TRACHEOSTOMY : TRACHEOSTOMY Dr. Saurabh Kumar
St. Stephens Hospital
New Delhi What is a Tracheostomy? : What is a Tracheostomy? A tracheostomy is a artificial (usually) surgically created airway fashioned by making a hole in the anterior wall of the trachea and the insertion of a tracheostomy tube, which may or may not be permanent History : History Tracheostomy is one of the oldest surgical procedures.
A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC.
Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC.
The first successful tracheostomy was performed by Brasovala in the 15th century. Slide 4: Modern percutaneous tracheostomy (PCT) device was developed by Toye and Weinstein in 1969,
The wireguided technique for percutaneous tracheostomy was developed and reported in the same year by the American surgeon, Ciaglia.
Ever since the PCT has evolved, the resources required for a surgical tracheostomy (ST), the need of operating room, and personnel have been eliminated Indications : Indications Upper Airway obstruction secondary to –
infections, inflammatory conditions, neoplasms,
Postoperatively , obstructive sleep apnea
Access for pulmonary toilet
Prolonged ventilatory support
Airway protection in head injured or comatose patient
and in postoperative neurosurgical patients Contraindications : Contraindications Absolute
1. Need for an emergency airway
2. Performance of the procedure in children as cartilages is soft.
1. High degree of ventillatory support–PEEP >8cm H2O, FiO2 > 50%
2. Unstable cervical spine
3. Uncorrected coagulopathy
4. Presence of neck mass or pervious neck surgery
5. History of mediastinal irradiation due to intrathoracic fibrosis
6. Previous history of surgical tracheostomy
7. Increased intracranial pressure Advantages of Tracheotomy : Advantages of Tracheotomy Increased patient mobility
More secure airway
Improved airway suctioning
Early transfer of ventilator-dependent patients from the intensive care unit (ICU)
Less endo-laryngeal injury
Enhanced oral nutrition
Enhanced phonation and communication
Decreased airway resistance for promoting weaning from mechanical ventilation
Decreased risk for nosocomial pneumonia How To Create a Tracheostomy : How To Create a Tracheostomy Cricothyroidotomy
For Urgent Procedures
Can be done in the ICU at the bedside
Surgical Tracheostomy Anatomy : Anatomy The trachea is a fibromuscular tube supported by 20 hyaline cartilages which are opened posteriorly.
The soft tissue posterior wall is in contact with the oesophagus.
Trachea lies in midline of the neck extending from cricoid cartilage (C6) superiorly to the tracheal bifurcation at the level of sternal angle (T5).
In adults it is 12-16 cm long and 13-16 mm wide in women and 16-20 mm wide in men
The blood supply is primarily supported by the bracheocephalic artery and through the inferior thyroid and bronchial arteries.
The nerve supply is by parasympathetic and sympathetic fibres.
The parasympathetic supply to the trachea is by the recurrent laryngeal nerve – a branch of the vagus nerve Tracheostomy Tubes : Tracheostomy Tubes Tracheostomy tubes are available in a variety of sizes and styles, from several manufacturers.
Dimensions of tracheostomy tubes are given by their inner
diameter (ID), outer diameter (OD), length, and curvature.
Tracheostomy tubes can be angled or curved, a feature that can be used to improve the fit of the tube in the trachea.
Cuffs on tracheostomy tubes include high-volume low-pressure cuffs, tight-to shaft cuffs, and foam cuffs.
Tracheostomy tubes which have an inner cannula are called dual cannula tracheostomy tubes. Metal versus Plastic tracheostomy tubes : Metal versus Plastic tracheostomy tubes Tracheostomy tubes can be of either metal or plastic.
Metal tubes are constructed of silver or stainless steel.
Metal tubes are not used commonly because they are
→ rigid construction
→lack a 15 mm connector for attachment
to a ventillator Slide 14: Plastic tubes are most commonly used and are made from polyvinyl chloride or silicone.
Polyvinyl chloride softens at body temperature (thermolabile), conforming to patient’s tracheal anatomy and centering the distal tip in the trachea Tracheostomy tube selection : Tracheostomy tube selection Slide 16: While selecting a tracheostomy tube, the ID and OD, its curvature and proximal and distal length must be considered.
If the ID is too small, it will
→increase the resistance through the tube,
→make airway clearance difficult,
→ increase the cuff pressure required to create a
If the OD is too large,
→ Difficulty in speech
→difficult to pass through the stoma.
→may not conform to the shape of the trachea,
→compression of the membranous trachea, Slide 17: Tracheostomy tubes are available in standard length or extra length.
Extra length tubes are constructed with either extra proximal length (horizontal extra length) or with extra distal length (vertical extra length)
Extra proximal length facilitates tracheostomy tube placement in patients with a large neck (eg, obese patients).
Extra distal length facilitates placement in patients with tracheaomalacia or tracheal anomalies.
Care must be taken to avoid inappropriate use of these tubes, which may induce distal obstruction of the tube Cuffed Tracheostomy tube : Cuffed Tracheostomy tube Cuffed tracheostomy tubes
→allow airway clearance,
→protection from aspiration
→ positive pressure ventilation
It is recommended that cuff pressure be maintained at 20–25 mmHg (25–35 cm H2O) to
minimize the risks for both
tracheal wall injury and aspiration. Fenestrated tracheostomy tubes : Fenestrated tracheostomy tubes The fenestrated tracheostomy tube is similar in construction to standard tracheostomy tubes, with the addition of an opening in the posterior portion of the tube above the cuff.
With the inner cannula removed, the cuff deflated, and the tracheostomy air passage occluded, the patient can inhale and exhale through the fenestration and around the tube. Slide 20: This allows for assessment of the patient’s ability to
breathe through the normal oral/nasal route
→ preparing the patient for decannulation
→ allowing phonation
Supplemental oxygen administration to the upper airway (eg, nasal cannula) may be necessary if the tube is capped. Percutaneous tracheostomy : Percutaneous tracheostomy 1955, Shelden et al - first attempted PCT with cutting trocar into the trachea.
The wire-guided technique for percutaneous tracheostomy was developed and reported in 1986 by the American surgeon, Ciaglia.
1990, Griggs et al - the guidewire dilating forceps (GWDF)
Several variants of the percutaneous tracheostomy technique
have been developed.
Using a wire guided sharp forceps(Griggs technique)
using a single tapered dilator (BlueRhino)
passing the dilator from inside the trachea to the
outside (Fantoni’s technique);
using a screw like device to open the trachea wall
(PercTwist). Technique : Technique As an alterative to ST , percutaneous dilational tracheostomy (PDT) has become a very common method of placing a tracheostomy in critically ill patients in the intensive care unit.
It is rapid, simple, easy to learn, and cost effective.
The procedure should be deferred in patients having an
Activated partial thromboplastin time >45 seconds
Platelet count of < 75,000⁄ ml. Slide 23: To prevent inadvertent injury of the membranous posterior tracheal wall or too lateral a location of the tracheostomy,
a technique of observing and directing the needle and wire placement, using fiberoptic bronchoscopy is recommended
In order to visualize the upper rings of the trachea with the bronchoscope, the endotracheal tube (ET) must be withdrawn until the its tip is just in the larynx.
Patients requiring a tracheostomy only for airway access or protection often can have a laryngeal mask airway replace the endotracheal tube to provide the route for bronchoscopic visualization. Slide 24: PDT is usually performed in an anesthetized patient, and can be done in the intensive care unit or operating room.
The patient should be monitored by SpO2, EtCO2 and ECG.
The patient is positioned as for the surgical tracheostomy
A pillow is placed under the shoulders, the neck is moderately extended, and the first three tracheal rings are identified
The anterior neck is prepared with povidine iodine and draped with sterile sheets.
The skin overlying first and second tracheal rings is infiltrated subcutaneously with 3-5 ml of 1% xylocaine with epinephrine (1:200,000), and a 1.5 cm vertical incision is made and blunt dissection is performed to expose the pretracheal fascia. Slide 25: The anterior trachea is palpated and the intended site is punctured with a 14G intravenous cannula in a postero-caudal direction.
The entry of the IV cannula in trachea is confirmed by aspiration of air into a saline filled syringe. →A guide wire is inserted through the cannula, and the cannula is withdrawn, →The tracheal opening is dilated over the guide wire until a stoma of sufficient size to accommodate the desired tracheostomy tube is created.→The method of dilating the tracheal opening over the guide wire varies with various methods : →A guide wire is inserted through the cannula, and the cannula is withdrawn, →The tracheal opening is dilated over the guide wire until a stoma of sufficient size to accommodate the desired tracheostomy tube is created.→The method of dilating the tracheal opening over the guide wire varies with various methods Ciaglia technique : Ciaglia technique With Ciaglia technique, the tracheal opening is dilated by using a series of plastic dilators inserted over the guide wire Griggs Technique : Griggs Technique Using a tracheal spreader modified to thread over the wire; this technique involves forceps dilation to create the skin path and tracheal stoma.
The trachea is entered between the appropriate tracheal rings with an intravenous catheter.
The guide wire is threaded through the catheter.
The sharp-tipped dilating forceps are passed over the wire, spread in the skin and soft tissues of the neck and into the trachea, and spread again Slide 29: A tracheostomy tube is placed over the guide wire and through the passage created.
Tracheal injury may be higher with this technique (especially if performed without bronchoscopy) than the other PDT techniques. Blue Rhino dilator : Blue Rhino dilator Blue Rhino dilator is a single, tapered dilator that is used instead of the sequential dilators of Ciaglia.
It has a slippery coating that makes insertion very easy.
It is softer and therefore (probably) less likely to damage the membranous tracheal wall.
Since there is only a single dilator to pass, insertion is more rapid.
A substantial amount of force is needed to insert the dilators and tracheostomy tube, which often collapses the trachea and fractures a tracheal ring Fantoni technique : Fantoni technique In an attempt to prevent membranous tracheal (posterior) wall injury and protect the anterior rings from fracture, Fantoni devised a special dilating tube that is placed translaryngeally through the trachea and pulled out rather than forced in. Slide 34: After the guide wire is placed, a fiberoptic scope is used to direct the retrieval of the wire and bring it out of the endotracheal tube in Fantoni’s technique.
The special tube is pulled from the inside through the trachea and dilates its own path
After placement, the dilating tip is removed, the upper part of the tube reversed in the trachea and the cuff inflated.
During placement, a small-diameter cuffed endotracheal tube can be used to support gas exchange while dilation is being performed Perc Twist technique : Perc Twist technique Perc Twist , a screw action dilator that was designed to allow dilation with twisting while lifting the trachea rather than pushing down. Choosing a Technique ST vs PCT : Choosing a Technique ST vs PCT Coagulation abnormalities favor ST over PDT, since bleeding vessels are more easily controlled under direct vision.
High levels of need for oxygenation would favor ST over PDT (ie, Fio2> 0.7 and positive end-expiratory pressure > 10 mm Hg
Patients with unstable or fragile cervical spines would favor ST over PDT.
Patients having recent surgical repair of neck injuries may benefit from PDT because of its lower wound-infection rate.
Patients with “unfavorable” neck anatomy would favor ST over PDT (ie, previous surgery, neck masses, poor neck mobility, or obesity) EARLY COMPLICATIONS : EARLY COMPLICATIONS Early bleeding: This is usually the result of increased blood pressure as the patient emerges from anesthesia and begins to cough.
Plugging with mucus
Atelectasis LATE COMPLICATIONS : LATE COMPLICATIONS Bleeding - Due to tracheoinnominate fistula
→ 0.4% with mortality rate of 85% to 90%.
→Major airway hemorrhage may occur within first several days or as long as 7 months after performance of a tracheostomy.
→Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy
Tracheo- and laryngomalatia
Stenosis It can develop from 1 to 6 months after decannulation
risk for tracheal stenosis ranges between 0% and 16% Slide 39: Tracheoesophageal fistula
fewer than 1% of patients as a result of pressure necrosis of the tracheal and esophageal mucosa from the tube cuff
Risk factors : high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus
Failure to decannulate Tracheotomy care : Tracheotomy care Humidification
Tube position To prevent decubitus of trachea
Skin care To prevent irritation and secondary
inflammation due to discharge
Inner tube care Daily to remove and clean crusts Tracheostomy and weaning : Tracheostomy and weaning A lot of research is being done on the optimal timing of performing a tracheostomy.
For patients requiring prolonged mechanical ventilation, performing an early tracheostomy (within 2 days) is considered to facilitate early weaning.
Advantages of early tracheostomy
→ reduced dead space
→decreased airway resistance,
→decreased work of breathing,
→better secretion clearance by suctioning,
→reduced requirements of sedatives and MR
→ better glottic function with
→reduced risk of aspiration, atelectasis,pneumonia
→shortened ICU stay Surgical Tracheostomy : Surgical Tracheostomy Surgical tracheostomy (ST) is usually performed in the operating room on a patient under general anesthesia, but it may be performed at the bedside in the intensive care unit.
The patient’s shoulders are elevated with head extension (unless cervical disease or injury is present), elevating the larynx and exposing more of the upper trachea.
Local anesthesia with a vasoconstrictor is usually infiltrated into the skin and deeper tissues Slide 45: The skin of the neck over the 2nd tracheal ring is identified, and a vertical
incision about 2–3 cm in length is created.
Sharp dissection following the skin incision is used to cut across the platysma muscle, and bleeding controlled by hemostats and ties or electocautery. Slide 46: Blunt dissection parallel to the long axis of the trachea is then used to spread the submuscular tissues until the thyroid isthmus is identified
If the gland lies superior to the 3rd tracheal ring, it can be bluntly undermined and retracted superiorly to gain access to the trachea Slide 47: There are 2 basic approaches
to tracheal entry.
the 2nd tracheal ring is divided laterally and the anterior portion removed.
Lateral sutures are used to provide counter traction during tracheostomy-tube insertion.
These are left uncut to provide assistance if the tube is accidentally dislodged later. Speech with tracheotomy : Speech with tracheotomy Spontaneous breathers
Tolerate cuffless mech. ventilation
For mechanically dependent patients that may tolerate cuff deflation
For unable to close the tube outlet with finger (quadriplegia) (Passy-Muir valves) Slide 49: A tracheostomy speaking valve is a one-way valve, allows air in, but not out
This forces air around the tracheostomy tube, through the vocal cords and the mouth upon expiration, enabling the patient to vocalize THANK YOU : THANK YOU