Oldest surgical procedure- Tracheostomy!! Know about it...

1. TRACHEOSTOMY

2.  A Tracheostomy is an artificially( usually)
surgically created airway fashioned by making
a hole in the anterior wall of trachea and the
insertion of a tracheostomy tube, which may
or may not be permanent.
Tracheotomy is the opening into trachea
where as tracheostomy is converting the
opening into stoma onto the skin surface.

3.  Tracheostomy is one of the oldest surgical
procedure.
 A tracheotomy was portrayed by the Egyptians and
Indians in the early years.
 Extensive history of tracheostomy can be best
divided into five periods:
 1. The period of Legend (3100BC to AD 1546)-
 The first elective tracheotomy by Asclepiadus of
Bithynia in AD100.
 This operation ws described by Claudius Galen,
renowned physician in AD 131
 References were made to tracheotomy, but was
considered both useless and dangerous due to
high risk of wound infection
 Hippocrates condemned tracheostomy

4.  2. The period of Fear(AD 1546-1833) in
the history of tracheostomy:
 During this era, this procedure ws
considered as irresponsible and barbaric.
 By early 1600s, it started getting
acceptable for few conditions like FBs etc.
 Bcoz of fear and mistrust abt procedure, it
prevented therapatic use of it, for eg. In
1799,dec4th,first US president died of
acute(within 36 hours) upper airway
obstruction sec. to peritonsillar abscess
 3.The period of Dramatisation(AD 1833-
1932):
 It was considered as operation of life or
death.
 The operative technique of tracheostomy
was studied, refined and defined by
Chevalier Jackson in 1909.
 He also designed the metallic double
lumen tube

5.  4. The period of Enthusiasm(AD 1932- 1965)
 Wherein saying “if u think tracheostomy……do it”
became popular.
 Indications for tr. Were actively sought for and both
surgical and medical world became strong advocates
for it
 5.The period of Rationalisation(AD 1965 to present):
 In 1965, it became apparent tht oral or nasal
intubation was quicker and safer than tr. So began
this period wherein tr. Vs intubation ws debated.
 Seldinger introduced PCT in 1953
 PCT using guidewire introduced by Ciaglia et al.
 In 1990 Griggs et al developed another guidewire
dilating forceps for PCT

6.  The trachea begins at the
lower border of cricoid
cartilage(C6) superiorly to
the tracheal bifurcation at
the level of sternal angle(T5).
 Made up of 16 to 22 C-
shaped cartilage anteriorly
joined by annular ligaments
and posteriorly by trachealis
muscle.
 Located in midline
position,but can be deviated
to right as in advanced age
or severe COPD.
 The average distance from
cricoid to carina is approx
12-16 cm long,2.3 cm wide.

7.  Anterior to the trachea in the neck is the
isthmus of the thyroid gland at about the level
of 2nd to 4th tracheal cartilages.
 Below this is the inferior thyroid veins, lymph
nodes, and sometimes a thyroid ima artery.
 Anterior to all of these are the strap muscles.
 Lateral to trachea in the neck are the lobes of
thyroid gland, great vessels and recurrent
laryngeal vessels.

8.  The innominate artery crosses the trachea
either behind the sternum or in the lower
portion of neck.
 During tracheostomy the careful surgeon will
palpate this region to assess the presenceof
high riding innominate artery.
 The jugular venous arch connecting two
anterior jugular veins lies superficial to the
strap muscles just above the suprasternal
notch.

9.  The basic anatomical relationships need to
be kept in mind in performing a
tracheostomy.
 High tracheostomies (above 2nd tracheal
cartilage) are generally associated with a
higher rate of tracheal stenosis and
perichondritis of cricoid cartilage.
 Low tracheostomy (below 4th tracheal
cartilages) will encounter more vascular
structures such as thyroid veins, ant. Jugular
arch, or a high innominate artery.

10.  Horizontal skin incisions tend to be more
cosmetic, although the ext. jugular veins and
lateral anatomic structures must be
considered during dissection.
 Vertical skin incisions tend to be avascular.
 Paediatric larynx and tracheal anatomy varies
from adult and has a great clinical
signiicance.

13.  Arteries of central neck:
 Common carotid A.
 Carotid bifurcation
 Internal carotid A
 Ext. carotid A. and br.
 Superficial veins of central neck:
 Ext. Jugular vein and ant jugular vein
 Deep veins of central neck:
 Internal jugular vein

15. Nerves of central neck:
 Cutaneous innervation
 Tenth nerve and its br.
 Twelfth nerve and ansa cervicalis
Visceral structures of neck
 Thyroid gland
 Larynx
 Trachea and esophagus

16. Prolonged intubation
Facilitation of ventilation support
Inability of patient to manage secretions
Upper airway obstruction
Inability to intubate
Adjunct to major head and neck surgery
Adjunct to management of major head and neck trauma
Cummings: Otolaryngology: Head & Neck Surgery, 4th
ed.2005.
Goldenberg D, et al Tracheotomy: changing indications and a
review of 1,130 cases, J Otolaryngol 31:211–215, 2002

18. Tracheostomy in a number of medical and surgical
conditions e.g.:-
 Trauma to the chest.
 C.C.F. & pulmonary edema.
 C.O.P.D
 Head injury.
 Coma.
 Strychnine poisoning.
 Tetanus, Rabies, Poliomyelitis.
 Neurological conditions.
 Before doing major head and neck surgery
tracheostomy is done to prevent post operative
complications.

19. Emergency tracheostomy
Elective – therapeutic or prophylactic
Permanent

20.  Emergency: when airway is complete or
almost completely obstructing as in FBs or
acute infections.
 Elective: planned unhurried procedure.Often
temporary and closed when indication is
over.
 Therapeutic: to relieve respiratory
obstruction,remove tracheobronchial
secretions or gv assisted ventilation.
 Prophylactic: in extensive surgeries of
tongue, floor of mouth, mandibular resection
or laryngofissure.
 Permanent tracheostomy: In b/l abd.
paralysis, laryngectomy,
laryngopharyngectomy.

21. high
Above the level
of thyroid
isthmus
-Violates 1st
tracheal ring
-Ca larynx
mid
Preferred one
2nd & 3rd rings
low
Below the level
of isthmus
-Trachea is deep
-close to vessels
-impinges on
supra sternal
notch

22.  Position: supine with a pillow under the
trachea. This brings trachea forward.
 Anesthesia: mostly done under local with 2%
lignocaine with epinephrine. Sometimes GA
is used.
 Incision:Vertical- midline of neck, from
cricoid above to sternal notch.
 Most favoured incision. Can be used in both
elective and emergency. Rapid access with
minimum bleeding and tissue dissection.
 Horizontal -2 fingers breadth above the
sternal notch. Used in elective procedure
only. Cosmetically better scar.

23.  Strap muscles separated in midline and
retracted laterally.
 Thyroid isthmus is displaced upwards or
divided-ligated.
 Identification of tracheal rings by colour and
palpation
 confirmation- 4% lignocaine loaded syringe
introduced, withdrawn to see for air
bubbles, also to suppress cough.
 Vertical incision given in trachea from below
upwards in 3 or 4th tracheal rings
 Tube of appropriate size used. Tied to neck
with reaf knot.
 Skin sutures not required.

24. Incision 1 cm below the cricoid or
halfway between the cricoid and the
sternal notch.
Retractors are placed, the skin
is retracted, and the strap
muscles are visualized in the
midline. The muscles are
divided along the raphe, then
retracted laterally

27. Baby with
One Fingertip
D
One Fingertip Fits
Under the Adult Ties
BLS

28. ANATOMICAL POSITIONING OF
A TRACHEOSTOMY TUBE

29. INFANTS
•Sub glottic haemangioma
•Sub glottic stenosis
•Laryngeal cyst
•Glottic web
•Bilateral vocal cord paralysis
CHILDREN
•Acute laryngotracheal bronchitis
•Epiglottitis
•Diphtheria
•External laryngeal trauma
•Prolonged intubation
•Juvenile laryngeal papillomatosis

30.  GA
 Trachea –soft and compressible
 Too much of extension- Pleural injury,
innominate , thymus injury
 Silk sutures on either side of trachea to
secure it in midline
 Not to incise deeply as it can cause
posterior tracheal wall injury.
 Not to excise ant. Wall of trachea- only
incision is given
 Avoid infolding of ant tracheal wall
 Proper selection of T tube

31.  Nursing: constant supervision of pt after
tracheostomy for bleeding, displacement or
blocking of tube and removal of secretions.
 Removal of secretions: Suction
 Prevention of crusting and tracheitis:
Humidification, use of normal or hypotonic
saline or RL. If tenacious secretions, use of N-
acetylcysteine to loosen crusts
 Care of T.tube: Inner tube cleaning
 Care of inflatable cuff
 Dressing: to avoid maceration of skin from
secretions
 Breathing exercises: recommeded to ventilate
the lungs fully and prevent pulmonary infections
 A calling bell, slate and a pencil for

32.  ICU Bed SideTracheostomy
 Minimally invasive alternative to open
tracheostomy
 Use of guide wire and Dilators
 Under the vision of Bronchoscope through
endotracheal tube
 Less time ,Less Expensive
 Not suitable for thick neck and in emergency

34.  Intraoperative
Complications.
 Anaesthesia
complications
 Bleeding and injury to big
vessels
 Apnoea- due to sudden
washout of co2
 Injury to recurrent laryngeal
nerve
 Injury to tracheoesophageal
wall
 Pneumothorax- injury to
apical pleura

35.  Bleeding, reactionary or secondary
 Tracheostomy tube obstruction
 Tracheostomy tube displacement
 Subcutanoues empysema
 Tracheitis and tracheobronchitis with
crusting in trachea
 Atelectasis and lung abcess
 Local wound infection and
granulations

36. • Hemorrhage, due to erosion of major vessels
• Laryngeal stenosis, due to perichondritis of
cricoid cartilage
• Tracheal stenosis, due to tracheal ulceration
and infection
• Tracheo –oesophageal fistula
• Problems of decannulation
• Persistant tracheocutaneous fistula
• Problems of T.scar- keloid formation
• Corrosion of tracheostomy tube and aspiration
of its fragments into tracheo bronchial tree

37. 5/24/2015 37

38.  T. tube should not kept longer than necessary
 To decannulate, it shud be plugged or corked
and the pt shud be able to sleep overnight
with the tube closed before decannulation
 After tube removal , pt is closely monitored
for resp.distress and tachycardia

39.  It may be:
 Persistance of the condition for which
tracheostomy was done.
 Obstructing granulations: around stoma or at
tip of tube
 Tracheal oedema or subglottic stenoses
 Incurving of tracheal wall at the site of
tracheostome
 Tracheomalacia
 Psychological depandance

40. 1. Increased patient mobility
2. More secure airway
3. Increased comfort
4. Improved airway suctioning
5. Early transfer of ventilator-dependent
patients from the intensive care unit (ICU)
6. Less direct endolaryngeal injury
7. Enhanced oral nutrition
8. Enhanced phonation and communication
9. Decreased airway resistance for promoting
weaning from mechanical ventilation
10.Decreased risk for nosocomial pneumonia
in patient subgroups

41.  A tracheostomy tube
is:-
◦ Inserted through the
tracheostomy to
maintain a patent
airway
◦ Secured in place by
tapes tied around the
neck
◦ Ideal T.tube:
◦ Rigid enough to
maintain the airway.
◦ Yet flexible enough to
limit tissue damage
◦ Comfortable to the pt.

42. Parts Description
Outer cannula 1. Main body of the tube which passes into
trachea
2. Diameter – inner dia of this outer cannula
Inner cannula 1. Removable tube –passes into outer tube
2. A bit longer
3. Can be locked
Cuff 1. Balloon at the distal end
2. Protection
Pilot balloon 1. Ext balloon connected by a inflation line to
cuff
Flange – neck
plate
1. Supports the tube
2. Straight strip- adults
3. Angulated- pediatric
4. Adjustable flanges- bulky neck
Introducer/
obturator
1. Beveled tip shaft
2. Smooth round dilating tip
3. Reduces trauma – insertion
Fenestrations 1. Single/ multiple
2. Speaking
3. Coughing

43.  Passy Muir valve
 Speaking valves are
one way valves that
allow inhalation
through the
tracheostomy tube
but block exhalation
through the cannula
forcing exhaled gas
through vocal cords
allowing phonation

45.  Cuffed- when
inflated, this
tube seals the
airway and
prevents the
aspiration of
oral or gastric
secretions.

46.  Maintains airway
once aspiration risk
has passed.
 Increases airflow to
the larynx.
 Required in
 Long term T. pts
 Pts who do not
require a seal
 Paediatrics

47.  Fenestrated

48. 

49. 

51. 

52. 

53. 

54.  PVC- Most cost effective, for short term use ,
More prone to infections.
 Silicone –soft material, unique characteristic of
reducing adherence of secretions and bacteria
 Siliconised PVC- sufficient rigidity,
Thermosensitive, More pt. comfortable. Eg
Portex ultra
 Silver- 92.8% silver, Cu and P with silver lining,
For prolonged use. Eg Negus and Chavelier
Jackson
 Sialistic –silicon rubber, less rigid. Eg. Moore