Tracheostomy & tracheal surgeries

TRACHEOSTOMY & Tracheal Surgeries S.SUKRUTH

Definition

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

Functions of Tracheostomy

1. Alternative pathway for breathing 2. Improves alveolar ventilation In cases of respiratory insufficiency :

(a) Decreasing the dead space by 30-50% (normal dead space is 150 ml).(b) Reducing the resistance to airflow.

3. Protects the airways By using cuffed tube, tracheobronchial tree is protected against aspiration of:

(a) Pharyngeal secretions, as in case of bulbar paralysis or coma.(b) Blood, as in haemorrhage from pharynx, larynx or maxillofacial injuries. With tracheostomy, pharynx and larynx can also be packed to control bleeding.

4. Permits removal of tracheobronchial secretions When patient is unable to cough as in coma, head injuries, respiratory paralysis; orwhen cough is painful, as in chest injuries or upper abdominal operations, the tracheobronchial airway can be kept clean of secretions by repeated suction through the tracheostomy, thus avoiding need for repeated bronchoscopy or intubation which is not only traumatic but requires expertise.

5. Intermittent positive pressure respiration (IPPR) If IPPR is required beyond 72 hours, tracheostomy is superior to intubation.6. To administer anaesthesia laryngopharyngeal growths or trismus.

Indications of Tracheostomy

A. Respiratory obstruction.B. Retained secretions.C. Respiratory insufficiency.

Types of Tracheostomy

Emergency tracheostomy Elective or tranquil tracheostomy Permanent tracheostomy Percutaneous dilatational tracheostomy Mini tracheostomy (cricothyroidotomy)

1. Emergency tracheostomy

It is employed when airway obstruction is complete or almost complete and

There is an urgent need to establish the airway. Intubation or laryngotomy are either not possible or

feasible in such cases.

2. Elective tracheostomy(syn. tranquil, orderly or routine tracheostomy)

This is a planned, unhurried procedure It is of two types: (a) Therapeutic: to relieve respiratory obstruction, remove tracheobronchial secretions or give assisted ventilation. (b) Prophylactic: to guard against anticipated respiratory obstruction or aspiration of blood or pharyngeal secretions such as in extensive surgery of tongue, floor of mouth, mandibular resection or laryngofissure

3. Permanent tracheostomy

Required for case of bilateral abductor paralysis or laryngeal stenosis.

Technique

Whenever possible, endotracheal intubation should be done before tracheostomy. This is specially important in infants and children.

Position Supine with a pillow under the shoulders

so that neck is extended. Anesthesia

2 % lignocaine & 1 in 2 lakh adrenaline

injected into incision line

Steps Of Operation

1. A vertical incision in the midline of neck, extending from cricoid cartilage to just above the sternal notch.

This is the most favoured incision and can be used in emergency and elective procedures. It gives rapid access with minimum of bleeding and tissue dissection.

2. After incision, tissues are dissected in the midline. Dilated veins are either displaced or ligated.

3. Strap muscles are separated in the midline and retracted laterally. 4. Thyroid isthmus is displaced upwards or divided between the clamps,

and suture-ligated.

5. Trachea is fixed with a hook and opened with a vertical incision in the region of 3rd and 4th or 3rd and 2nd rings.

This is then converted into a circular opening. The first tracheal ring is never divided as perichondritis of cricoid cartilage with stenosis can result

6. Tracheostomy tube of appropriate size is inserted and secured by

tapes

Lubricated tracheostomy tube inserted into trachea

Confirm presence of tube in trachea with help of ambu bag &

auscultation

7. Skin incision should not be sutured or packed tightly as it may lead to development of subcutaneous emphysema.

8. Gauze dressing is placed between the skin and flange of the tube around the stoma

Pic - Betadine soaked gauze or Sofratulle put around the tracheostomy opening.

9.Tapes of tracheostomy tube tied around the neck keeping a space for 1 finger. Neck kept flexed.

Skin incision closed loosely to avoid surgical emphysema.

Post Operative Care

1.Constant Supervision 2.Suction 3.Tracheostomy tube care 4. Others 5.Prevention of crusting and tracheitis

Decannulation

Adult: plug or seal tube opening & if tolerated for 24 hrs, remove

tube.

Child: Sequentially reduce size of tube. After tube removal close

wound. Healing occurs within 1 week. Secondary closure after

freshening the wound margin is required rarely. Infant or a young child-Decannulate in operation theatre-Equipment for re-intubation should ne available like good headlight,

laryngoscope, proper sized endotracheal tubes and a tracheostomy tray

-After decannulation observe for respiratory distress,t achycardia, colour.

-Oximetry is useful

Complications of tracheostomyIMMEDIATE(at time of operation)

INTERMEDIATE(first few days or days)

LATE(prolonged use of tube)

Haemorrhage Bleeding Haemorrhage

Apnoea Displacement of tube Laryngeal stenosis

Pneumothorax Blocking of tube Tracheal Stenosis

Injury to recurrent laryngeal nerves

Subcutaneous Emphysema

Tracheooesophageal Fistula

Aspiration of blood Tracheitis & Tracheobronchitis

Problems of decannulation

Injury to oesophagus Atelectasis & lung abcess

Problems of tracheostomy scar

Local wound infections & granulations

Persistent tracheocutaneous fistula

Procedure for immediate airway management

JAW THRUST OROPHARYNGEAL AIRWAY NASOPHARUNGEAL AIRWAY (TRUMPET) LARYNGEAL MASK AIRWAY TRANSTRACHEAL JET VENTILATION ENDOTRACHIAL INTUBATION CRICOTHYROTOMY/LARYNGOTOMY/MINI TRACHEOSTOMY EMERGENCY TRACHEOSTOMY

Jaw thrust

Oropharyngeal Airway

Nasopharyngeal Airway (Trumpet)

Laryngeal Mask Airway

Transtracheal Jet ventilation

Endotracheal Intubation

Cricothyrotomy/Laryngotomy/Mini tracheostomy

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