Tracheostomy

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Tracheostomy

• Professor Magdy Amin RIAD MD, FRCS. Ed
• Department of Otolaryngology
• Ain Shams University

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Tracheostomy

• Definition
• Surgical opening in the trachea for respiration
• Temporary or permanent
• Tracheotomy" and Tracheostomy
• The opening, or hole, is called a stoma

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Tracheostomy history

• One of the oldest surgical procedures
• Tracheotomy was portrayed on Egyptian tablets
  dated back to 3600 BC
• The first successful tracheotomy was performed by
  Prasovala in the 15th century
• In the 16th century, Guidi invented an original
  method for tracheotomy
• Well documented studies do not appear until the
  early 1900's

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Indications of tracheostomy

• (A) To bypass an upper airway obstruction
  (larynx, upper trachea)
• (B) Lower respiratory airway obstruction (lower
  trachea, lungs, bronchi)
• (C) Prophylactic (without obstruction)

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(A) Bypass an upper airway obstruction

• (I) Laryngeal causes
• ? Congenital web, stenosis,laryngomalacia
• ?Trauma Mechanical , Chemical, physical
• (FB, maxillofacial injury, laryngeal fracture,
  Burns of the face or the neck)
• ?Inflammatory acute LTBitis, supraglottitis,
  diphteria, Scleroma, Syphilis , TB
• ? Neuromuscular Myasthenia G, bilateral VF
  palsy
• ?Benign RRP------ Malignant Laryngeal
  carcinoma, extensive pharyngeal tumors

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• (II) Tracheal causes
• (to bypass an upper tracheal obstruction)
• ? In the neck? upper tracheal tumors, enlarged
  goiter, malignant goiter, malignant cervical
  lymph nodes
• ? In the chest? Retrosternal G, enlarges thymus,
  mediastinal lymph nodes
• (III) Supra-laryngeal causes
• -Ludwigs angina
• -Post-cricoid carcinoma
• - Retropharyngeal abscess
• - Obstructive sleep apnea

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(B) Lower respiratory airway obstruction (lower
trachea, lungs, bronchi)

• (I) Central or peripheral causes ?Cough reflex
  depression ?unable to expel chest secretions
• 1) Central causes? prolonged coma
• Traumatic head injury
• Toxic Barbiturates, Uremia,
  ketoacidosis
• Cerebrovascular Hge, thrombosis,
  embolism
• Brain tumors
• 2) Peripheral causes
• - Paralysis of respiratory muscles
  (Polio, Diphteria)
• - Severe chest injury Flail chest, rib
  fracture
• (II) Intact cough reflex but cannot protect the
  lower airway
• Aspiration in bilateral adductor paralysis,
  Pseudo-bulbar palsy

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(C) Prophylactic (without obstruction)

• 1) Before extensive oral or pharyngeal surgery
  (cancer tongue, maxillectomy)
• (2) Temporary in laryngeal surgery (partial
  laryngectomy, laryngofissure)
• (3) Prolonged intubation for more than 10 days

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Contraindications

• No absolute contraindications to tracheostomy
• It should be done once indicated (life saving)
• A strong relative contraindication is laryngeal
  carcinoma where laryngectomy (definite
  management) should be planned and prior
  manipulations of the tumor is avoided ?Stoma
  recurrence

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Value of tracheostomy

• (1) In upper airway obstruction ? by pass the
  obstruction
• (2) In lower airway obstruction ?
• Suction of secretions
• Administration of warm oxygen
• Reduction of dead space to its half for
  better utilization of inspired air

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Types of tracheostomy

• High (above the thyroid isthmus at 1st 2nd
  tracheal rings)

Mid (behind thyroid isthmus at 3rd 4th
rings) This is the best

• Low (below the isthmus at 5th 6th rings)
• WHEN?
• -away from laryngeal lesion (RRP)
• Upper tracheal tumors
• After TL
• Disadvantages
• Deeply situated
• Difficult to reach
• Injury to pleura, innominate vein

Advantages Easy, rapid, trachea is
fixed Disadvantages Cricoid cartilage
injury?perichondritis,necrosis??fibrosis?subglotti
c stenosis
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Tracheostomy timing

• Emergent ("slash")
• This should only be considered when the
  patient is in extremis, which is when a
  cricothyrotomy should be performed.
• Urgent ("awake")
• Patients in acute respiratory distress may
  need acute surgical intervention.
• This can be performed in the OR under LA.
• The patient's anxiety and restless movements
  will challenge the surgeon and the
  anesthesiologist however, the patient's
  vigilance is required to maintain the airway.
• These patients should be sedated and paralyzed
  only with extreme caution. It is better to have
  an agitated patient with an open airway than a
  relaxed patient with a complete obstruction.
• The risk of pneumothorax is increased in a
  patient with increased work of breathing, as the
  cupulae expand high into the neck with high
  negative inspiratory pressures.

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Tracheostomy timing (Cont., )

• Elective
• Most elective tracheostomies are performed on
  intubated patients (for prolonged intubation)
• Additionally, patients undergoing extensive
  head and neck procedures may receive a
  tracheostomy during the operative procedure to
  facilitate airway control during convalescence
• A smaller population of patients with chronic
  pulmonary problems (eg, sleep apnea) elect to
  undergo tracheostomy

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Operative technique

• Anesthesia
• No (urgent, comatosed)
• LA ( 1 Novocain adrenaline)
• GA ( children, neurotic, elective)
• Position Supine with extended neck? more
  superficial position of the trachea
• N.B Overextension of the neck should be
  avoided as it further narrows the airway
• Incision
• Midline longitudinal (upper cricoid
  cartilage to the suprasternal notch)? in urgent
  cases ? easy, less bleeding
• Transverse between the above points ?better
  cosmetically

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Tracheostomy tube with cuff, pilot inflating
balloon and pressure manometer
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Surgical notes

• Opening of the trachea in infants and children is
  called tracheotomy where no resection of the
  tracheal wall
• In infants ?caution must be taken as the neck is
  soft and pliable
• Tracheotomy in infants and children should be
  performed after bronchoscope or endotracheal tube
  placement ? Vital control of airway, rigidity to
  the trachea, prevent large excursion of the
  copulae into the neck
• Midline vertical incision through 3rd,4th,5th
  rings
• Immediate postoperative A-P lateral chest x ray
  ? ascertain tube site, exclude pneumothorax and
  pneumomediastinum

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Complications

• Immediate

Delayed
Operative

1. Hemorrage
2. Subcutaneous emphysema
3. Pneumothorax
4. Pneumomediastinum
5. TOF (1ry)
6. RLN injury
7. Aspiration
8. Malpositioned tube
9. Aerophagia

• Delayed hemorrhage
• Tracheal stenosis
• Tracheomalacia
• Delayed TOF
• Dysphagia
• Tracheocutaneous fistula

1. Complications of anesthesia
2. 1ry hemorrhage
3. Injury to structures
4. Apnea acute pulm. Oedema

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• Tracheostomy complications may be grouped into
  intra-operative, early post-operative (lt 7 days),
  and late post-operative (gt 7 days) categories
  (Bourjeily et al 2002).

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Immediate complications

• (1) Reactionary hemorrhage
• ?Slipped ligature, staining
• TTT ? reopen the wound ligate the bleeding
  vessel
• (2) Surgical emphysema
• ? SC air collection due to small tube with wide
  tracheostomy, tight sutures,
• ? May extend to the mediastinum
• TTT ? Remove sutures and replace with a large tube

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• (3) Pneumothorax
• ? Injury of the apex of the pleura ? dyspnea
• ? More common in children
• ? Diagnosed by PO dyspnea, no air entry,
  collapsed lung
• TTT Intercostal tube with underwater seal
• (4) Mediastinal emphysema
• ? Extension from SC emphysema
• ? Affects cardiac function
• (5) Respiratory obstruction
• ? Due to tube complications
• ? Manifest as phonation without tube
  occlusion, stridor reappears

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Delayed complications

• 2ry Hemorrhage
• ? -Infection
• - Ulceration of the anterior tracheal
  wall by the tip of the tube ? innominate artery
  injury
• (2) Infection (wound or chest infection)
• (3) Tube complications
• ? Difficult extubation
• ? Fistula formation (early or late)
• ? tracheocutaneous fistula
• (4) Tracheal stenosis

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Percutaneoud dilatational tracheostomy
Placement of guide wire
Introduction of tracheal needle
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Insertion of guiding catheter
Serial dilation
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Placement of tracheostomy tube
Not indicated in emergency cases Bed side in
the ICU
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Tracheostomy Care

• Daily care of the trach site is needed to prevent
  infection and skin breakdown under the
  tracheostomy tube and ties
• should be done at least once a day more often if
  needed.
• Steps
• 1) Clean the skin around the trach tube
• 2) Check the skin under the trach ties
• 3) Check cuff pressure every 4 hours (usual
  pressure 15 - 20 mm Hg)

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• 4) Humidification
• 5) Frequent suction of the tube
• 6) Antibiotics
• 7) Mucolytics amble fluids
• 8) Changing of the tube after the 3rd day
• 9) Deflation of the cuff every 2 hours for 10
  minutes
• 10) Always ensure adequate placement of the
  tube

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Decannulation

• The removal of the tracheostomy tube.
• Once the reason is resolved
• In the hospital under the care of ORL surgeon
• Observation for several hours
• If difficult ? diagnostic evaluation

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Decannulation (Cont.,)

• Some procedures for decannulation
• Simple removal of the tube (/-) minor surgical
  procedures.
• Place a smaller tube and plug the tube for
  increased amounts of time. When the child is
  tolerating the plug 24 hours a day, then the tube
  can be removed
• Include the decannulation as part of a
  reconstructive procedure
• Surgical decannulation (when repair of the
  trachea around the tube is needed)
• N.B Sleep studies in the hospital setting are
  often ordered to be sure apnea is not present

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Causes of difficult decannulation

• (1) Persistance of the original etiology
• (2) Anterior tracheal wall dislocation
• (3) Stomal granulation tissue
• (4) Oedema of tracheal mucosa
• (5) Emotional dependence on tracheostomy
• (6) Unable to tolerate upper airway resistance
• (7) Subglottic stenosis
• (8) Tracheomalacia
• (9) Incoordination of laryngeal opening reflex
• (10) Impaired development of the larynx
• (11) GERD