricothyroid muscles, central cricothyroid
arteries) are jeopardized;
 the cannula may not fit.
 Damage to the cricoid cartilage from the scalpel or pressure
necrosis leads to perichondritis and possibly stenosis
 overall complication rate:
 32%, which is 5 times that of tracheostomy under controlled
circumstances

17. Urgent tracheostomy
 Patients in acute respiratory distress may need acute surgical intervention
 Urgent tracheostomy can be performed in a controlled environment (eg,
operating room) with the patient under local anaesthesia.

18. Indications for Urgent Tracheostomy
 Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
 Upper airway foreign body that cannot be dislodged with Heimlich and basic
cardiac life support manoeuvres
 Supraglottic or glottic pathologic condition (eg, infection, neoplasm,
bilateral vocal cord paralysis)
 Neck trauma that results in severe injury to the thyroid or cricoid cartilages,
hyoid bone, or great vessels
 Subcutaneous emphysema

19.  Facial fractures that may lead to upper airway
obstruction (e.g, comminuted fractures of the mid
face and mandible)
 Upper airway edema from trauma, burns, infection,
or anaphylaxis
 Prophylaxis (as in preparation for extensive head
and neck procedures and the convalescent period)
 Severe sleep apnea not amendable to continuous
positive airway pressure devices or other less
invasive surgery

20. Elective tracheostomy
 Most are performed in patients who are already intubated and who are
undergoing a tracheostomy for prolonged intubation
 patients undergoing extensive head and neck procedures may receive a
tracheostomy during the operative procedure to facilitate airway control
during convalescence
 A smaller population of patients with chronic pulmonary problems (eg,
sleep apnea) elects to undergo tracheostomy

21. Best practice protocol
 Initial decision for tracheostomy by attending physician
 Attending physician to discuss procedure with patient and/or family
 Informed consent by Surgeon (risks, benefits, and alternatives)
 Pre op: CBC, Coagulation profile, Group and screen
 NPO after midnight

22. Tracheostomy Techniques
 Percutaneous
 Open

23. Open tracheostomy: Patient positioning
• Best performed in an operating room with adequate
equipment and assistance
• Position the unconscious or anesthetized patient
supine with the neck extended and the shoulders
elevated on a small roll.
• can also be done at the bedside in the intensive care
unit
• Overextension of the neck should be avoided
because it further narrows the airway
• overextension can lead to placement of the
tracheostomy too low (toward the carina) and too
close to the innominate artery (especially in the very
mobile paediatric trachea).

24. Open tracheostomy: Skin Incision
 Palpate the landmarks (eg, thyroid notch, sternal
notch, cricoid cartilage) and mark them with a pen
 Apply anaesthesia
 3-cm vertical skin incision initiated below the inferior
cricoid cartilage.
 Many advocate the horizontal skin incision, which is
made along relaxed skin tension lines and gives better
cosmesis but a horizontal incision may trap more
secretions.
 Subcutaneous fat may be removed with
electrocautery to aid in exposure and to prevent later
fat necrosis
 Meticulous hemostasis throughout the procedure

25. Open tracheostomy: Dissection
 Dissection proceeds through the platysma until the
midline raphe between the strap muscles is identified
 Palpate the inferior limit of the field to assess the
proximity of the innominate artery
 Cauterize or ligate aberrant anterior jugular veins
and smaller vessels.
 Midline dissection is essential for hemostasis and
avoidance of paratracheal structures
 The strap muscles are separated and retracted
laterally, exposing the pretracheal fascia and the
thyroid isthmus.

26.  The lateral retraction also serves to stabilize the trachea in the midline
 the thyroid isthmus, typically lies anteriorly over the first 2-3 tracheal
rings
 A retracted isthmus may be irritated if it rubs against the tracheostomy
tube in the postoperative period, causing bleeding
 Thus although it may be retracted out of the field, it must often be divided
in some cases.
 Elevate the isthmus off the trachea with a hemostat and divide it
 Division is performed sharply or with electrocautery and suture ligature
 Dry the field

27. Open tracheostomy: trachea incision
 Clean the remaining fascia off of the anterior
face of the trachea
 warn the anaesthesiologist of impending
airway entry
 Complete preparations for Deflate
endotracheal tube balloon
 Injection of topical anaesthesia can stem the
cough reflex of an awake patient
 Make tracheal opening
 Simple horizontal (bedside)
 T-Shape
 U-shape
 H-shape

28.  silk stay suture can be placed through the tracheal wall
on each side and taped to the neck skin on either side.
 Marking the tape that holds these sutures to the skin
with "Do not change or remove" is prudent
 These sutures are removed after the first tracheostomy
tube change 5-7 days postoperatively

29. Open tracheostomy: Trachea entry
 Suction secretions and blood
 Slowly withdraw endotracheal tube
 Secure the cricoid with a hook and elevate it
superiorly to facilitate control of the tracheal
entry
 Replace lateral retractors into trachea
 Enter trachea
 airway is confirmed intact based on carbon
dioxide return and bilateral breath sounds
 secure the tracheostomy tube to the skin with
4-0 permanent sutures.

30.  Attach a tracheostomy collar with the head flexed to avoid
unnecessary slack in the collar
 To avoid the risk of subcutaneous emphysema and subsequent
pneumomediastinum, the skin is not closed
 Place a sponge soaked with iodine or petrolatum gauze between
the skin and the flange for 24 hours to deflect infection and
anxiety about minor oozing of the skin edge.
 https://img.medscape.com/pi/meds/ckb/68/27068.mp4

31. Parts of tracheostomy tube

32. Tracheostomy Tube size
 Ideal tube size
 maximizes the functional internal diameter
while limiting the outer diameter to
approximately three quarters of the internal
diameter of the trachea
 reduces airway resistance and the work of
breathing while facilitating airflow around the
tube
 Most women no. 6 Shiley cuffed tracheostomy
tube
 Most men no. 8 Shiley cuffed tracheostomy

33.  Ideally, the end of the tracheostomy tube should be 2-3 cm from
the carina to avoid the potential for the tube to enter the
mainstem bronchus with neck flexion
 A tube that is too short abuts the posterior tracheal wall, causing
obstruction and ulceration.
 A tube that is too long curves forward and erodes the anterior
tracheal wall, which can be perilously close to the innominate
artery.

34. Tracheostomy Tube types
1. single-cannula tubes:
a. Uncuffed (A)
b. cuffed (B):
2. Double-cannula
• Removable inner tubes
• fenestrated and non
fenestrated inner cannulae
• Obturator for insertion

36. Cuffed Tracheostomy tubes
Allow positive pressure ventilation and prevent aspiration
Indications :
 Risk of aspiration
 Newly formed stoma in adult
 Positive-pressure ventilation
 Bleeding (eg, in a multiple-trauma patient)
 Unstable condition

37. Contraindications :
 Child younger than 12 years
 Significant risk of tracheal tissue damage from cuff
irritates the trachea and provokes and trap secretions,
even when deflated
Use only when necessary
Even modern low-pressure cuffs should be deflated
regularly (four times a day) to prevent pressure necrosis
cuff pressures should be checked regularly in patients on
mechanical ventilation

38. Uncuffed tracheostomy tubes
 Indications :
 Stable stoma
 Paediatric and neonatal patients
 Upper-airway obstruction due to tumours or
neuromuscular disorders causing vocal cord palsy
 Contraindications:
 Dependent on positive-pressure ventilation
 Significant risk of aspiration
 Newly formed tracheostomy

39. Fenestrated Tracheosotomy tubes
 permit airflow, which, in addition to air leaking
around the tube, allows the patient to phonate and
cough more effectively
 single or multiple fenestrations on the superior
curvature of the shaft
 Both Outer and /or inner
 Cuffed fenestrated tubes are particularly used in
patients who are being weaned off their
tracheostomy when a period of cuff inflation and
deflation is required
Fenestrated cuffed and
uncuffed tubes.

40.  Uncuffed fenestrated tubes are used in patients who no
longer depend on a cuffed tube.
 contraindicated in patients who require positive-
pressure ventilation, as some of the air will leak out of
the fenestrations.
 Standard fenestrations are rarely in the right place; if flush
with the tracheal wall, they instead cause irritation and
granulation and should not be used.

41. Flange or neck plate
 attached to the proximal end of the tube prevents
the tube from descending into the trachea
 allows for securing the tube with tapes, ties, or
sutures
 tube size and type is often imprinted on the neck
plate for easy identification
 Certain tubes have a swivel neck plate that rotates
on two planes and facilitates dressing and wound
care
 These also allow distal tracheal obstructions to be
bypassed through a conventional tracheostomy
Adult swivel, neonatal, and
pediatric neck flanges.

42. Adjustable-neck-flange
tubes
 Certain tubes have an adjustable flange that
allows variable tube length and may be
useful in patients with larger necks.
 These also allow distal tracheal obstructions
to be bypassed through a conventional
tracheostomy
Bivona and Portex adjustable-
neck-flange tubes.

43. Post Op care
 Manage in intensive care for first 24 hours
 Keep spare tube by patients bedside, preferably have a
tracheostomy tray
 Surgical review POD1 + follow up instructions
 First trach change + suture removal POD7
 Observe in hospital for stoma maturity then discharge

44.  If the patient is stable for 24 - 48 hours with the
trach cuff deflated or with a cuffless tube in
place, the patient may be discharged at the
attending physicians discretion.
 For awake patients who are tolerating a cuffless
trach or a deflated trach cuff, a Passey-Muir
(speaking) valve may be ordered by the
attending physician or pulmonologist

45.  A qualified respiratory therapist can apply the
speaking valve and instruct the patient in it's use.
 When necessary, speech therapy should be consulted
to help the patient phonate correctly with the speaking
valve

49. Follow up
 Tracheostomy risks include blocking of the tube by debris, and dislocation of
the tracheostomy cannula
 use of a multidisciplinary team and a tracheostomy-care protocol can improve
outcomes
 Role of ICU nurses, ENT surgeons and intensivist
 Dependent on available technology, teaching activities, and personnel involved
in the decision to remove the tracheostomy
 Cleaning the inner cannula might prevent infection, and although the inner
cannula increases the imposed work of breathing, it helps keep a clear artificial
airway.
 An important part of follow-up is the decision on when to decannulate

50. Long-Term Tracheostomy Care
 Patient and caregiver education/ training
 basic airway anatomy
 medical justification for the tracheostomy,
 tube description and operation,
 Appropriate tube selection
 signs and symptoms of respiratory and upper-airway distress,
 Airway management/ventilation
 signs and symptoms of aspiration,
 suctioning technique,
 tracheostomy tube-cleaning and maintenance,

51.  stoma-site assessment and cleaning,
 cardiopulmonary resuscitation,
 emergency decannulation and reinsertion procedures,
 tube-change procedure,
 Equipment supply, use and ordering procedures,
 Humidification needs
 Speech
 financial issues.
 scheduled follow-up plan with the attending physician

52. Decannulation
 Removal of tracheostomy cannula
 most important criteria regarding the decision to decannulate are
ability to cough, frequency of airway suctioning, and the patient’s
condition
 If it is felt that trach is no longer needed and will not be needed in
the foreseeable future, a trial of breathing with the trach cuff
deflated will be undertaken.
 If this is tolerated, the current trach tube may remain in place with
the cuff deflated, or change the trach to a cuffless smaller tube
(#6 Shiley).

53.  The trach tube may then be plugged with the plug (with
a red button) provided with the trach tube.
 If the patient is stable for 24 - 48 h with the trach
plugged, remove the trach, and the stoma will be
allowed to close.
 If upper airway pathology such as tracheal stenosis is
suspected, the pulmonologist will perform a flexible
bronchoscopy prior to decannulation.
 Once the tube has been removed, occlude stoma with a
tight dressing
 Change dressing when airleak becomes apparent to
prevent tracheocutaneous fistula

58. Late complications
 Tracheal Stenosis
 Swallowing difficulty
 Permanent voice change
 Tracheocutaneous fistula
 Scarring of the neck
 Decannulation problem
 Disfiguring Scar

59. Summary
 Tracheostomy is an operative procedure that creates a surgical
airway in the cervical trachea.
 It is a viable alternative to prolonged endotracheal intubation,
any patient requiring intubation for >5-7days should be on
tracheostomy
 It has several benefits to the patient, physician and caregiver
 It could be emergent or elective
 It could be done through a percutaneous or open approach
 Post operative and long term care are important, so patient
and care giver should be adequately educated and carried
along

60. Refrences
 Cheung, Nora H, and Lena M Napolitano. "Tracheostomy: Epidemiology, Indications, Timing,
Technique, and Outcomes." Respiratory Care 59.6 (2014): 895-919.Web. 18 June. 2018.
 Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing
percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000 Nov. 118(5):1412-8.
 Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous
tracheostomy. Laryngoscope. 2007 Mar. 117(3):447-54.
 Lewarski JS. Long-term care of the patient with a tracheostomy. Respiratory care. 2005 Apr
1;50(4):534-7.
 MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and
discontinuing ventilatory support: a collective task force facilitated by the American College of
Chest Physicians; the American Association for Respiratory Care; and the American College of
Critical Care Medicine. Chest. 2001 Dec. 120(6 Suppl):375S-95S.

61.  Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B,
Dawson C, et al. Clinical consensus statement: tracheostomy
care. Otolaryngol Head Neck Surg. 2013 Jan. 148(1):6-20. [
 Tobin AE. Tracheostomy teams - filling a void. Crit Care Resusc. 2009
Mar. 11(1):3-4.
 Young PJ, Pakeerathan S, Blunt MC, Subramanya S. A low-volume,
low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit
Care Med. 2006 Mar. 34(3):632-9.
 Joshua Tackie Ofoli. Tracheostomy, indications, procedure and care
ppt at 2018 national update

62. THANK YOU