Department of surgery, JNMCSawangi(M), Wardha
LERNING OBJCTIVES
To know about surgical anatomy of tracheaTo know about various techniques of
tracheostomyTo know about various tubes usedTo know about things to look for during
tracheostomyTo know about complications occurring
during the procedure and their management
What is a Tracheostomy?
A tracheostomy is a artificial (usually) surgically created airway fashioned by making a hole in the anterior wall of the trachea and the insertion of a tracheostomy tube, which may or may not be permanent
Why Perform a Tracheostomy 1Upper airway obstruction
urgent (cricothyroidotomy)non-urgent (conventional tracheostomy)
Facilitation of airway toiletLong term ventilation
Difficulty in weaning the ventilator Decreases airway resistance (tube size)
Paralysis of respiratory muscles (e.g. disease)Eliminates dead space
Why Perform a Tracheostomy 2Surgical reasons
Including head and neck surgeryTrauma
Including burns
How To Create a TracheostomyCricothyroidotomy
For Urgent ProceduresPercutaneous Tracheostomy
Can be done in the ICU at the bedsideSurgical Tracheostomy
Subthyroid incision to trachea between 2nd and 3rd tracheal rings
When to Create a TracheostomyControversial
ETT can be in situ for over 4 weeks in some studies!!!
Generally, consider a tracheostomy if patient intubated for 7 days with no foreseeable extubation in the next few days
Procedure
SkinDissectionSeparate strapsDivide thyroid
isthmusWindow in tracheaBelow 1st ringStitch in placeIncision=ba
d
Hole=good
Landmarks
Thyroid cartilage
Cricothyroid membrane
Crycoid cartilage
Types of Tracheostomy Tubes 1Cuffed, Uncuffed, Fenestrated,
UnfenestratedCuffed required for
Aspiration risk PPV
Fenestrated Facilitates weaning Allows vocalisation
Types of Tracheostomy Tubes 2“Button”
A plugUseful when there is a possibility of requiring
the tracheostomy tube again
Percutaneous Tracheostomy
Tracheostomy
cuffsTo protect airwayTo allow
ventilation
Uncuffed Cuffed
Single/Double lumen
Double lumen allows easy cleaning
Single lumen has a greater internal diameter
Immediate Problems 1PTX (4%)Wound infection (reasonable common)Bleeding
Usually only in coagulopathic patientsDifficult insertionAccidental decannulation
hypoxia and possible difficult re-insertionOcclusion due to secretions
Immediate Problems 2Air embolismAspirationSurgical emphysema
Long Term Problems 1Subglottic stenosis
Incidence decreased by low pressure cuffsIncidence increased by cricothyroidotomy over
surgical tracheostomyTracheal stenosisOesophago-tracheal fistulaIncreased bacterial colonisation of the
airways
Long Term Problems 2Vocal cord dysfunction
Chronic Recurrent laryngeal nerve injury
TemporaryStomal granulations and scarringNon healing of woundErosion into the innominate artery (<1%)
Occurs in 1st and 2nd weekSwallowing Problems
Benefits of a TracheostomyMore comfortable and more stableTube size can be larger (less resistance)Allows tubes to be changed more easilyBetter quality suctioningDepending on indication for tube and the
type of tube, patients can eat and talkCan promote oral nutrition
Post-op careNursing job with medical responsibilityRegular gentle suctioningMeticulous wound and stoma carePrimary goal is to keep tube in stomaTube change after 5 days if required –
earlier can be riskyENT do not normally need to be involved
in all aspects of trache care!!
General Care of a TracheostomySterile suctioning (as prone to infections)Gases given should be humidifiedEmergency equipment should be immediately
present (at bedside)
fenestrations
Allow patient to ventilate past tube via upper airway
Allow speech
Equipment of tube change
Nurse or assistantOxygen maskTracheal dilatorsSuctionNew tube (tested)Good light source BougieIntubation equipment available
DecannulationWhen ventilation or suctioning no longer
needed, and patient can control their own airway and not be at risk for aspiration
Can occur when patient has Good cough Good ABGs (relative, for the patient) Clear lungs No pathogens in sputum
Make sure…
Ready to be decannulatedNo further need for tracheostomyMaintaining own airwayNot aspirating
Steps to decannulation
1. Involve physio2. Change to fenestrated uncuffed tube3. Start capping off tracheostomy (NOT with
a cuffed unfenestrated tube!)4. When 24 hrs of uninterrupted capping at
normal sats, decannulation is possible
Decannulation itself
1. Prepare equipment (Same as for tube change, including fresh tube)
2. Take a deep breath3. Remove tube and suction stoma4. Close with steristrips and sleek5. Daily dressing and steristrip change6. Patient to cover wound when talking
• Always follow ABC
• A blocked tube is invariably the problem
• Remove tube if rapid suctioning fails or is even slightly delayed
• Direct ventilation over stoma may be effective
• An ET tube works well through a tracheal stoma
In SummaryMost traches are elective for a specific
cause (or perhaps multiple causes)Not free of complications which can be
early (immediate) or lateHave many benefits over a conventional
ETTMay be permanent or temporaryCuffed or uncuffed, fenestrated or
unfenestrated
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