Tracheostomy is a surgical procedure where an opening is created in the trachea to allow for breathing. It can be temporary or permanent. Temporary tracheostomies are either elective or emergency procedures, while permanent tracheostomies disconnect the trachea from the pharynx. Complications of tracheostomy include bleeding, infection, tracheal stenosis, tracheocutaneous fistula, and tube displacement. Care after tracheostomy involves securing the tube, humidification, suctioning secretions, and managing swallowing difficulties. Decannulation is done gradually by changing to smaller tubes and blocking the tube for longer periods.

1. Tracheostomy(sbo-2)
Tracheostomy is used to describe the creation of a stoma at skin surface which leads into the
trachea.Tracheostomy which was performed in ancient Egypt.
Tracheostomy may be temporary or permanent.
Temporary Tracheostomy
Temporary tracheostomy elective or emergency.
An elective temporary tracheostomy may be part of a planned procedure,such as a major head &
neck operation,following which postoperative swelling might result in upper airway obstruction ,or
for prolonged respiratory support in a ventilated patients.
An emergency temporary tracheostomy may be indicative of an underestimation of the severity of
a patient’s breathing difficulties.In most instances,other than severe trauma,it should be possible to
carry out an urgent tracheostomy using local anaesthesia.
In extreme cases it is usually possible to gain control of the airway via a cricothyroidotomy.
Permanent tracheostomy
Permanent tracheostomy is an elective procedure carried out as part of an operation involving
removal of the larynx,such as a laryngectomy or laryngopharyngectomy or sa part of a diversion
procedure for aspiration problems.The trachea is permanently disconnected from the pharynx &
proximal end of the trachea is sutured to the skin.
A temporary tracheostomy differs from permanent tracheostomy in that there is still a
communication between the pharynx & the lower airway via the larynx.
In a permanent tracheostomy the only access to the lower airway is via the tracheostome.
Effects of tracheostomy
a)Laryngeal bypass. All of the laryngeal functions are lost,the patient is unable to cough or phonate.
b)A reduction in respiratory dead space.
c) A redundant area is created between the tracheal opening & the larynx in which mucus tends to
accumulate & then fall back into the lungs.
d)The filtration of particulate matter & humidification of inspired air by the nasal mucosa is lost.
e)An increase risk of infection.
f) The trachcostomy tube will act as a foreign body causing local inflammation& it tends to move
during swalling & normal neck movements,may cause abrasion along the length of the tract.

2. Indications of tracheostomy
Upper airway obstruction; The most common indication for tracheostomy.Use of nasopharyngeal
airway or fibroptic intubation,it is unusual to be presented with a patient for whom tracheostomy is
the first option.
Removal of secretions; As secretions accumulate in the lower respiratory tract ,gas diffusion within
the alveoli deteriorates resulting in respiratory failure. Accumulation of secretions are congestive
cardiac failure, infection,pulmonary odema &bulbar palsy.Once a tracheostomy has been carried
out secretion can be aspirated with minimal upset to the patient.
In addition ,the reduction in respiratory dead space makes it easier for the patient to breath.
Prolonged ventilation The tracheostomy provides the safest means of assisstng ventilation. The
tracheostomy is more secure than a nasotracheal or orotracheal tube & the reduction of respiratory
dead space facilitates the process of weaning the patient off the ventilator.Post-intubation
laryngotracheal stenosis develops if the patient intubated more than 3weeks.
Part of another procedure ;A temporary tracheostomy is an integral part of many head neck
procedures.In circumstances where postoperative swelling can be predicted &patient medical
condition is not good,then a temporary tracheostomy should be carried out.
Techniques of tracheostomy;
1)cricothyroidotomy/Minitracheostomy; The patient lies supine with head extended over a
pillow.>thyroid cartilage is gripped between the thumb & middle figure,index finger can be used to
palpate the cricothyroid membrane.>the airway is entered using a needle & cannula attached to
a10-ml syringe half full of saline..>Once air is aspirated,the needle is angled in a caudal direction &
cannula is passed over the needle into trachea.> An air way can be maintained connecting the
cannula to an ambubag using endotracheal tube adaptor.
Dis advantage;adequate tissue oxygenation can be achieved in this way, co2 is not cleared
effectively.And some trauma to the cricoids cartilage with risk of subsequent subglottic stenosis.
2)Percutananeous tracheostomy; The patient lies supine with head extended. A needle & cannula
are used to puncture the trachea below the first tracheal ring.>air is aspirated into a syringe half
filled with saline.>the needle is withdrawn & a guide wire is inserted into the trachea through the
cannula using the seldinger technique.>multiple graded dilators are used to create a passage wide
enough to receive a tracheostomy tube. Whole procedure can be observed using a flexible
Bronchoscopy.
In percutaneous tracheostomy ,the pretracheal tissues fit tightly around the tracheostomy
tube.Early displacement of the tube before any fibrosis has taken place results in collapse of the
tissues & sudden closure of the tracheostome with potentially fatal consequences.

3. 3)Open surgical tracheostomy; The patient lies supine with a sandbag under the shoulders for neck
extension..The horizontal incision is sited midway between lower border of the cricoids
cartilage & the suprasternal notch. In a true emergency tracheostomy midline vertical
incision & cut down directly onto the surface of trachea, thus gaining rapid control of the
airway.
Skin & subcutaneous tissues are divided horizontally to the depth of the strap muscles.
The straps muscles are separated vertically by blunt dissection in the midline,at this point thyroid
isthmus identified.this should be divided between clamps,or retracted rather than divided.
If retracted, reintubation could be hampered by the isthmus spring back into position.
Identify the cricoids cartilage& palpate each of the tracheal rings.In general ,the incision should be
through 2nd to 4th tracheal rings.It is important to refrain from any damage to the cricoids
cartilage,increase incidence of post operative subglottic stenosis.(An exception to this rule
laryngeal malignancy, the tracheostome should be placed high to allow resection of the
tracheostomy site at the time of laryngectomy.
Incision on trachea ;A vertical midline incision between silk stay sutures is ideal./If a cartilage
window is removed there may be an increase risk of subsequent tracheal stenosis or
tracheomalasia. In elderly patients the tracheal rings are calcified & cartilage window is
best./ superiorly or inferiorly based flap, This procedure facilitate tube change & increase
incidence of tracheocutaneous fistula.
4) Translaryngeal tracheostomy;In children & young adult ,percutaneous tracheostomy is not
advised.The increase elasticity of the tracheal cartilages means that they are easily
compressed & this can lead to temporary loss of oxygenation as well as trauma to the
posterior wall.
Tube types(features)
1)Cuff-type tubes can inflated to prevent the aspiration of blood or saliva,to prevent the leakage of
ventilating gasesor prolonged mechanical ventilation.High volumne low pressure cuffed tube will
achieve this aim.
2)Inner tube; an inner tube project 2-3mm beyond the end of the outer tube so that secretion or
crusts will collect inner tube.
3)Fenestration; sited at the point of maximum curvature,which may be a single hole or multiple
small holes, allow air to pass through the larynx to increase the volumne of air available for
phonation.
4)Rigid tube may cause an abrasion on the posterior tracheal wall.It is useful to use an armoured
tube.
5)adjustable flange.

4. Postoperative management
When a patient return to the ward, a specialist nersing care is required. There should be writing
material available for them to use.
Tracheostomy tube should be secured with sutures until the first tube change.which should be on
the 3rd postoperative day .when the tube is changed ,the sutures can be changed for tracheostomy
tapes.A secure knot on the both side of the neck.knot will not be too loose or too tight.
The cuff should be remain inflated for as long as risk of aspiration.(rarely needs more than 1st 12hrs.)
Humidification & removal of secretions,Inthe early postoperative period frequent suction is
needed.nebulizer the incidence of crust formation can be reduced.wet gauze can be used.
Swallowing two main causes, the tube has a normal tendency to limit the normal movement of the
larynx during swallowing & overinflation of cuff can cause the sensation of pressure in the upper
oesophagus.
Complications
Early ;1)haemorrhage most common complication,usual source of bleeding are the anterior thyroid
vessel & isthmus of thyroid.
2) apnoea due to blow out of co2.
3)air embolism;air can be sucked into venous system in large quantities,& pass into the right
atrium. Avoided by good surgical technique & meticulous haemostasis.
Intermediate;
Extubation or tube obstruction; displacement of tube into the pretracheal space often goes
unnoticed>patient become dyspnoea.
Tube lumen may impinges on the posterior wall or posterior wall prolapsed in to obstruct the lumen.
It can be avoided by changing a different type or a longer tube.
Subcutaneous emphysema;if the skin is too tightly closed,then air will be trapped in the
subcutaneous plane.Air can track as far as lower eyelid &down into upper chest.In most severe
cases the tube may dislodged.Immediate opening the wound &repositioning of the tracheostomy
tube.IT may occur in posterior tracheal wall laceration.
Infection;perichondritis;
Fistula A trachea-oesophageal fistula; from severe damage to the posterior tracheal wall at the time
of surgery or from persistent rubbing of a poorly positioned tube.
Late
Tracheaocutaneous fistula ; can be reduced if a completely air tight seal used following
decannulation. If granulation tissue, silver nitrate cautary can effect closure of the fistula.

5. Tracheal stenosis.
Decannulation
Decannulation should be stepwise fashion.Initial cuffed tube has been changed for an uncuffed
tube,fenetrated tube ,allow enough air flow around the tube to allow the patient to breath easily
with the tube lumen occluded.In this ease tube can be blocked off with some form of obturator,
during the daytime only initially.then 24hrs, followed by decannulation.
In patient who has been tracheotomy-dependent for long time.>due to psychological dependence
much slower sequence of tube occlusion over a whole week.

6. Tracheal stenosis.
Decannulation
Decannulation should be stepwise fashion.Initial cuffed tube has been changed for an uncuffed
tube,fenetrated tube ,allow enough air flow around the tube to allow the patient to breath easily
with the tube lumen occluded.In this ease tube can be blocked off with some form of obturator,
during the daytime only initially.then 24hrs, followed by decannulation.
In patient who has been tracheotomy-dependent for long time.>due to psychological dependence
much slower sequence of tube occlusion over a whole week.