TRACHEOSTOMY is a surgical procedure to maintain a patent airway to the person who is in airway distress or electively in certain surgical procedures like oncological resections to maintain an adequate oxygenation to the patient by creating a stoma on the trachea

1. TRACHEOSTOMY
K. KRISHNA LOHITHA
Dept of ORAL &MAXILLOFACIAL SURGERY

2. CONTENTS
DEFINITION
SURGICAL ANATOMY OF TRACHEA
TYPES OF TRACHEOSTOMY
FUNCTIONS OF TRACHEOSTOMY
INDICATIONS
SURGICAL TECHNIQUES
TRACHEOSTOMY TUBES
POSTOPERATIVE CARE
COMPLICATIONS
REFERENCES

3. DEFINITION
• Tracheostomy is an opening in the anterior
wall of trachea and converted into a stoma on
the skin surface.
• The terms tracheostomy and tracheotomy
have been used interchangeably.
• The tracheotomy means opening the trachea,
which is a step of tracheostomy operation.

4. ANATOMY OF TRACHEA
• The trachea is a tubular structure, about 15 cm long in adults
• Extending from the cricoid cartilage(c6) to the bronchial bifurcation
at the level of sternal angle(T5)
• It has an outer diameter of 2.5 cm.
• It consists of 18 to 22 C-shaped cartilages joined by fibroelastic
tissue and closed posteriorly by the trachealis muscle.
• The anterolateral portion is made up of incomplete rings of cartilage,
and the posterior aspect by a flat muscular wall.
• As it passes downwards, it follows curvature of the spine, and courses
slightly backwards
• Becomes intrathoracic at 6th cartilagenous ring
• Near the tracheal bifurcation, it deviates slightly to right

7. In the neck, the trachea has the following relations.
Anterior:
1. Skin and subcutaneous tissue
2. Platysma
3. Superficial fascia(investing layer)
4. Anterior jugular vein, innominate artery
5. Strap muscles(sternothyroid , sternohyoid)
6. Pretracheal fascia enclosing thyroid and inferior thyroid veins
7. Isthmus of the thyroid gland covering the second and third
tracheal rings
In children, the left brachiocephalic vein extends into the neck and
then lies in front of the trachea.

8. Posterior:
(1). Oesophagus lies behind the cervical trachea, separating it
from the vertebral column and the prevertebral fascia.
(2). Recurrent laryngeal nerve in the tracheo-
oesophageal groove.
On either side:
(1) The corresponding lobe of the thyroid glands;
(2)The common carotid artery within the carotid
sheath.

10. VESSELS AND NERVES:
• ARTERIES
• The trachea is supplied by branches from the inferior thyroid
arteries.
• VEINS
• Superior and middle thyroid veins drain into IJV biaterally
• Inferior thyroid veins drain into left braciocephalic vein
• Lymphatics: pretracheal and prelaryngeal lymphnodes
• NERVES
• Parasymphathetic nerves (from the vagus through the recurrent
laryngeal nerve) are secretomotor to the mucous membrane, and
motor to the trachealis muscle.
• Sympathetic nerves (from the cervical ganglion) are
vasomotor.
.

12. FUNCTIONS OF TRACHEOSTOMY
1.Obstruction: bypass the obstruction in the upper airway
2.Ventilation:improves alveolar ventilation
dead space: decreases dead space by 30-50%
resistance: reduces resistance to airflow
3.Protection: cuffed tracheostomy tube protects tacheobronchial tree
agaimst aspiration of secretions and blood
secretions: pharyngeal secretions in case of bulbar paralysis and
coma
blood: bleeding from pharynx, larynx , maxillofacial injuries
packing: allows packing of pharynx and larynx to control bleeding
4. Suction
5. Intermittent positive pressure ventilation
6.anaesthesia: trismus & laryngopharyngeal growths
7. Enabling pt to swallow without reflex apnoea

13. INDICATIONS
1. Upper Respiratory Tract Obstruction.
Infection, Trauma, Neoplasm, foreign body, oedema, Bilateral
abductor paralysis, Congenital anomalies.
2. Retained secretions
Inability to cough, Painful cough, Aspiration of pharyngeal
secretions, paralysis and spasm of respiratory muscles
3. Respiratory insufficiency
Emphysema, bromchiectasis, chronic bronchitis
4. Prolonged Ventilation
5. Part of another procedure

14. TYPES OF TRACHEOSTOMY
A) Timings
• Emergent Tracheostomy (slash trach)
• Urgent (awake) Tracheostomy
• Elective Tracheostomy
• Temporary Tracheostomy
• Permanent Tracheostomy
B) Level and Site
1. High, 2. Mid and 3. Low Tracheostomy
C) SURGICAL TECHNIQUES
1. Cricothyroidotomy/Minitracheostomy
2. Open tracheostomy
3. Percutaneous dilatational tracheostomy
4. Translaryngeal tracheostomy

15. Emergent Tracheostomy- emergency airway distress is
accompanied with impending death. The complication rate of
emergency tracheostomy is as high as 21%. This emergent
situation is an ideal indication for cricothyrotomy.
Urgent Tracheostomy: This is done in the operation theater under
local anesthesia with minimal sedation. The patient has respiratory
distress, and needs immediate surgical intervention.
Elective Tracheostomy: routine planned surgery. It is
performed where all operative surgical facilities such as
endotracheal intubation, local and general anesthesia, are
available.
Therapeutic & Prophylactic:

16. • „„Temporary Tracheostomy:
tracheostomy is usually temporary, and is closed
when causative disease is cured.
• „Permanent Tracheostomy:
It is indicated in cases of bilateral abductor
paralysis and laryngeal stenosis. In cases of
laryngectomy and laryngopharyngectomy,
A tracheostome is created where lower tracheal
stump is stitched to the surface skin.

17. High Tracheostomy:
It is done at the level of first tracheal ring.
The high tracheostomy is generally avoided because of the
postoperative risk of perichondritis of the cricoid cartilage and
subglottic stenosis.
In cases of carcinoma larynx with stridor when total
laryngectomy would be done, high tracheostomy is indicated.
Mid Tracheostomy:
It is done through the second and third tracheal rings, and
needs either division of the thyroid isthmus or its retraction
upwards.
Low Tracheostomy:
It is done below the level of isthmus where trachea becomes
deep, and lies close to large vessels.

18. SURGICAL TECHNIQUES

19. Cricothyroidotomy/Minitracheostomy
In an emergency, rapid entry to the airway can be achieved through
the cricothyroid membrane.
Once cricothyroid has been breached the airway can be maintained
either with minitracheostomy tube(open cricothyrotomy) or a
large bore cannula.(needle cricothyrotomy)

20. INDICATIONS:
•Maxillofacial injuries
•Foreign body obstruction
•Emeses
•Clenched teeth
•Repeated failed intubation
•Cervical spine injuries
•Burns
•Smoke inhalation
CONTRAINDICATIONS
•Infants and children
•Inflammatin and malignancy of
larynx and surrounding area

21. PROCEDURE
Patient lies in supine
Clean the patients neck in a sterile fashion
The skin is infiltrated with local anaesthesia.
 anatomical landmarks is ascertained by palpation. The
laryngeal prominence is the most reliable landmark.llocate
cricothyroid membrane
Stabilise the trachea with left hand

22. Once the anatomy of the larynx is identified, the procedure can be
performed with 2
incisions:
1.Incision through the skin( In the emergency setting a
vertical incision is preferable, as it avoids injury to
the anterior jugular veins minimizing bleeding and
allows for some leeway in placement)
2-3 cm midline vertical skin incision
2. 1-2 cm transverse Incision through the cricothyroid membrane
Insert scalpel handle and rotate 90 degree or use a hemostat to open
airway
a tracheal hook is inserted under the thyroid cartilage. Gentle vertical
dilation is needed, enough to allow passage of a 6 mm or 7 mm tube,
but care should be taken to avoid damage to the inferior edge of thyroid
cartilage, thus reducing the risk of subglottic stenosis.

23. •This cricothyrotomy is reliable only for short duration
•In orfer to maintain patency of airway and to avoid
complications of cricothyrotomy, tracheostomy should be
considered within 24-48 hours
Complications
•Perichondritis
•Subglottic edema
•Laryngeal stenosis

25. CANNULA, SYRINGE AND ENDOTRACHEAL
TUBE ADAPTOR ASSEMBLY.

26. MINITRACHEOSTOMY KIT.

27. OPEN TRACHEOSTOMY
•The procedure is most commonly performed under general
anesthesia in a previously intubated patient.
•Occasionally, when the patient presents in acute distress, the
procedure is performed in the nonintubated patient under local
anesthesia.

28. PROCEDURE
•The patient is placed on the operating table
with a rolled towel or sheet under the shoulders to extend
The neck unless thepatient has documented or suspected cervical
spine injuries. In such cases, extension of the neck is
contraindicated because of the risk of spinal cord compression.
•Adults with airway obstruction may not be able to tolerate the
supine position, and tracheostomy may need to be performed
with the patient sitting up at 45 degrees.

29. Skin Incision:
• Lidocaine (Xylocaine) with 1:100,000 epinephrine is injected
into the skin and subcutaneous tissue to aid haemostasis.
• A vertical midline cervical incision that extends from cricoid
cartilage to just above the sternal notch is the most frequently
used skin incision.
• A transverse incision (5 cm above the sternal notch) has the
advantage of a cosmetically better scar.
• Sharp dissection is carried through the subcutaneous tissue.
• Platysma is dissected and suplatysmal plane entered, then
superficial facia is dissected
• The anterior jugular veins should be identified and retracted
laterally.

37. STRAP MUSCLES:
• The strap muscles are split in the midline
and retracted laterally.
THYROID ISTHUMUS:
• it is either displaced upwards or divided between the clamps
TRACHEA:
• After injecting few drops of 4% lignocaine to suppress
cough reflex trachea is incised with a vertical incision in the
region anywhere between second to fourth tracheal rings.
• The incision is then converted into a circular opening.
• Trachea may be fixed with a hook before the incision.

38. TRACHEAL HOOK( blunt or sharp):
blunt tracheal hook retracts the tracheal isthmus and expoes
trachea
While making incision in the tracheal wall, sharp hook is applied
to lower border of cricoid cartilage to stabilise trachea
TRACHEAL DILATOR:
Keeps the cut tracheal edges open . Its tip is blunt. Blades spread
outon approximating its rings. A curved artery forceps also serves
this purpose
TRACHEOSTOMY tube:
An appropriate size tracheostomy tube is selected and secured in
position

39. TRACHEOSTOMY IN INFANTS AND CHILDREN
Following precautions to be taken to avoid complications:
•Stay strictly in midline. Position without neck or head deviation.
Fix the larynx by putting a finger on either side of larynx
•Trachea is soft and compressible in infants. Surgeon tends to
displace the trachea and go deep or lateral to it. Tracheostomy id
done under general endotracheal anaesthesia
•Too much neck extension pulls thoracic structures into the neck.
The vulnerable structures are pleura, innominate artery, thymus.
The risk of making tracheostomy near suprasternal notch is higher

40. •Silk sutures placed in trachea on either side of midline. The
excision of circular piece of ant tracheal wall is never done
Traction sutures are inserted to reduce the possibility of creating
a false passage in the event that the tracheostomy tube becomes
displaced in the immediate postoperative period before a tract
has been formed
•Tracheal lumen is narrow
•Infolding of ant tracheal wall while inserting tube is avoided
•Tracheostomy tube of proper dimensions and materialshould be
selected
•Post operative chest x ray and neck ascertains the position of
tracheostomy tube

41. PERCUTANEOUS DILATATIONAL
TRACHEOSTOMY (PDT)
PDT involves the placement of a tracheostomy tube without direct
visualization of the trachea.
The general consensus is that PDT should only be performed on
intubated patients.
It is considered to be a minimally invasive procedure that can be
performed at the bedside in monitored settings. Bronchoscopic
guidance is considered the standard of care.
PREOPERATIVE CRITERIA
•This minimally invasive, bedside procedure is
•performed only on intubated adult patients with
long neck, admitted in ICU
•Ability of patient to hyper extend the neck
•Easy reintubation in case of accidental extubation

42. CONTRAINDICATIONS:
Absolute
need for emergency airway access
Relative
children younger than 12 years of age
h/o difficult intubation
anatomical
cervical spine injuries,abnormality of trachea and larynx
short and thick neck
local tyracheostomy site problems
visible pulsating vessels, active infection, goitre
Hematological:
platelet count:< 40,000/mm3
BT time:>10 mins
PT/PTT:>1.5 times of control

43. PROCEDURE:
•The patient is positioned and draped as for standard, open
tracheostomy. A skin incision is made and the pretracheal tissue
cleared with minimal blunt dissection.
•The endotracheal tube is withdrawn until the cuff is just at the
level of the glottis.
•The endoscopist can place the tip of the bronchoscope such that
the light from its tip is visible through the surgical wound, thus
highlighting the target area.
• The operator then enters the tracheal lumen below the second
tracheal ring with a needle introducer.
•A guide wire is then inserted through the needle .
•The track extending from the skin to the tracheal
lumen is then serially dilated over a guide
wire.(CIAGLIA METHOD)

44. •A tracheostomy tube is then introduced under direct
bronchoscopic view over the dilator.
•Proper placement is then confirmed by viewing the
tracheobronchial tree through the tracheostomy tube, and the
tube is secured into place with sutures and ties.

45. TECHNIQUES OF PERCUTANEOUS
DILATATIONAL TRACEOSTOMY
Ciaglia method
Griggs method
Blue rhino dilator
Perc twist

46. BLUE RHINO DILATOR
FANTONii
PERC TWIST

47. TRANSLARYNGEAL TRACHEOSTOMY
•In children and young adults, percutaneous tracheostomy is not
advised. The increased elasticity of the tracheal cartilages means
that they are easily compressed and this can lead to temporary loss
of oxygenation as well as trauma to the posterior tracheal wall.
•To counteract these problems a technique of translaryngeal
tracheostomy has been described
FANTONi

48. TRACHEOSTOMY TUBES
The purpose of a tracheostomy tube is
1.to provide an airway,
2.to provide for the possibility of artificial positive pressure
ventilation if needed,
3.to seal the trachea to reduce aspiration of material from above
the tube or in the hypopharynx,
4. to provide a means of suctioning the
tracheobronchial tree.

49. PARTS OF TRACHEOSTOMY TUBE

50. TRACHEOSTOMY TUBES CAN BE
CLASSIFIED INTO FOUR MAJORGROUPS:
1. dual-cannula, cuffed;
2. dual-cannula, uncuffed;
3. single-cannula, cuffed;
4. single-cannula, uncuffed.
Certain types of tubes with unique features are metal
tracheostomy tubes, fenestrated tubes, and extra-length
tubes.
Accessories- Speaking valve, Occlusion cap.

52. PRINCIPLES TO CONSIDER IN TUBE
SELECTION
•Position and shape of the tip of the tube
•Tube curvature
•Tube length
•Outer diameter
•Fenestration position
•Tube material
•Healing of the stoma by regular wound care
•Be comfortable and do not cause neck pain when moving
•If possible, it should permit speech and esthetically pleasing

53. CHOOSING OF TRACHEOSTOMY TUBE
Cuffed versus uncuffed tube:
• The first decision when choosing the type of tracheotomy
tube is whether or not the patient requires a cuffed tube.
• Patients who require PPV require a cuffed tube
• If the patient is ventilator dependent, a tube with a low-pressure
cuff would minimize pressure against the tracheal wall.( 15-
25cm H2O / 10-18 mm hg)

54. Dual versus single cannula tracheostomy
tube:
• The primary advantage of a dual-cannula tube is that the inner
cannula can be remov ed, inspected and cleaned or replaced if
necessary. Single-cannula tubes do not have
this feature.
• If other factors (such as the desire to speak, ventilator
dependency, or altered anatomy) are considered, a single-cannula
tracheostomy tube may be the better choice.

55. CHOOSING OPTIMAL TUBE SIZE
The appropriate size and type of tube for each
patient are determined by the goal of the care plan,
which takes the following factors into
consideration: need for
positive-pressure ventilation, phonation,
secretions,amount and
hemodynamic
viscosity of
stability, airway anatomy,
and coexisting medical disorders.

56. SIZE OF TRACHEOSTOMY TUBE AND THE
AGE OF PATIENT
Age group preterm
neonates 1–2 years
3–6 years
6–12 years
12–14 years
Adults
Tracheostomy tube size lumen (mm)
2.5–3.0
3.5–4
4.5–5
5.5–6
7
8–9
(Roughly calculated with the following formula in
Children:
Size (number) of tube = (Age/4) + 4. It indicates internal
diameter in mm.)

57. POSTOPERATIVE CARE
• Watch for bleeding and displacement, and
blocking of tube.
• „Paper pad and a pencil for patient’s
cannotcommunication as these patients
speak.
• Regular suction (hourly or half-hourly)
depending on the amount of secretion for their
removal.
• Properhumidification that prevents crusting.

58. • Tracheostomy tube: Inner cannula is removed, and
cleaned regularly for the first 3 days to prevent
respiratory distress.
• Outer tube is changed daily after 3–4 days of
tracheostomy when a track is formed that facilitates
easy tube placement.
• „Periodical deflation of cuffed tube prevents
pressure necrosis and dilatation of trachea.

59. CARE OF THE TRACHEOSTOMY TUBE
CUFF
Proper inflation of the cuff can ensure an adequate
delivery of tidal volume and prevent loss of air around
the cuff, thus preventing hypoxemia.
Inadequate cuff inflation has also been implicated in the
development of ventilator- associated pneumonia.
Alternatively, hyperinflation of the cuff can result in
ischemia of the trachea, which can lead to tracheal
necrosis, tracheomalacia, and tracheal stenosis.

60. CHANGING THE TRACHEOSTOMY TUBE
Indications for changing a tracheostomy tube
Elective:
• Facilitate weaning/speech production
• To increase patient comfort
• To allow non-routine cleaning and dressing of a tracheostomy wound
• To allow treatment of granulation tissue at stoma site and/or
fenestration
Emergency:
• Blocked tube
• Misplaced or displaced tube
• Cuff failure Faulty tube
• Resuscitation

61. CARE OF THE STOMA
• A healthy stoma should be clean and dry with pink
edges, though in the early postoperative period it is
normal to see dried blood around the stoma.
• Any redness, swelling, or pus is abnormal.
• A small amount of blood should be expected with
each tracheostomy tube change especially when a
cuffed tube is inserted or removed.
• The constant exposure of the stoma to
secretions can be very irritating to the skin so the
stoma must be cleansed regularly and kept dry.

62. KEY POINTS OF A TRACHEOSTOMY
DRESSING CHANGE ARE:
1. Remove old dressing and tapes.
2. Clean the stoma and surrounding area with saline
and gauze.
3. Dry the peri-stoma area.
4. Apply keyhole dressing around the stoma/under
flange of tracheostomy tube.
5. Apply transparent film dressing if required.
6. Inspect dressing frequently.
7. Change dressing when exudate visible

64. SUCTIONING

65. SUCTIONING
Frequency of suctioning
Size of suction catheter
Application of suction
Oxygenation
Depth of suctioning
humidification

66. FREQUENCY OF SUCTIONING
It is commonly held that suctioning should be done only as
needed,
In order to prevent obstruction of the tube and the accumulation of
secretions.
In the early postoperative period the patient will require frequent
suction to clear secretions.
This need will gradually settle as the trachea becomes accustomed
to the presence of the tracheostomy tube and the patient learns to
clear the secretions by coughing

67. SIZE OF SUCTION CATHETER.
The effectiveness of the catheter is directly related to its size, with
larger catheters being more effective.
The catheter should not be more than half the internal diameter of
the tracheostomy tube. This allows space around the outside of the
suction catheter for air to pass to the lungs during suctioning
(Size of tracheostomy tube divided by 2) x3
Eg. 8/2=4, 4x3=12 French gauge.

68. APPLICATION OF SUCTION
When suction is applied, secretions as well as oxygen are removed
from the tracheobronchial tree.
The application of suction using high negative pressure for a
prolonged period of time could result in trauma to the trachea in
addition to hypoxemia and cardiac arrhythmias.
It is recommended that suction be applied for less than 12
seconds, only upon withdrawal of the catheter, and with a suction
pressure of less than –80 to –120 mm Hg.

69. Oxygenation.
Oxygenation is part of the suctioning procedure and is
used to avoid hypoxia and its sequelae. Oxygenation
can be accomplished prior to, during, and after the
procedure even though it is usually referred to as
preoxygenation.

70. DEPTH OF SUCTIONING
Shallow suctioning is placing the tip of the suction catheter no
further than the depth of the airway, and deep suctioning is
anything beyond that point.
Numerous studies have recommended introducing the suction
catheter to the level of the carina, and then withdrawing 1–2 cm
before applying suction.
However, in patients with large amounts of secretions, deep
suctioning may be necessary.

71. HUMIDIFICATION
•mucous membranes often require moisture added because, the
tracheostomy tube bypasses the airway
•Humidification can be provided by a tracheostomy collar or
atomised saline
•Lack of adequate humidification can cause the trachea to
squamous metaplasia, dessication of tracheal mucosa, impaired
ciliary function

72. THE PROPERTIES OF AN IDEAL HUMIDIFIER
• Provision of adequate levels of
humidification
• Maintenance of body temperature
• Safety
• Lack of microbiological risk to the patient
• Suitable physical properties
• Convenience
• Economy

73. COLD-WATER
HUMIDIFICATION
HEATED WATER
HUMIDIFICATION

74. HEAT AND
MOISTURE
EXCHANGER TRACHEAL BIB

75. COMPLICATIONS
The complications of tracheostomy are categorised
under
1) Immediate complications
2) Intermediate complications
3) Late complications

76. IMMEDIATE COMPLICATIONS
1.Anaesthetic complications
2.Haemorrhage
3. Apnea
4. Air embolism
5. Pneumothorax
6.Tracheoesophageal fistula
7. False passage
8. Aspiration of blood
9. Cardiac arrest
10. Local damage: cricoid cartilage
RLN

77. INTERMEDIATE COMPLICATIONS
•Bleeding: reactionary and secondary
•Displacement of tube
•Obstruction of tube
•Subcutaneous emphysema
•Pneumomediastinum and pneumothorax
•Crusting in trachea
•Tracheitis and stromal cellulitis
•Tracheobronchitis
•Severe infections: mediastinitis, clavicular osteomyelitis,
necrotising fascitis
•Atelectasis and lung abscess
•Local wound infections and granulations

78. LATE COMPLICATIONS
•Haemorrhage due to granulation tissue and innominate artery
blowout
•Laryngeal stenosis
• tracheal stenosis
•Tracheoesophageal fistula
•Difficult decannulation
•Keloid scar
• corrosion of tracheostomy tube

79. DECANNULATION
Decannulation: removal of tube
Should be considered once causative condition is under
control, as prolong use of tube causes, tracheal ulceration,
stenosis, granulations, scars
METHOD: the tube is occluded and patient is watched for
respiratory distress. If there is no distressfor 24 hrs, tube is
removed and wound is taped. Wound healing takes place in a
week. Rarely, secondary closure is required
In children, decanulatio is done using progressively small
sized tubes

80. CONCLUSION:
Over the course of centuries, tracheostomy has evolved into a
safe procedure.
Endoscopic percutaneous dilatational tracheostomy is a safe and
attractive bedside alternative to open surgical tracheostomy in
intubated adult ICU patients.
Obese individuals are at an increased risk for accidental
decannulation regardless of the technique used.
The use of bronchoscopy is mandatory with PDT and markedly
reduces or eliminates the risk of life threatening complications
Consistently high standards of nursing care is key in preventing
complications regardless of surgical technique used

81. Timely changes of soiled tracheostomy ties, frequent cleaning of
surgical site, and attention to neck plate-skin interface all
minimize skin maceration, breakdown, and wound infection.
Continuous high humidity, judicious suctioning, and/or changing
of inner cannula effectively prevent the formation of mucous
plugs.

82. REFERENCES
Mohan Bansal: diseases of Ear , nose and throat
DINGRa: diseases of ear, nose , throat, head and neck surgery:6th
edition
Anatomy and physiology of tracheostomy: scott k epstein MD
Surgical tracheostomy; henry H Rowshan; atlas of oral and
maxiofacial surgery clinics
Techniques for Performing Tracheostomy Charles G Durbin Jr MD
FAARC
Techniques of surgical tracheostomy Peter A. Walts, MD, Sudish C.
Murthy, PhD, MD, Malcolm M. DeCamp, MD*; clinics in chest
medicine
Open Tracheostomy Procedure Christine B. Taylor, MD , Randal A.

83. THANKYOU