Tracheostomy is a surgical procedure that creates an opening into the trachea through the neck. It establishes an alternative airway and is often temporary. The document discusses the history of tracheostomy, indications for the procedure, surgical steps, types of tracheostomy tubes, post-operative care including suctioning and humidification, and potential complications both immediate and long-term. Key points covered include contraindications, anatomy, techniques for open and percutaneous tracheostomy, and maintenance of the tracheostomy site.

1. TRACHEOSTOMY
Dr. Amit Jha
1st year PG Resident
ENT-HNS

2. Contents
 Introduction
 History
 Indications & contraindications for Tracheostomy
 Armamentarium & Surgical anatomy
 Surgical/open tracheostomy
 Tracheostomy care & maintenance
 Complications
 Percutaneous tracheostomy
 References

3.  TRACHEOTOMY
Surgical procedure in which an opening is made in the anterior
wall of the trachea to establish an airway.
Often temporary and reversible.
- Hiester 1718
 TRACHEOSTOMY(tomos= cut , stoma=mouth)
Surgical creation of an opening into the trachea through the neck
with the trachea being brought into continuity with the skin.
Most often, not always permanent.
- Negus 1938

4. History
 2000 BC :Rig Veda
 400 BC: Hippocrates condemned tracheostomy,
citing threat to carotid arteries.
 Hierronymus, Fabricus and Habicot provided the
first technical descriptions of surgical procedure.
 1546 : first successful tracheostomy Antonius
Mvsa Brasavola,

5.  1921:Jackson defined and refined surgical airway management
technique
 1955: Percutaneous tracheostomy was described by Shelden,
 1969:Toy and Weinstein described a PT using the guide wire
approach of Seldinger.
 1985 Ciaglia et al described PDT.

6. Functions of tracheostomy
1. Alternative pathway for breathing: circumvents obstruction in
upper airway
2. Improves alveolar ventilation:↓ses dead space & resistance to
airflow
3. Protects airway: against aspiration
4. Permits removal of tracheobronchial secreations
5. Intermittent positive pressure respiration: if >72hrs better than
intubation

7. Indications
1.Acute upper airway obstruction
2. Potential upper airway obstruction
3. Protection of the lower airway
4. Patients requiring artificial respiration.
Bailey &Love’s short practice of surgery

8.  Absolute indications for Tracheostomy, for conditions other
than impending respiratory obstruction, include (IPPV):
1. When injuries are severe enough to cause hypercarbia and/or
hypoxemia from the outset- flail chest, lung contusion or
aspiration.
2. Control of cerebral oedema (by controlling blood gases) in
severe head injuries
Rowe & Williams
Indications

9. Indications
 Major laryngeal trauma
 Inability to intubate or perform needle cricothyrotomy in
pediatric pt
 Facilitation of management of cervical spine injury or oncologic
ressection of head & neck.
 Laryngeal foreign body or pathology (e.g., tumor) prohibiting
cricothyrotomy
 Prolonged ventillation
Fonseca trauma

11. TYPE of Trachesotomies

12. High Tracheostomy-
It is done above the level of thyroid isthmus(
i.e, II, III, IV tracheal rings).
Tracheostomy at this site can cause
perichondritis of the cricoid cartilage &
subglottic stenosis so its generally avioded.
Only indication is Ca larynx because in such
cases, total larynx anyway would ultimately be
removed & a fresh tracheostome made in a
clear area lower down.

13. Mid Tracheostomy
Is the most preferred one & is done through
the II & III rings & would entail division of
the thyroid isthmus or its retraction upwards
or downwards to expose this part of trachea.

14. Low Tracheostomy
It is done below the level of isthmus. Trachea is
deep at this level & close to several large
vessels, also there are difficulties with
tracheostomy tube impringes on suprasternal
notch.

15. JACKSON’S SAFETYTRIANGLE
Triangular space in neck
• Base: Lower end of thyroid cartilage
• Apex: Suprasternal notch
• Sides: Inner edges of sternocleidomastoid muscle
So named as this marks the area through which safe dissection can
be done for tracheostomy
Also represents the area into which infiltration anesthesia is
given during tracheostomy under local anesthesia

16. Types of tracheostomy
 Emergency
 Elective / tranquil
 Therapeutic : to relieve respiratory obstruction
 Prophylactic : to guard against anticipated respiratory
obstruction or aspiration
 Permanent
 Percutaneous dialational
 Mini tracheostomy (Cricothyrotomy)

17. Armamentarium
1) Mollinson’s Retractor
2) Tracheal Hook
3) Tracheal Dilator

18. Various type of the tubes
1. Silver/Metal tubes- outdated.
E.g.Alder-Hey and Sheffield.
2. Plastic tubes -most commonly used. flexible, comfortable & less traumatic.
 Silicon tubes-
E.g.- Romsons tubes, Portex tubes, Shiley tubes.
 Polyvinylchloride (PVC) tubes
 Silastic tubes

19. • Plastic and metal
• Cuffed and uncuffed
• Fenestrated and unfenestrated
• Single and double lumen

20. Metal tubes are constructed of silver or stainless
steels.
Metal tubes are not used commonly because they
are
→ expenseive,
→ rigid construction
→ uncuffed
→lack connector to
Ventilator

21. • Can be made with cuff
• It has connector to
anesthetic machine and
ventilator
• Cause less mechanical
damage to trachea

22. • To protect airway
uncuffed cuffed

23. • Allow patient to
ventilate past tube
via upper airway
• Allow speech

24. • Double lumen allows easy cleaning
Single lumen has a greater internal diameter

26. Tube selection
 The length - The standard tube lengths are 60–90 mm (adult), 39–
45 mm (pediatric) and 30–36 mm (neonatal).
 The diameter - largest tube that fits comfortably should be used.
(this is approx. 3/4th diameter of the trachea.)
woman- No.6 or No.7
man- No.7 or No.8.
 Cuff tube- necessary when aspiration is a problem or when a
positive pressure ventilation is required.
Cuff should be deflated at regular intervals atleast 5mins/hr.

27. Size selection of tube in children
Endotrachial tube
Age/4 + 4
Tracheostomy tube
Upto 6 yrs = (age/3)+3.5
Over 6 yrs = (age/4)+4.5

28. TRACHEOSTOMY SURGICAL STEPS

29. STEPS
1.Airway control
endotracheal intubation/ventilation and
oxygenation by means of a bag and mask.
If the airway is under control, a more orderly
& less traumatic tracheostomy can be
performed.
2.Patient position-supine position,
place shoulder pad & head ring for to allow
maximum extension of neck.

31. The incision is made through the
Subcutaneous tissue and platysma,
down to the deep cervical fascia.
The anterior jugular veins will be
Encountered superficial to the deep
cervical fascia on either side of the
midline.
Note that the trachea is deeper than one imagines.

32. A self-retaining retractor can now be inserted and the
dissection continued until the strap muscles are encountered.
These should be separated in the midline. The assistant can
do this using a pair of Langenbeck retractors.
The dissection is continued with blunt ended dissecting
scissors. If one stays in the midline, it is a relatively bloodless
field and one continues deeper until the thyroid isthmus is
identified.

33. 2 PRINCIPLES OF ENTERING TRACHEA
 Cricoid cartilage or 1st tracheal ring must not be cut or
injured
 Incision in trachea must not extend below 4th tracheal ring
 Tracheostomy hook between 1st & 2nd tracheal ring,
superior traction to elevate trachea
 V
arious entrance incisions like U, INVERTED U, TAND
CRUCIFORM, or a window may be created.

34.  A traction suture with 2-0 silk
from tip of flap to inferior margin
of skin


Trousseau dialator or kelly
hemostat inserted and spread
vertically
Tracheal lumen should be
visualised an inferiorly hinged
tracheal flap Bjork’s flap is made
which is sutured to the skin.

35. TRACHEOSTOMY TUBE INSERTION
 Tracheal dilators will be needed to
enable the tube to be inserted into the
tracheal lumen.
 The assistant should now hold the tube
in situ until it is secured. Use a flexible
suction catheter down the tube to
suction any blood or mucus out of the
trachea and connect the catheter mount
to the tracheostomy tube and the
anaesthetic tubing

38. Skin closure
 incision should not be sutured or dressed
tightly. (subcutaneous emphysema,
pneumomediastinum & pneumothorax.)
 Asmall gauze pad may be placed b/w
the flange of the tube and the skin

39. Tracheostomy: Pediatric Anatomical consideraions
 Dome of pleura extends in to neck and is this vulnerable to injury
 The hyoid bone, thyroid cartilage and the cricoid cartilage lie higher in the neck.
 Trachea is pliable and difficult to palpate
 Recurrent laryngeal nerve
Neck is short so less working space
 Cricoid can be injured

40. VARIATION
 In children short neck: left brachiocephalic vein may come up above the
suprasternal notch so that dissection is rather more difficult and dangerous.
 Also, child’s trachea is softer and more mobile than the adult’s and therefore
not so readily identified and isolated.
 Its softness means that care must be taken, in incising the child’s trachea, not to
let the scalpel plunge through and damage the underlying oesophagus.
 In contrast, the trachea may be ossified in the elderly and small bone shears
required to open into it.

41. Tracheostomy: Pediatric
1.Bronchoscope/ETT inserted to provide, an
airway and rigidity to the trachea.
2. Do not to insert the knife too deeply
3. A vertical skin incision is used. Before the
anterior tracheal wall is incised, silk retraction
sutures are placed in either side of the midline.
4. Tape the silk retraction sutures to the chest wall
5. Silastic tubes are preferable

42. Tracheostomy care
Fixation of tube
Positioning
Suctioning
Humidification
Changing of tube
Care of inflatable cuff
Dressing
Decannulation
Breathing exercises and nutrition

43. Bedside equipment
• Spare tubes of Same / smaller size.
• Tracheal dilator.
• Suctioning equipment
-Ensure everyday equipment is assembled and working.
• Humidification unit
-Ensure everyday equipment is working properly.
• Container to hold speaking valve, occlusive cap/button or spare inner cannula.

45. Fixation of tube

46. Positioning

47. Suctioning

48. Humidification
Aims:
 To prevent drying of pulmonary secretions (tracheitis & crust
formation).
 To preserve muco-ciliary function.
Various methods of humidification
A) HEATED HUMIDIFIERS.
B) HEAT MOISTURE EXCHANGE FILTERS.
C) NEBULIZERS.
-In addition to atmospheric humidification,
-Instill 3 -4 drops of hypotonic saline/ sodium bicarbonate 1-2ml/h
-Thick, copious secretions use mucolytic agents.

49. Dressing

50.  Fresh place for 3 - 5 days for the permanent
tract to form.
 loss of the tracheal opening into the
neck wound, disastrous
consequences.
 A tube in an infant should not be
changed for the first time without a
bronchoscope on hand.
Care of tube :

51. CARE OF CUFFED TRACHEOSTOMY TUBE
Inflate:
• Immediately post-op
• during mechanical ventilation
Deflate:
• Cuff should be deflated atleast 5mins every hr.
• First suction the oropharynx.

52. 1. It is recommended that endotracheal suctioning should be performed only when
secretions are present, and not routinely;
2. It is suggested that pre-oxygenation be considered if the patient has a clinically
important reduction in oxygen saturation with suctioning;
3. Performing suctioning without disconnecting the patient from the ventilator is
suggested;
4. Use of shallow suction is suggested instead of deep suction, based on evidence
from infant and pediatric studies;
5. It is suggested that routine use of normal saline instillation prior to
endotracheal suction should not be performed;
American Association for Respiratory Care (AARC)
Guidelines- Recommendations
AARC Clinical Practice Guidelines: Restrepo RD, Brown JM II, Hughes JM Endotracheal Suctioning of Mechanically Ventilated
Patients With Artificial Airways 2010 Respir Care 2010;55(6):758–764. © 2010 Daedalus Enterprises

53. 5. The use of closed suction is suggested for adults with high FIO2, or PEEP,or at
risk for lung derecruitment, and for neonates;
American Association for Respiratory Care (AARC)
Guidelines- Recommendations
6. Endotracheal suctioning without disconnection (closed system) is suggested in
neonates;
7. Avoidance of disconnection and use of lung recruitment maneuvers are
suggested if suctioning-induced lung derecruitment occurs in patients with
acute lung injury;
8. It is suggested that a suction catheter is used that occludes less than 50% the
lumen of the endotracheal tube in children and adults, and less than 70% in
infants;
9. It is suggested that the duration of the suctioning event be limited to less than
15 seconds
AARC Clinical Practice Guidelines: Restrepo RD, Brown JM II, Hughes JM Endotracheal Suctioning of Mechanically Ventilated
Patients With Artificial Airways 2010 Respir Care 2010;55(6):758–764. © 2010 Daedalus Enterprises

54. Complications of tracheostomy
 Immediate Intermediate Late

55. Immediate
 Hemorrhage
 Air embolism
 Apnoea
 Cardiac arrest
 Local damage

56. Hemorrhage
 Anterior jugular veins
 Inferior thyroid veins
 Thyroid gland

57. Air embolism
 Inadvertent opening of large neck veins
 Air sucked in and passing rapidly into right atrium
 Tamponade and death

58. Apnoea
 Sudden discharge of carbon dioxide
 Allow the patient to breath a mixture of 95% oxygen
and 5% carbon dioxide during the procedure

59. Cardiac arrest
 Exessive adrenaline production
 Rapid rise of ph
 Hyperkalemia

60. Local damage

61. Intermediate
 Dislodgement
 Surgical emphysema
 Pneumothorax/pneumomediastinum
 Scabs and crusts
 Infection
 Tracheal necrosis
 Tracheoarterial fistula
 Tracheo-oesophageal fistula
 Dysphagia

62. Dislodgement
 Post operative oedema, hematoma and emhysema
 Prevention:
 Suturing flanges in early period and tapes in later
period

63. Surgical emphysema
 Subcutaneous
emphysema is alarming
but it is not fatal
 Too large incision
 Tube partially
obstructed/diverts air
into soft tissues
 Too tight closure of
subcutaneous tissues
 Excessive coughing

64. Pnuemothorax/pneumomedistinum
 Direct puncturing of
pleura
 Tube is inserted
between the anterior
wall of trachea and soft
tissues of anterior
mediastinum

65. Scabs and cysts
 Tracheostomy alters the basic physiology

66. Infection
Pseudomonas,
stahphylococcus, hemolytic
streptococci and candida

67. Tracheal necrosis
 Over sized tracheostomy
tubes,
 Improper curve of the
tube,
 Impingement of tip of
the tube
 Pressure of cuff

68. Tracheoarterial fistula
 Occurs in 0.1-1%
 Mortality 80-90%
 Hemmorrhage occurring 3days to
6wks after tracheostomy should be
thought of as a result of TIF
 Low tracheal incision
 Improper position of tube against the
vessel
 Improper curve or length of tube
 Secondary to pressure

70. Traheo-oesophagial fistula
 Over inflated or improperly fitting cuffed tube
 Positive pressure ventilation

71. Dysphagia
Managed by feeding through ryles tube

72. Late
 Stenosis
 Difficulty with decannulation
 Tracheo cutaneous fistula

73. Stenosis
 3 distinct levels
 1)stoma
 2)cuff site
 3) tip of tube
 Caused by
 Inflatable cuff
 Scar contracture

74. Difficulty in decannulation
In long standing cases
Granulations
Fibrous masses
Tracheal strictures

75. Tracheocutaneous fistula and scars
 Due to migration of squamous epithelium from skin
into trachea

76. Percutaneous tracheostomy




• 1955, Shelden et al - first attempted PCT with cutting trocar into the
trachea.
• The wire-guided technique for percutaneous tracheostomy was
developed and reported in 1986 by the American surgeon, Ciaglia.
• 1990, Griggs et al - the guidewire dilating forceps (GWDF)
• Several variants of the percutaneous tracheostomy technique
have been developed.
Using a wire guided sharp forceps(Griggs technique)
using a single tapered dilator (BlueRhino)
passing the dilator from inside the trachea to the
outside (Fantoni’s technique);
using a screw like device to open the trachea wall
(PercTwist).

77. • percutaneous dilational tracheostomy (PDT) has become a very
common method of placing a tracheostomy in critically ill patients
in the intensive care unit.
• It is rapid, simple, easy to learn, and cost effective.
• The procedure should be deferred in patients having an
INR>1.4,
Activated partial thromboplastin time >45 seconds
Platelet count of < 75,000⁄ ml.

78. • To prevent inadvertent injury of the membranous posterior
tracheal wall or too lateral a location of the tracheostomy,
a technique of observing and directing the needle and wire
placement, using fiberoptic bronchoscopy is recommended
• In order to visualize the upper rings of the trachea with the
bronchoscope, the endotracheal tube (ET) must be withdrawn
until its tip is just in the larynx.
• Patients requiring a tracheostomy only for airway access or
protection often can have a laryngeal mask airway replace the
endotracheal tube to provide the route for bronchoscopic
visualization.

79. • PDT is usually performed in an anesthetized patient, and can be done
in the intensive care unit or operating room.
• The patient should be monitored by SpO2, EtCO2 and ECG.
• The patient is positioned as for the surgical tracheostomy
• A pillow is placed under the shoulders, the neck is moderately
extended, and the first three tracheal rings are identified
• The anterior neck is prepared with povidine iodine and draped with
sterile sheets.
• The skin overlying first and second tracheal rings is infiltrated
subcutaneously with 3-5 ml of 1% xylocaine with epinephrine
(1:200,000), and a 1.5 cm vertical incision is made and blunt
dissection is performed to expose the pretracheal fascia.

80. • The anterior trachea is
palpated and the intended
site is punctured with a 14G
intravenous cannula in a
postero-caudal direction.
• The entry of the IV cannula
in trachea is confirmed by
aspiration of air into a saline
filled syringe.

81. →A guide wire is inserted through the cannula, and the cannula
is withdrawn,
→The tracheal opening is dilated over the guide wire until a
stoma of sufficient size to accommodate the desired
tracheostomy tube is created.
→The method of dilating the tracheal opening over the guide
Wire varies with various methods

82. Contraindications
Absolute-
1. Need for an emergency airway.
2. Performance of the procedure in children as cartilages is soft.
Relative-
1. High degree of ventillatory support–PEEP >8cm H2O, FiO2 > 50%.
2. Unstable cervical spine.
3. Uncorrected coagulopathy.
4. Presence of neck mass or pervious neck surgery.
5. History of mediastinal irradiation due to intrathoracic fibrosis.
6. Previous history of surgical tracheostomy.
7. Increased intracranial pressure.

83. Ciaglia technique
• With Ciaglia technique,
the tracheal opening is
dilated by using a
series of plastic dilators
inserted over the guide
wire

84. Griggs Technique
• Using a tracheal spreader
modified to thread over the
wire; this technique involves
forceps dilation to create the
skin path and tracheal stoma.
• The trachea is entered between
the appropriate tracheal rings
with an intravenous catheter.
• The guide wire is threaded
through the catheter.
• The sharp-tipped dilating
forceps are passed over the
wire, spread in the skin and soft
tissues of the neck and into the
trachea, and spread again

85. • A tracheostomy tube is placed over the guide
wire and through the passage created.
• Tracheal injury may be higher with this
technique (especially if performed without
bronchoscopy) than the other PDT techniques.

86. Complications of Percutaneous Tracheostomy
Complications of Percutaneous technique are not common
1. false passage of the tracheostomy tube,
2. pneumothorax,
3. delayed bleeding,
4. puncture of the posterior tracheal wall,
5. premature extubation during the procedure and loss of the
airway.

87. CRICOTHYROTOMY-
It is a horizontal incision in cricothyroid membrane. It is done
in dire emergency due to non-availability of instruments for
tracheostomy or endotracheal intubation.
Mini Tracheostomy-
It is a vertical stab incision through cricothyroid membrane. It
allows ready access, delivery of oxygen & removal of chest
secretions.

88. References
1. Rowe &William’s Maxillofacial injuries 2nd edition-vol I
2. Oral & maxillofacial trauma :Fonseca-3rd edition-vol I
3. Bailey & love’s short practice of surgery 23rd edition.
4. Scott and Brown’s Otolaryngology 8th edition vol I ,vol II
5. Operative otolaryngology Head and Neck –Eugene N Myers vol I
6. Diseaes of Nose ,Throat , Ear – Logen Turner
7. Text book of Otolaryngology and head and neck surgery -Byron &Bailey
8. Clinically oriented Anatomy -5th edition –Keith L Moore
9. An atlas of head & neck surgery-Lore’ 3rd edition