JACKSON’S SAFETY TRIANGLE
Triangular space in neck
• Base: Lower end of thyroid cartilage
• Apex: Suprasternal notch
• Sides: Inner edges of sternocleidomastoid muscle
So named as this marks the area through which safe
dissection can be done for tracheostomy
Also represents the area into which infiltration
anesthesia is given during tracheostomy under local
Depth from skin: 18 mm to 32 mm
Length: 11 cm
Levels: C6 to Upper border of T5
Rings: 16 to 20
2nd, 3rd, 4th rings are covered by thyroid isthmus
Cartilaginous ring C-shaped i.e. incomplete posteriorly.
The edges of the C are connected by trachealis muscle which helps in narrowing the
tracheal lumen during coughing-Thus higher velocity of air is generated.
RELATIONS OF THE TRACHEA
Cervical part of trachea
Thoracic part of trachea
CERVICAL PART OF THE TRACHEA
The skin and the superf. & deep fascia.
Jugular arch & overlapped by the sternohyoid and
Tracheal cartilage 2-4 isthmus of the thyroid
Above which an anastomotic artery connect the b/l sup.
Below and in front are the pre tracheal fascia, inf. Thyroid V
communicative band between Ant jugular V, thymic remnants
& thyroidea ima A.
In Children the brachio cephalic A crosses, obliquely in front of
the trachea at or a little above the upper border of the
manubrium; Left BCV also rise a little above this level
• Paired lobes of the thyroid gland descending to the
5th or 6th tracheal cartilageas
• The carotid sheath enclosing the common carotid A,
IJV & vagus nerve.
• The inferior thyroid A lies laterally.
• Oesophagus- running between the trachea & the
• The recurrent laryngeal nerves ascend on either
THORACIC PART OF TRACHEA
Origin of sternohyoid & sternothyroid Muscles
Inferior Thyroid & Left brachiocephalic V
Brachio cephalic A (R)
Deep cardiac plexus
Thoracic duct (left & posterior to the oesophagus)
Right - Right lung upper lobe & pleura
Right BCV, Sup. Venacava,
Rt Vagus Nerve & Azygous V.
Left- Left CCA & Left subclavian A,
Arch of Aorta, Left Vagus Nerve,
Left recurrent laryngeal nerve
BLOOD SUPPLY OF THE TRACHEA
Mainly by the Inferior Thyroid Artery
Thoracic end – Bronchial arteries which anastomose
with the Inferior Thyroid A and also supply the
VEINS: to Inferior Thyroid venous plexus
• LYMPHATICS: Pretracheal & (R & L) Paratracheal LN
Inferior tracheobronchial ‘sub-
Tracheal branches of the vagi.
Recurrent laryngeal nerves.
The sympathetic trunks.
RLN – motor fibers to the muscles of the trachea an
trachealis muscle, also carry sensory fibers from the
Sympathetic nerve fibers – derived mainly from middle
LAYERS OF DISSECTION
Platysma (absent is midline)
Two anterior jugular veins and
anastomosing veins between them
Deep fascia (investing layer)
The patient should be positioned on the operating table
with the neck extended. This is accomplished by
placing a shoulder pad under the patient’s shoulders.
This results in extension of the neck and exposes more
of the trachea as it is brought up out of the chest.
The head should be supported in a head ring and the
patient should be lying squarely on the table.
Marking the Incision
The trachea and
be palpated in
order to establish
where to make the
This should be a
the sternal notch
and the cricoid
can be felt just
inferior to the
Infiltrate skin with
2% Xylocaine with
before scrubbing or
after cleaning the
surgical field with
betadine or with an
septic, surgical skin
A second tube
should be available
as well as a
selection of smaller,
and larger tubes in
case a problem
A catheter mount is
also needed to
anaesthetic tube to
be attached to the
items include a
cricoid hook, a
tracheal dilator and
• The patient should be draped using three small
and one large sticky drape.
• A head drape should not be used, as it needs to be
unwrapped in order to gain access to the ET tube
and this cannot be done in a hurry, as it is
• Place one small sticky drape on either side of the
neck, up to the angle of the jaw making sure that
the anaesthetic tube is not stuck to the drape. The
third drape is applied horizontally just under the
The incision is
made through the
platysma, down to
the deep cervical
The anterior jugular
veins will be
superficial to the
deep cervical fascia
on either side of the
Note that the
trachea is deeper
than one imagines.
A self-retaining retractor can now be inserted
and the dissection continued until the strap
muscles are encountered.
These should be separated in the midline. The
assistant can do this using a pair of Langenbeck
The dissection is continued with blunt ended
dissecting scissors. If one stays in the midline, it
is a relatively bloodless field and one continues
deeper until the thyroid isthmus is identified.
If the trachea is low in the neck
and one is having difficulty
accessing the upper trachea, then
there are two strategies to bring
the trachea further up into the
Firstly a Cricoid hook can be used.
The hook is inserted into the
trachea just under the cricoid
cartilage and the trachea is gently
pulled upwards into the incision.
This usually works well.
An alternative strategy is to insert
a deep Travis retractor and place
the upper arm against the lower
edge of the thyroid cartilage and
the lower, against the upper edge
of the sternum. When the retractor
is opened the trachea is drawn
upwards by the pull on the more
robust thyroid cartilage.
Dealing with Thyroid Isthmus
There are different opinions regarding this-
1. Dividing the Isthmus between two clamps and
2. Pulling thyroid Isthmus up.
3. Pulling thyroid isthmus down.
Once the isthmus is divided or pulled up or down
the trachea will be exposed and the rings should
Meticulous haemostasis is essential at this stage
as it is difficult to visualize the depths of the
wound once the tube is in situ. The surgeon
should therefore pay attention to any bleeding at
this stage by judicious use of bipolar diathermy.
The tracheostomy should be sited over the 2nd
and 3rd or 3rd and 4th tracheal cartilages. It is
always better to identify Cricoid cartilage by
palpation and count the rings downwards.
The tracheostomy must not involve the first
tracheal ring because of the high incidence of
post-op, subglottic stenosis if it is divided.
• The trachea should be incised longitudinally in the
midline through these cartilages or if the cartilages
are heavily calcified, a window, big enough to
take an appropriate sized tube, should be cut in the
anterior aspect of the tracheal cartilages.
• Care must be taken not to dissect laterally as the
recurrent laryngeal nerves may be damaged.
• A pair of heavy scissors may be necessary to cut
through heavily calcified cartilages.
When one is ready to make the incision in the
trachea, the anaesthetist should be alerted so that
he/she can be ready to withdraw the tube.
Check that all the equipment is available and
working before making your incision. Make
especially sure that the right size tube has been
If the trachea is relatively deep to the skin
edge, an adjustable flange tube is
recommended as there is less likelihood of
the tube being displaced in the early post-
Make every effort not to puncture the cuff of the
tube. The easiest way to do this is to ask the
anaesthetist to push the tube further down the
trachea towards the carina before making the hole.
Once the trachea is incised the tube is withdrawn
under direct vision until the tip is just above the
It should not be removed as it can be rapidly
advanced to secure the airway in the event of a
Tracheostomy Tube Insertion
Tracheal dilators will be needed to enable the tube
to be inserted into the tracheal lumen.
The assistant should now hold the tube in situ
until it is secured. Use a flexible suction catheter
down the tube to suction any blood or mucus out
of the trachea and connect the catheter mount to
the tracheostomy tube and the anaesthetic tubing.
Inflate the cuff of the tube with enough
air to create a seal.
The anaesthetist should confirm that
there is good CO2 return and that the
patient is oxygenating well and that the
air-pressures are adequate.
Check the cuff on the tracheostomy
tube is staying inflated as it can be
punctured by a sharp edge of calcified
cartilage. If it has, then change the tube.
The tracheostomy wound should be closed with
monofilament, interrupted sutures to the skin. This
is a loose closure and no more than two or three
sutures are needed on either side of the tube.
Tight closure may result in surgical emphysema
especially if positive pressure ventilation is used.
The sutures can be removed after seven days.
Securing the Tube
• The tube itself should be secured with both
tracheostomy ties and sutures.
• This will prevent the tube from falling out if
someone is offended by blood on the ties and
decides to change them in the immediate post-
• The tube is sutured in place using a thick silk stitch.
The stitch is placed through the loop provided for
the ties and not through the plastic of the flange
The sutures are tied with just enough slack to
allow the gauze soaked in betadine (or Lyofoam)
dressing to be inserted between the skin and the
The tracheostomy tapes are tied around the neck
only once the sand bag has been removed from
behind the patient’s shoulders and the neck has
The easiest way to securely fasten the tapes to the
flange of the tube is to make a loop with a long and
short limb and pass this loop through the flange and
then pull the ends of the tape through the loop and
pull them tight. This will lock the tape in place.
Now pass the long ends of the tape under the
patient’s neck and tie securely to the opposite short
The tapes should be tied in such a way that only the
tip of one finger can be placed between them and
the skin of the neck and they should be tied with
proper knots and not bows!
Vertical Incision between Cricoid and
Straight incision up to or including trachea in
Insert the tube as soon as possible
Once tube is in place and patient is ventilated,
ICU Bed Side Tracheostomy
Use of guide wire and Dilators
Under the vision of Bronchoscope through endo
Not suitable for thick neck and in emergency
COMPLICATIONS OF TRACHEOSTOMY
Bleeding and injury to big vessels
Injury to tracheoesophageal wall
Tracheostomy tube obstruction
Tracheostomy tube displacement
Prevent complications associated with
Help in the full recovery of the patient.
Give the patients and attendants an understanding
of the problem.
Can be considered under two periods:
1)Care when the patient needs the tracheostomy.
2)Care when the patient needs to be weaned off the
While doing tracheostomy care what to
document in the file?
Date and time:
Size of the tube:
Position and Patency:
Condition of the tracheostomy wound:
SaO2 with or without O2 supplementation:
Secretions in suction:
Condition of patient before care and after care:
Signature and name:
After doing a tracheostomy, you have put
somebody into danger by preventing him from
shouting for help if he needs any.
The best way to prevent this is by giving a hand
bell to the patient which he can ring whenever
he needs help.
However if the patient is on ventilator, we have
Care when the patient needs the
1) Care of the wound/stoma
2) Care of the tube
3) Care of the lungs and trachea
First and foremost thing to do after a tracheostomy
is done: Do a chest X ray.
This helps in knowing the position of the tube,
how far is it from the carina and if any problems
have occurred during tracheostomy. Also the
condition of the lung is documented.
Care of the wound/stoma
We have opened the skin into the lung by doing
Infection can enter from the surface into the
lung or vice versa.
Also the incision site can get infected.
Hence a barrier is to be maintained between the
lung and the skin.
Simple sterile dressing with an antibiotic soaked
guaze is all that is needed.
Take a simple 2 by 2 square gauze.
Clean the operative site with betadine.
Cut the gauze half in the midline.
Soak it with antibiotic solution or ointment.
Place the gauze in such a way that the cut part
accomodates the tube and the remaining stays on
Inspect the wound daily for any granulations or
If there are granulations, antibiotic steroid is
If there is infection, take a swab for c/s and treat
Make sure the tube retainers are secure.
Change dressing once daily.
During the process of decannulation, just apply a
tight bandage to the wound. It just heals without
Care of the tube
Change tube retainers if loose. Do not take any chance.
Tube retainers should not be too tight or too loose.
As a general rule, put two fingers beneath the knot while tying
so as to get the adequate tension of the retainer.
Tube to be changed every one week- asses the progress of the
patient and change to suitable tube.
If patient needs long term tracheostomy, better to change to a
tube with least tissue reaction.
Clean inner cannula regularly.
Check for the patency of the tube.
When the tube is patent without any block, there is absolutely silent
The air blast measured by keeping a cotton wool near the
tracheostomy tube opening- there is very good movement of the wool.
If there is noise, the the tube is partially blocked.
If the patient is sweating, appearing tense and anxious, then the tube
is near complete blocked.
Do not depend on the SaO2 as it will not drop for a long time after the
tube is blocked.
Partial block can be cleared by suctioning.
Near complete block requires a tube change immediately, or
else patient will land up in negative pressure pulmonary
What to do?
Do not panic.
Deflate the cuff in case of cuffed tube.
Remove the inner cannula if it is there, there ends the
Get a tube same size or smaller.
Change the tube. Law states that two medical personnel
should be there while changing the tube.
If the tracheostomy is less than 48 hours old, have a
tracheostomy set with you.
Alternatively use the rail road technique of changing the
Railroading technique of changing tube
Insert suction catheter and remove the
tube, keep catheter in place without
Thread a new tube over the suction
catheter and secure it in place,then
remove the catheter.
Standard technique: give extension, remove the old tube, introduce the
new tube as if introducing a suction catheter for suctioning. Do not
force push the tube. It might form a false track.
Care of the lungs and trachea
Care of the cuff.
Humidification and oxygenation.
Expulsion of secretions
Using a cuff pressure manometer, check the pressure of the
tracheostomy cuff. Should be less than 25 cm of H2O. If
more chances of tracheal injury. If more pressure is needed,
then change the tube. As a simple rule, air in cc about half
the size of tracheostomy tube is sufficient for adequate
volume and pressure of the cuff.
Check if the cuff is functioning daily by pressing the pilot
and waiting for it to slowing fill up.
Also patient will elicit a cough reflex when the pilot is
pressed if cuff is intact.
Deflate cuff hourly for five minutes-not really needed if
pressure and volume are correct.
Most of the problems related to tracheostomy
happen due to the technique of wrong
Vigorous suctioning can cause both barotrauma
as well as physical trauma, leading to bleeding
and lung collapse.
Unsterile technique can cause lung infection.
Timid technique can cause retention of
secretions and tube block.
Suction sos if there is gurgling/rattling. No need
for hourly suction.
Tips for suctioning:
Use a suction catheter whose size is less than or
equal to half of the ID of the tracheostomy tube
to be suctioned.
Set the suction pressure to 60-150 mm of Hg by
adjusting the knob on the machine.
Do not introduce the suction catheter too much
inside else it will injure the carina. See the chest
x ray to find out how much away from the carina
is the tube tip. Measure the length of the tube
from the obturator. Mark on the suction catheter
how much to introduce.
Alternatively use a flexible bronchoscope to
measure the length.
Use sterile universal precautions.
Number in FG Size of catheter
Can be used
GREY 5 1.70 3.0, 3.5
LIGHT GREEN 6 2.00 4.0, 4.5, 5.0
BLUE 8 2.70 5.5, 6.0
BLACK 10 3.30 6.5,7.0,7.5
WHITE 12 4.00 8.0, 8.5, 9.0
DARK GREEN 14 4.70 9.0
ORANGE 16 5.30 WE DO NOT HAVE
TUBES FOR THIS
RED 18 6.00
Instill few drops of saline into the tracheostomy
opening. Followed by few drops of sodium
bicarbonate solution. Helps in softening the
secretions and easy expulsion.
Wait for cough reflex. Hold your breath.
Introduce the suction catheter sterile in closed
position and take it out slowly in revolving
motion after opening the suction. Catheter should
be out before you feel like re-breathing again.
Can be repeated.
In case of ventilated patients, increase the PEEP,
disconnect the tube, suction.
Closed suction system
Alternatively a novel method of suctioning called
the closed suction system can be used wherein
1)there is no need to disconnect the patient from the
ventilator while suctioning.
3)no need to change catheters
4)no need for sterile precautions
5)cost effective in the long run
The set up is connected to the tracheostomy tube
and kept. Suction can be done any time without
disturbing the ventilation.
Care when the patient needs to be
weaned off the tracheostomy
1)humidification, temperature regulation and
2)expulsions of secretions and swallowing
Humidification, temperature regulation
Usually achieved while on oxygen because it is
humidified. A HME(heat and moisture
exchanger) is fixed to the circuit which does the
job of conserving heat.
Oxygen can be given by mask or by T-piece
recovery kit(if not on ventilator).
If patient not needing oxygen a Thermovent –T
can be connected to the tracheostomy.
Alternatively , the stoma/tube can be kept
covered with a wet gauze.
Expulsion of secretions
Physical therapy in the form of chest
Pharmocological agents like terbutaline,
Swallowing therapy is started to help in
handling the secretions and meet the nutritional
Speech while on tracheostomy
If using an metal tube, patient can simply occlude
the opening of the tube with thumb during
expiration to phonate.
If using cuffed tubes, special tubes designed for the
same to be used.
If using uncuffed portex or tracoe tubes, other than
digital occlusion, specially designed speaking
valves as attachments for the tubes are available.
Advantage being the hands are free, if needed,
oxygen also can be delivered simultaneously which
does not happen with digital occlusion.
CARE AT HOME
Patient and attendants are educated while in the
hospital regarding self tracheostomy care.
Strictly no water sports.
Commercially available kits for dressing and tube
cleaning can be purchased.
To buy a suction machine.
Tracheostomy shower cap to be used while taking
Always to carry a smaller size tube in case there is
Tracheostomy is not needed if:
Indication for the procedure is tided over.
Patient is breathing without ventilator; maintaining
saturation on room air.
Able to handle his secretions without aspiration .
Excellent cough reflex and healthy lung.
Once a decision has been made that the patient does not
need a tracheostomy any more, the procedure of
decannulation is started.
IDL to look at condition of vocal cords.
X ray neck lateral view, to look at the airway above the
Alternatively a flexible nasopharyngolaryngoscopy will
If the condition is feasible, first down size the
tube to the smallest size through which only
inspiration happens fully, but expiration happens
through both glottis and the tube. Patient should
be able to produce a faint voice without the tube
being occluded, good voice with the tube
In adults about a size 6 Romson tube
Gradually block the tube for 48 hours and allow
for normal activities.
If no distress, remove the tube and plaster it.
Observe for 24 hours and discharge.
Be the first to comment
Login to see the comments
May. 7, 2020
Jun. 23, 2020
Jul. 14, 2020
Jul. 22, 2020
Jul. 27, 2020
Sep. 4, 2020
Sep. 27, 2020
Sep. 30, 2020
Oct. 13, 2020
Nov. 13, 2020
Nov. 16, 2020
Nov. 25, 2020
Jan. 2, 2021
Jan. 28, 2021
Feb. 7, 2021
Mar. 10, 2021
Apr. 9, 2021
Jun. 21, 2021
Jun. 29, 2021
Aug. 3, 2021
Slides regarding tracheostomy and care to be taken.