2. INTRODUCTIONINTRODUCTION
Tracheostomy is the surgical creation of an
opening maintained by a tube on the anterior
aspect of the cervical tracheal wall (windpipe).
A tracheotomy – opening is not maintained by a
tube (temporary opening).
◦ Sometimes the terms "tracheotomy" and
"tracheostomy" are used interchangeably.
The opening, or hole, is called a stoma.
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3. ANATOMYANATOMY
The trachea lies below the
thyroid cartilage, which
forms the front wall of the
larynx.
The thyroid isthmus
crosses the trachea and the
recurrent laryngeal nerve
(to the vocal cords) lies on
each side of the trachea.
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5. ANATOMY AND PHYSIOLOGYANATOMY AND PHYSIOLOGY
The trachea is a rigid structure formed from rings
of cartilage to ensure that the airway always
remains open.
Its function is to maintain and protect the airway.
The trachea is lined with mucus glands, which
humidifies air as it passes through the trachea and
catches small particles before they reach the
lungs.
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6. ANATOMY AND PHYSIOLOGYANATOMY AND PHYSIOLOGY
The trachea also has specialized hair like
structures called cilia that move rhythmically to
sweep mucus and particles back up to the
throat.
The trachea also has many defensive cells that
kill organisms that enter the trachea
The trachea is supplied by nerves that are part
of the cough reflex that helps get rid or
irritants
7. INDICATIONSINDICATIONS
To bypass upper airway obstruction
To protect the lower respiratory tract /provide
pulmonary toilet
To provide a long-term route for mechanical
ventilation in cases of respiratory insufficiency
Prophylaxis (as preparation for extensive head
and neck procedures and the convalescent
period)
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8. INDICATIONSINDICATIONS
UPPER AIRWAY OBSTRUCTION
Congenital anomalies:
◦ bilateral Choanal atresia, subglottic
stenosis/web, laryngeal web/cysts,
Tracheomalacia, Vocal Cord Paralysis (VCP),
Congenital abnormalities of the airway,
Treacher Collins and Pierre Robin Syndromes
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9. INDICATIONSINDICATIONS
Acquired:
◦ Infection/Inflammation:
Acute epiglottitis, Croup (LTB), Ludwig’s
angina, Retropharyngeal abscess, Anaphylaxis
(severe allergic reaction)
◦ TRAUMA:
Foreign body obstruction, Airway burns from
inhalation of corrosive material, smoke or
steam, radiation, Severe neck or mouth
injuries, Laryngeal injury or spasms
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10. INDICATIONSINDICATIONS
◦ TUMOURS:
Benign (eg RRP, Haemangioma, Angiomas,
Cystic Hygroma, etc) or Malignant (eg SCCa,
Lymphoma)
◦ Miscellaneous
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TRACHEO-BRONCHIAL TOILETING
◦ Long-term unconsciousness or coma,
◦ Tetanus
◦ Aspiration related to muscle or sensory
problems in the throat
◦ Bulbar palsy
11. INDICATIONSINDICATIONS
RESPIRATORY INSUFFICIENCY
◦ Neuromuscular diseases paralyzing or weakening chest muscles
and diaphragm
◦ Chronic pulmonary disease to reduce anatomic dead space
◦ Chest wall injury
◦ Diaphragm dysfunction
◦ Disorders of respiratory control such as Congenital Central
Hypoventilation or Central Apnea
◦ Fracture of cervical vertebrae with spinal cord injury
◦ Need for prolonged respiratory support, such as
Bronchopulmonary Dysplasia (BPD)
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12. INDICATIONSINDICATIONS
ADJUNCT FOR HEAD & NECK
SURGERY
• Maxillofacial surgery, laryngectomy,
Maxillectomy, Other major head and neck
surgeries
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14. SURGICAL TYPESSURGICAL TYPES
◦ Tracheostomy
Emergent ("slash") – when patient is in respiratory
arrest
Urgent ("awake") – usually done under L.A.
Elective (with patient already intubated)
Classical or Percutaneous
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15. INTRAOPERATIVE DETAILSINTRAOPERATIVE DETAILS
(Classical Tracheostomy)(Classical Tracheostomy)
Position
sitting or semirecumbent position with extension of the neck
Palpate the landmarks.
Infiltrate lidocaine (1%) with 1:200,000 parts
epinephrine
Make the horizontal skin incision
◦ Landmarks: midway between sternal notch and the
cricoid cartilage,
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16. INTRAOPERATIVE DETAILSINTRAOPERATIVE DETAILS
Dissection through skin, subcutaneous tissue,
and platysma to reveal the strap muscles
At the level of the strap muscles, the dissection
is changed to the vertical plane.
The pair of sternohyoid and sternothyroid
muscles are separated from each other in the
midline by vertically incising the fascia that
connects the muscles
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17. INTRAOPERATIVE DETAILSINTRAOPERATIVE DETAILS
Retractors then pull the strap muscles to each
side, revealing the thyroid isthmus.
At this point, the cricoid cartilage is identified
by palpation through the wound, and the
overlying fascia is sectioned near its inferior
border.
the thyroid isthmus, which typically lies
anteriorly over the first 2-3 tracheal rings, may
be retracted out of the field, often it must be
divided.
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18. INTRAOPERATIVE DETAILSINTRAOPERATIVE DETAILS
Injection of topical anesthesia can stem
the cough reflex of an awake patient
before incision is made to enter the
trachea.
suction secretions and blood out of the
lumen and insert the previously tested
tracheostomy tube with or without the
aid of tracheal dilator.
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19. INTRAOPERATIVE DETAILSINTRAOPERATIVE DETAILS
After an intact airway is confirmed with carbon
dioxide return and bilateral breath sounds,
secure the tracheostomy tube to the skin with 4-
0 permanent sutures.
Attach a tracheostomy collar with the head
flexed to avoid unnecessary slack in the collar.
The skin is not closed tightly to avoid the risk of
subcutaneous emphysema and subsequent
pneumomediastinum.
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21. TRACHEOSTOMY PROCEDURETRACHEOSTOMY PROCEDURE
A horizontal skin incision is
marked midway between
the cricoid cartilage and the
sternal notch. The skin is
infiltrated with Xylocaine-
Epinephrine to decrease the
bleeding.
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22. TRACHEOSTOMY PROCEDURETRACHEOSTOMY PROCEDURE
The isthmus of the thyroid gland
is either retracted or divided in
the midline. (In this picture, the
isthmus has been divided and
retracted laterally, along with the
strap muscles.)
The anterior tracheal wall is
divided between the third and
fourth tracheal rings. A clamp is
used to widen the tracheal
opening. The endotracheal tube
is seen inside the tracheal lumen.
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24. TRACHEOSTOMY TUBESTRACHEOSTOMY TUBES
METALS (usually has an obturator, an
inner and outer tube)
Chevalier Jackson, Negus, Durham, Koenig,
Alder Hey
SYNTHETIC (most are made from PVC,
silicone or other synthetic plastics that are
non-toxic)
Portex & Shiley (have low-pressure cuffs)
Paediatric types – Franklin tube of GOS, Portex,
Shiley. None has a cuff
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33. DECANNULATION METHODDECANNULATION METHOD
INVOLVES:
◦ Adequate re-evaluation of the indication to be
sure it is no longer required
◦ Observe speech/cry with tube blocked
temporarily
◦ Indirect Laryngoscopy (adult)
◦ Fiberoptic laryngoscopy and bronchoscopy
through the stoma
◦ X-ray soft tissue neck is necessary
34. METHODMETHOD
PROCESS:
◦ Change tube to a smaller size
◦ Spigot for most of the day, leaving it open during the
night
◦ If tolerated, spigot for 24 hours, including a period of
sleep.
◦ A close watch should be kept for any sign of
respiratory distress.
Difficult decannulation is usually done as a
surgical procedure if the normal process fails
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35. DIFFICULT DECANNULATIONDIFFICULT DECANNULATION
Usually seen in children, but could occur in adult
Reasons:
1. Failure to correct the reason for the tracheostomy
2. Granulation tissues obstructing the airway
3. Tracheomalacia
4. Disuse of acquired reflexes controlling glottic closure & opening
during breathing & swallowing
5. Psychological dependence on the tracheostomy
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36. DIFFICULT DECANNULATIONDIFFICULT DECANNULATION
Process:
Usually done under general anaesthesia via oro/naso-tracheal
intubation
the T. tube is removed and the stoma is closed in layers and
sterile dressing applied
Patient allowed to be fully awake with the ETT in place,
before extubation.
If the patient is a child, he is kept in an intensive care unit, and
the endotracheal tube is removed after a day or two and
dressing applied to the stoma for 24 – 48 hours by which
time its closure would have been completed.
37. How to Perform an EmergencyHow to Perform an Emergency
TracheotomyTracheotomy
Find the indentation between theFind the indentation between the
Adam's apple and the CricoidAdam's apple and the Cricoid
cartilage.cartilage.
Make a half-inch horizontalMake a half-inch horizontal
incision about one half inchincision about one half inch
deep.deep.
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38. How to Perform an EmergencyHow to Perform an Emergency
TracheotomyTracheotomy
Pinch the incision or insert yourPinch the incision or insert your
finger inside the slit to open it.finger inside the slit to open it.
Insert your tube into the incision,Insert your tube into the incision,
roughly one-half to one inch deep.roughly one-half to one inch deep.
