4Jackson’s metallic tube Made of German silver (alloy of Ag + Cu + P)Has obturator (pilot), inner tube & outer tubeInner tube is longer than outer tube for its removal & cleaning. Outer tube maintains patency. Pilot is inserted into outer tube for smooth & non-traumatic insertion of tubeLock prevents expulsion of tube during cough
6Fuller’s metallic tube Outer tube bi-valved. The 2 blades when pressed together, help in smooth entry of tube.Inner tube is longer & has a vent for phonationPt phonates by closing main tube openingVent also helps in decannulation of tube
9Portex cuffed tubeMade of siliconized PolyVinylChloride. It is thermolabile & prevents crusting.Low pressure high volume cuff maintains an air-tight seal required for:Prevention of aspiration of secretionsPositive pressure ventilation
21Metallic Tubes Plastic Tubes Easily cleaned without suctionCleaning requires suctionCuff is absentCuff is presentCannot be connected to ventilatorCan be connectedRigid & less comfortable to patientSoft & more comfortableConcomitant radio-therapy is to be avoidedCan be given
23Functions of Tracheostomy 1. Relieves upper airway obstruction2. Improves alveolar ventilation by ing dead space by 30-50% & ing airflow resistance3. Prevention of aspiration of blood & secretions4. Removal of airway secretions in patient with inability to cough or with painful cough5. Administration of anesthesia
29Mid tracheostomy preferred High tracheostomy leads to subglottic stenosisLow tracheostomy is avoided as: Trachea is deeper Displacement of tracheostomy tube is common Proximity to great vessels Surgical emphysema is common Tracheostoma is close to tracheal bifurcation
41Exposure of thyroid isthmus Strap muscles retracted laterally with Langenbeck retractors to expose the trachea & thyroid isthmus
42Isthmus separation from trachea Thyroid isthmus detached from tracheal surface & retracted with blunt tracheal hook.
43Isthmus retraction to expose pre-tracheal fascia
44Division of thyroid isthmus If required, thyroid isthmus is divided between clamps.Transfixion sutures applied at the ends.
45Confirmation of trachea 5 ml syringe containing 4 % Lignocaine taken, its needle inserted into trachea & aspirated. Air bubbles confirm presence of needle in trachea.2 ml of solution injected into trachea & needle removed quickly to avoid breaking of needle during violent cough movements.
46Creation of tracheal window Sharp cricoid hook inserted below cricoid to steady trachea. Tracheal window created by excising anterior 1/3rd of 2nd & 3rd tracheal ring with No. 11 blade & Allis tissue forceps.
63Immediate Complications Occurs during operationPrimary Haemorrhage Air embolismCardiac Arrest Aspiration of bloodCO2 withdrawal ApnoeaInjury to: Apical pleura (pneumothorax),recurrent laryngeal nerve, oesophagus
64Intermediate Complications Occurs within first few daysReactionary & secondary haemorrhageBlocking or displacement of tubeSubcutaneous emphysema, pneumothoraxTracheitis & crustingAtelectasis & lung abscessWound infection & granulation tissue
66Causes of surgical emphysema after tracheostomy Dissection into many tissue planes in neckUse of smaller tracheostomy tubeTight closing of skin incisionExcessive struggling & coughing of pt during extubation
71Tracheostomy care Pt given 100 % oxygen. Deflate the tube cuff. Suction catheter with negative suction pressure ( mmHg) usedCatheter diameter should be < 1/3rd of internal diameter of tracheostomy tubeCatheter length introduced just enough to go beyond inner tube (10 cm)
72Tracheostomy careMultiple-eyed catheters produce less trauma than whistle tip cathetersLubricated catheter tip inserted (with suction off) as pt is inspiring. At end inspiration, suction put on & catheter withdrawn in rotating motion.Each suction procedure should last for seconds. Instill 0.5 ml NaHCO3 to liquefy crusts.
73Tracheostomy careChest auscultated for confirmation of adequate suctioning. Re-inflate cuff to a pressure of 25 mmHg. Patient oxygenated again.Tracheostomy wound dressing done BIDSteam inhalation TID. Moist gauze piece placed over tracheostomy tube opening. Regular chest physiotherapy, expectorants & mucolytics given.
81Tracheostomy tube changing Inner tube is removed & cleaned when blockedOuter tube never removed before 72 hrs to allow formation of tracheo-cutaneous tractCuff of Portex tube deflated for 10 minutes every 2 hours to prevent pressure necrosis & dilatation of trachea
86DecannulationAdult: 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.
88Decannulation difficulty Organic causes:Persistence of cause requiring tracheostomyObstructing tracheal granulationsTracheal oedemaSubglottic stenosisCollapse of tracheal wall (tracheomalacia)
89Decannulation difficulty Non-organic causes:Emotional dependence in childrenInability to tolerate upper airway resistanceIn-coordination of laryngeal opening reflexLong-standing tube leads to impaired laryngeal development
90Tracheostomy Intubation InvasiveNon-invasiveComplications are moreLessCan be kept for > 7 daysShould not be keptPt can speakCannot speakTracheo-bronchial toilet is easyDifficultDecreases dead space by 30-50%Does not
91Disadvantages of Tracheostomy Anosmia: no nasal air entryAphonia: avoided by phonatory ventAspiration: avoided by cuffed tubeInability to lift heavy weightInability to perform strenuous exerciseInability to swim
100Percutaneous Tracheostomy Trachea punctured with needle & cannulaNeedle removed & a guide wire passed into trachea via cannulaCannula removed & graded dilators passed over guide wire till the opening can admit a tracheostomy tube
102Cricothyrotomy1. Midline vertical skin incision made to identify cricothyroid notch. 2. Cricothyroid membrane incised horizontally, with # 11 blade, close to cricoid. 3. Knife handle inserted & rotated by 900, to widen the horizontal opening or tracheostomy tube is inserted. 4. Elective tracheostomy done as soon as possible to avoid subglottic stenosis.
106Tracheal fenestration Indicated for C.O.P.D. where tracheal opening is required for mechanical cleaning.Bilateral medial based skin flaps elevated & tracheal opening made.Distal edges of flaps sutured to margins of tracheal window.Lateral edges of 2 flaps sutured to each other to create watertight skin buttons.