Tracheostomy Dr. Vishal Sharma

Jackson’s metallic tube

Jackson’s metallic tube

Jackson’s metallic tube Made of German silver (alloy of Ag + Cu + P) Has obturator (pilot), inner tube & outer tube Inner 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 tube Lock prevents expulsion of tube during cough

Fuller’s bivalved metallic tube O

Fuller’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 phonation Pt phonates by closing main tube opening Vent also helps in decannulation of tube

Phonation via vent

Portex cuffed tube

Portex cuffed tube Made of siliconized PolyVinylChloride. It is thermolabile & prevents crusting. Low pressure high volume cuff maintains an air-tight seal required for: Prevention of aspiration of secretions Positive pressure ventilation

Cuffed double lumen tube

Cuffed fenestrated tube

Portex uncuffed tube For tracheostomy patient receiving radiation

Uncuffed double lumen fenestrated tube

Hands free speaking valve

Mechanism of speaking valve

Adjustable flange tube Used in obese neck, oedema neck

Salpekar double cuff tube Prevents ischemic necrosis of tracheal cartilage

Cold & hot water humidifiers

Heat & moisture exchanger

Nebulization attachment

Metallic Tubes Plastic Tubes Easily cleaned without suction Cleaning requires suction Cuff is absent Cuff is present Cannot be connected to ventilator Can be connected Rigid & less comfortable to patient Soft & more comfortable Concomitant radio-therapy is to be avoided Can be given

Tracheostomy tube size Age of pt Tracheostomy tube size Portex (I.D. in mm) Metallic (Fg) 1 – 3 yrs 4.0 – 4.5 16 4 – 6 yrs 5.0 18 7 – 9 yrs 5.5 20, 22 10 – 12 yrs 6.0 24, 26 13 – 18 yrs 7.0 – 7.5 28, 30 Adult 8.0 – 9.0 32, 34, 36

Functions of Tracheostomy 1. Relieves upper airway obstruction 2. Improves alveolar ventilation by ing dead space by 30-50% & ing airflow resistance 3. Prevention of aspiration of blood & secretions 4. Removal of airway secretions in patient with inability to cough or with painful cough 5. Administration of anesthesia

Indications for Tracheostomy

A. Respiratory obstruction  Trauma to airway : external, endoscopic  Infection: epiglottitis, croup, Ludwig’s angina, para-pharyngeal /retro-pharyngeal abscess  Neoplasm: laryngo-tracheal, pharyngeal  Foreign body in airway  Oedema of larynx: irritant, allergic, irradiation  Paralysis of larynx: B/L abductor palsy  Congenital: laryngeal web, cyst, choanal atresia

B. Retained airway secretions  Inability to cough: coma, respiratory muscle palsy or spasm, laryngectomy  Painful cough: chest injuries, pneumonia  Excessive secretions: pulmonary oedema C. Respiratory insufficiency  Chronic bronchitis, bronchiectasis, atelectasis, reatined airway secretions

D. Anesthesia administration in:  Laryngo-pharyngeal growths  Maxillo-facial trauma  Trismus  Severe Ludwig’s angina  Positive pressure ventilation for > 72 hrs

Types of Tracheostomy  Emergency  Elective  Temporary  Permanent  Therapeutic  Prophylactic High (1st ring): above thyroid isthmus Mid (2nd – 4th ring): behind thyroid isthmus Low (below 4th ring): below thyroid isthmus

Mid tracheostomy preferred High tracheostomy leads to subglottic stenosis Low 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

Steps of Tracheostomy

Positioning Supine position with extension of neck. General anesthesia with endotracheal intubation.

Infiltration  Cricoid palpated & a 5 cm horizontal incision marked 2 cm below it  2 % lignocaine & 1 in 2 lakh adrenaline injected into incision line

Horizontal Incision A 5 cm horizontal incision made with # 15 blade & deepened below subcutaneous tissue

Vertical Incision A 5 cm midline vertical incision can be made below cricoid in emergency tracheostomy. This avoids injury to blood vessels.

Exposure of strap muscles Investing layer of deep cervical fascia opened vertically with artery forceps. Palpation for tracheal rings done regularly during the dissection.

Retraction of strap muscles

Exposure of thyroid isthmus Strap muscles retracted laterally with Langenbeck retractors to expose the trachea & thyroid isthmus

Isthmus separation from trachea Thyroid isthmus detached from tracheal surface & retracted with blunt tracheal hook.

Isthmus retraction to expose pre-tracheal fascia

Division of thyroid isthmus If required, thyroid isthmus is divided between clamps. Transfixion sutures applied at the ends.

Confirmation 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.

Creation 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.

Cautery assisted window

Holding cartilage with Allis forceps

Tracheal window

Other options

Inferiorly based tracheal flap made & sutured Bjork flap Inferiorly based tracheal flap made & sutured to lower skin edge

Insertion of tracheostomy tube Endotracheal tube withdrawn into larynx Lubricated tracheostomy tube inserted into trachea Confirm presence of tube in trachea with help of ambu bag & auscultation

Suturing of flanges Cuff inflated with 5 ml of air & anesthetic circuit connected to the tube Neck extension released & flanges of tube sutured to skin to avoid tube movement

Tying the tapes 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.

Padded tapes

Insertion of medicated gauze Betadine soaked gauze or Sofratulle put around the tracheostomy opening.

Shower collar

Shower guard

Tracheostomy locket

Immediate Complications Occurs during operation Primary Haemorrhage  Air embolism Cardiac Arrest  Aspiration of blood CO2 withdrawal Apnoea Injury to: Apical pleura (pneumothorax), recurrent laryngeal nerve, oesophagus

Intermediate Complications Occurs within first few days Reactionary & secondary haemorrhage Blocking or displacement of tube Subcutaneous emphysema, pneumothorax Tracheitis & crusting Atelectasis & lung abscess Wound infection & granulation tissue

Surgical emphysema

Causes of surgical emphysema after tracheostomy Dissection into many tissue planes in neck Use of smaller tracheostomy tube Tight closing of skin incision Excessive struggling & coughing of pt during extubation

Tracheostomy site granulation

Late Complications Occurs after weeks / months Subglottic stenosis, tracheal stenosis Tracheo-arterial or Tracheo-venous fistula Tracheo-oesophageal fistula Persistent tracheo-cutaneous fistula Decannulation difficulty Tracheostomy wound scar / keloid Metallic tube corrosion & fragment aspiration

Anatomy of tracheal fistulae

Tube fragment aspiration

Tracheostomy care Pt given 100 % oxygen. Deflate the tube cuff. Suction catheter with negative suction pressure (10 -15 mmHg) used Catheter diameter should be < 1/3rd of internal diameter of tracheostomy tube Catheter length introduced just enough to go beyond inner tube (10 cm)

Tracheostomy care Multiple-eyed catheters produce less trauma than whistle tip catheters Lubricated 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 10-15 seconds. Instill 0.5 ml NaHCO3 to liquefy crusts.

Tracheostomy care Chest auscultated for confirmation of adequate suctioning. Re-inflate cuff to a pressure of 25 mmHg. Patient oxygenated again. Tracheostomy wound dressing done BID Steam inhalation TID. Moist gauze piece placed over tracheostomy tube opening. Regular chest physiotherapy, expectorants & mucolytics given.

Wall suction

Portable suction

Closed-system Multiple-use Suction Unit (CMSU)

Communication chart for pt

Electronic communication

Hand bells

Tracheostomy tube changing Inner tube is removed & cleaned when blocked Outer tube never removed before 72 hrs to allow formation of tracheo-cutaneous tract Cuff of Portex tube deflated for 10 minutes every 2 hours to prevent pressure necrosis & dilatation of trachea

Pt position in tube changing

Cleaning of inner tube

Tube removal over bougie

Obturator guide wire insertion

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.

Capping of tube opening

Decannulation difficulty Organic causes: Persistence of cause requiring tracheostomy Obstructing tracheal granulations Tracheal oedema Subglottic stenosis Collapse of tracheal wall (tracheomalacia)

Decannulation difficulty Non-organic causes: Emotional dependence in children Inability to tolerate upper airway resistance In-coordination of laryngeal opening reflex Long-standing tube leads to impaired laryngeal development

Tracheostomy Intubation Invasive Non-invasive Complications are more Less Can be kept for > 7 days Should not be kept Pt can speak Cannot speak Tracheo-bronchial toilet is easy Difficult Decreases dead space by 30-50% Does not

Disadvantages of Tracheostomy Anosmia: no nasal air entry Aphonia: avoided by phonatory vent Aspiration: avoided by cuffed tube Inability to lift heavy weight Inability to perform strenuous exercise Inability to swim

Percutaneous Tracheostomy

Insertion of cannula

Insertion of guide wire

Tracheal dilator over guide wire

Insertion of tracheal dilator

Tracheostomy tube

Insertion of tracheostomy tube

Percutaneous Tracheostomy Trachea punctured with needle & cannula Needle removed & a guide wire passed into trachea via cannula Cannula removed & graded dilators passed over guide wire till the opening can admit a tracheostomy tube

Cricothyrotomy

Cricothyrotomy 1. 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.

Tracheal fenestration

Tracheal fenestration

Tracheal fenestration

Tracheal 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.

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