TRACHEOSTOMY

TRACHEOSTOMY

• MAKING AN OPENING IN THE ANTERIOR WALL OF TRACHEA & CONVERTING IT IN TO A STOMA ON THE SKIN THE SURFACE

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 byrepeated suction through the tracheostomy, thus avoiding need for repeated bronchoscopy or intubation which is not only traumatic butrequires 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

• There are three main indications • A. Respiratory obstruction.• B. Retained secretions.• C. Respiratory insufficiency.

A. Respiratory obstruction

• 1. InfectionsAcute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria Ludwig's angina, peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess

• 2. TraumaExternal injury of larynx and trachea ,Trauma due to endoscopies, especially in infants and children,Fractures of mandible or maxillofacial injuries

• 3. NeoplasmsBenign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and thyroid

• 4. Foreign body larynx• 5. Oedema larynx

due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), radiation

• 6. Bilateral abductor paralysis• 7. Congenital anomalies

• Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia

B. Retained secretions

• 1. Inability to cough• Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic

overdose• Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre

syndrome, myasthenia gravis• Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning

• 2. Painful cough• Chest injuries, multiple rib fractures, pneumonia

• 3. Aspiration of pharyngeal secretions• Bulbar polio, polyneuritis, bilateral laryngeal paralysis

C. Respiratory insufficiency

• Chronic lung conditions, viz. emphysema, chronic bronchitis, bronchiectasis, atelectasis

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. Almost all operative surgical facilities are available, endotracheal tube can be put and local or general anaesthesia can be given. • 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

• bilateral abductor paralysis & laryngeal stenosis.

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above the level of thyroid isthmusperichondritis of the cricoid cartilage and subglotticstenosis and is always avoided. Only indication } carcinoma of larynx because in such cases, total larynx anyway would ultimately be removed and a fresh tracheostome made in a clean area lower down

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preferred oneThrough the II or III rings and would entail division of the thyroid isthmus or its retraction upwards or downwards to expose this part of trachea.

below the level of isthmus. Trachea is deep at this level and close to several large vessels; also there are difficulties withtracheostomy tube which impinges on suprasternal notch.

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.

• Anaesthesia• No anaesthesia }unconscious patients/ emergency procedure. • conscious patients, 1-2% lignocaine with epinephrine• GA with intubation+/-

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.

A transverse incision, 5 cm long, made 2 fingers' breadth above the sternal notch can be used in elective procedures. It has the advantage of a cosmetically better scar .

• 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.

• 6. 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 (Fig. 63.2).• 7. Tracheostomy tube of appropriate size is inserted and secured by

tapes • 8. Skin incision should not be sutured or packed tightly as it may lead

to development of subcutaneous emphysema.• 9. Gauze dressing is placed between the skin and flange of the tube

around the stoma.

• Compli cati ons• A. Immediate• (at the time of operation):• 1. Haemorrhage.• 2. Apnoea. This follows opening of trachea in a patient who had prolonged respiratory

obstruction. This is due to sudden washing out of CO2 which was acting as a respiratory stimulus. Treatment is to administer 5% CO in oxygen or assisted ventilation.

• 3. Pneumothorax due to injury to apical pleura.• 4. Injury to recurrent laryngeal nerves.• 5. Aspiration of blood.• 6. Injury to oesophagus. This can occur with tip of knife while incising the trachea and

may result in tracheo-oesophageal fistula.

• B. Intermediate• (during first few hours or days):• 1. Bleeding, reactionary or secondary.• 2. Displacement of tube.• 3. Blocking of tube.• 4. Subcutaneous emphysema.• 5. Tracheitis and tracheobronchitis with crusting in trachea.• 6. Atelectasis and lung abscess.• 7. Local wound infection and granulations.

• C. Late(with prolonged use of tube for weeks and months):• 1. Haemorrhage, due to erosion of major vessel.• 2. Laryngeal stenosis, due to perichondritis of cricoid cartilage.• 3. Tracheal stenosis, due to tracheal ulceration and infection.• 4. Tracheo-oesophageal fistula, due to prolonged use of cuffed tube or erosion of trachea

by the tip of tracheostomy tube.• 5. Problems of decannulation. Seen commonly in infants and children.• 6. Persistent tracheocutaneous fistula.• 7. Problems of tracheostomy scar. Keloid or unsightly scar.• 8. Corrosion of tracheostomy tube and aspiration of its fragments into the

tracheobronchial tree.

1. Jaw thrust

Lifting the jaw forward and extending the neck improves the airway by displacing the soft tissues. Neck extension should be avoided in spinal

injuries.

2. Oropharyngeal airway

It displaces the tongue anteriorly and relieves soft tissue obstruction. Ventilation can be carried out by face mask placed snugly over the face and

covering both nose and mouth. Ambu bag can be used for inflation of air or oxygen.

3. Nasopharyngeal airway (trumpet)

It is inserted transnasally into the posterior hypopharynx and relieves soft tissue obstruction caused by the tongue and pharynx. It is better tolerated

than oropharyngeal airway in awake patients.

4. Laryngeal mask airwayIt is a device with a tube and a triangular distal end which fits over the laryngeal inlet . Oxygen can be delivered directly into the trachea.

Though most commonly used for non-emergent airway control, it can be used as an alternative if standard mask ventilation is inadequate and

intubation unsuccessful

6. Endotracheal intubation

This is the most rapid method. Larynx is visualised with a laryngoscope and endotracheal tube or a bronchoscope inserted. No anaesthesia is

required. This helps to avoid a hurried tracheostomy in which complication rate is higher. After intubation, an orderly tracheostomy can be

performed.

7. Cricothyrotomy or laryngotomy or mini tracheostomy

This is a procedure for opening the airway through the cricothyroid membrane. Patient's head and neck is extended, lower border of thyroid

cartilage and cricoid ring are identified. Skin in this area is incised vertically and then cricothyroid membrane cut with a transverse incision. This

space can be kept open with a small tracheostomy tube or by inserting the handle of knife and turning it at right angles if tube is not available. It is

essential to perform an orderly tracheostomy as soon as possible because perichondritis, subglottic oedema and laryngeal stenosis can follow

prolonged laryngotomy.

8. Emergency tracheostomy

Technique of emergency tracheostomy is as follows: Patient's neck is extended, trachea identified and fixed between surgeon's left thumb and

index finger. A vertical incision is made from lower border of thyroid to suprasternal notch cutting through skin and subcutaneous tissues. Lower

border of cricoid cartilage is identified and a transverse incision made in pretracheal fascia. The thyroid isthmus dissected down to expose upper

three tracheal rings. Vertical tracheal incision is made in 2nd and 3rd rings, opened with a haemostat and the tube inserted. Bleeding can be

controlled by packing with gauze.

Emergency tracheostomy on a struggling patient with inadequate lighting, suction and instruments is fraught with many complications. If possible,

an endotracheal tube should be put for a more orderly procedure to be carried out.

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