Tracheostomy

DR. ISA BASUKI DEPARTMENT OF SURGERY AWS GENERAL HOSPITAL

FACULTY OF MEDICINE MULAWARMAN UNIVERSITY

Etymology and terminology

tracheotomy comes from two Greek words the root tom- (from Greek ) meaning "to cut

the word trachea (Greek )

Tracheostomy meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itself Definition: surgical procedure to bypass the airway in the patient with upper airway obstruction, to make tracheobronchial toliet easier in the patient with decreased consciousness or for need of ventilator installation

Indicaton: General
to bypass an obstructed upper airway; 2. to clean and remove secretions from the airway; 3. to more easily, and usually more safely, deliver oxygen to the lungs.
1.

Indications: Spesific
Airway Bypass
Severe inflammation of face, neck and larynx Tracheal injury Upper airway tumor Thyroid operation with complication of bleeding or bilateral recurrent nerve paralysis Neck radiotherapy Severe head and neck operating procedures Facial injury with multiple fracture

Bronchial Toilet
Head trauma with consciousness disturbances, uneffective cough Tracheobronchitis with an edema and a lot of secretes Thoracic trauma with uneffective cough Post surgical procedure wtih inadequate cough

Easier Ventilation
Prolonged ventilator after intubation > 48 hours

Contraindication

No

contraindication especially for emergency case

Differential Diagnosis

For

upper airway obstruction:

Pneumonia

Acidosis

Radiologic Examination
X-ray

of the neck AP/Lateral

Anatomy of the Neck

lies between the lower margin of the mandible above and the suprasternal notch and the upper border of the clavicle below. In the central region of the neck the respiratory system (the larynx and the trachea), and behind the alimentary system (the pharynx and the esophagus) At the sides of these structures are the vertically running carotid arteries, internal jugular veins, the vagus nerve, and the deep cervical lymph nodes

Contd

Superficial Fascia

thin layer that encloses the platysma muscle embedded in it are the cutaneous nerves, the superficial veins, and the superficial lymph nodes a thin but clinically important muscular sheet embedded in the superficial fascia External Jugular Vein Tributaries Anterior Jugular Vein

Platysma

Superficial Veins

Contd

Deep Cervical Fascia

Investing Layer

thick layer that encircles the neck, splits to enclose the trapezius and the sternocleidomastoid muscles thin layer that is attached above to the laryngeal cartilages surrounds the thyroid and the parathyroid glands and encloses the infrahyoid muscles

Pretracheal Layer

Prevertebral Layer

thick layer that passes like a septum across the neck behind the pharynx and the esophagus and in front of the prevertebral muscles and the vertebral column
local condensation of the prevertebral, the pretracheal, and the investing layers of the deep fascia that surround the common and internal carotid arteries, the internal jugular vein, the vagus nerve, and the deep cervical lymph nodes

Carotid Sheath

SURGICAL ANATOMY

Algorithm and Procedures

Dyspneu
Upper Airway Obstruction

Pneumonia

Acidosis

Chin lift, Jaw Thrust, Oropharyngeal/Nasopharyngeal Airway

Succeed

Unsucceed

Tools not ready yet

Tools ready

Cricothyroidotomy

Tracheostomy

Pre Operative

Informed consent explain about:

Operating procedures Loss of voices when tracheostomy canule still in the trachea Complication of operation

Should be done in the operating theatre as much as possible Adequate lightning One assistant required Tracheostomy set

Contd

Plastic or metal canule preparation Prophylactic antibiotic: Cefazolin or combination of Clindamycin and Garamycin Anaesthetic preparation:

Local or general anasthesia local anasthesia with lidocain (max dose 7 mg/kgBW)

Patients position is supine with hyperextension of the head give a cushion below the shoulder trachea will be exposed to the anterior Give the head a doughnut cushion

Types of Tracheostomy Tubes

Cuffed Tube with Disposable Inner Cannula

Used to obtain a closed circuit for ventilation

Cuffed Tube with Reusable Inner Cannula

Used to obtain a closed circuit for ventilation

Cuffless Tube with Disposable Inner Cannula

Used for patients with tracheal problems

Used for patients who are ready for decannulation

Contd

Cuffed Tube with Reusable Inner Cannula

Used for patients with tracheal problems Used for patients who are ready for decannulation

Fenestrated Cuffed Tracheostomy Tube

Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak

Fenestrated Cuffless Tracheostomy Tube

Used for patients who have difficulty using a speaking valve

Contd

Metal Tracheostomy Tube

Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.

Steps of Procedures
1.

Desinfection with povidone - iodine 10% or with Hibitane alcohol 70% at operating area (from lower lips chin neck until ICS 2, left and right until the anterior border of trapezius muscle)

2.
3. 4. 5.

Operation area is narrowed by sterile linen

Identification of trachea with palpation, starting from thyroid cartilage to jugular notch Perform a local anasthesia with lidocain 1% or 2% injection subcutaneously Vertical incision 3-4 cm (emergency case) or horizontal or collar incision (elective case), incision is deepened by cutting subcutis, fascia of neck superficial at the midline on the incision site

Contd
6. 7.

Hemostasis Put Langenbeck to the left and the right, balanced traction to mantain trachea in the midline. If theisthmus of the thyroid gland stand in the way, set aside the isthmus to the caudal and hold it with blunt hook. Identification of trachea, put sharp-one-tooth hook between cricoid and 1st tracheal ring Tracheal ring was cut vertically using No. 11 knife blade with a sharp edge facing up and direction of the incision to the cranial (2nd 3rd ring for high tracheostomy; 4th 5th ring for low tracheostomy)

8.

Contd
9.

Trachea maintained open with a blunt tooth hooks on the right and left side, clean the existing secretions by using a suction cannula and alternating with oxygenation

10.
11.

secretions were taken for culture and sensitivity test (for diphteria patients)
Insert the cannula tracheostomy carefully, at the time of inserting the tip, position of the axis perpendicular to the tracheal cannula, after entering surely turn the direction parallel to the axis of the trachea, proceed to thrust according the curve of cannula tracheostomy into the lumen of the trachea.

Contd
12.

check cannula into the lumen of the trachea, feel the breath of the hole cannula tracheostomy, or use the end of the string that vibrates at the blast of breath

13.

the whole latch is released, assistant hold the cannula, cannula is fixed with sutures at the right and left lobes of cannula to the skin of the neck and installing a ribbon strap around the neck.
If the incision is too wide, skin is sutured loosely (dont be too tight: can cause skin emphysem) Between cannula lobes and skin, put a sterile gauze cushion

14. 15.

Video

Complication

Intraoperative

Bleeding Reccurent laryngela nerve injury small risk Pneumothorax Cricoid cartilage injury Esophageal perforation Tracheoesophageal fistula Vocal cord injury

Complication

Post Operative

Early

Impaired swallowing function because of tracheostomy cuff Bleeding, Infection at operation site, Subcutaneous emphysema,

Late

Granuloma Tracheoesophageal fistula Tracheocutaneous fistula Laryngotracheal stenosis

Post Operative Management

Observation for the first 24 hours Treatment for primary disease Tracheostomy cannula management:

Suction of the secrete / hour Cleanse the smaller cannula / 6 hours Nebulizer with warm air for 15 minutes /6 hours

Treat tracheostomy wound with gauze replacement every treatment

References

Boldenham A, Whiteley S. Respiratory Emergencies. In Ellis BW, Brown SP eds. Hamilton Baileys Emergency Surgery 13th ed. Varghese Co. 2000, 43 45.

Shires GT, Thal ER, Jones RC. Trauma in Principle of Surgery Schwartz 8th ed. McGraw Hill Inc. 2005, 338 339
Cobb JP. Critical care: a system oriented approach. In Norton ed. Surgery Basic Science and Clinical Evidence. Springer, 2001, 282

Zollinger, J.R., Ellison, E., 2010. Zollingers Atlas of Surgical Operations, Ninth Edition, 9th ed. McGraw Hill Professional.

Thank You