Prof. Ali Tawfik Prof. Ali Tawfik Professor of E.N.T & Maxillofacial SurgeryProfessor of E.N.T & Maxillofacial Surgery

Mansoura universityMansoura university

Tracheostomy

An artificial opening in the anterior wall of the cervical trachea.

Indications of tracheostomy:1- Upper respiratory tract obstruction;

Laryngeal, supralaryngeal ,and tracheal causes.( Causes of stridor )2- Lower respiratory tract obstruction: (Secretory obstruction, Wet lung syndrome).

Tracheostomy

Insertion of the tube

This occurs in conditions inhibiting the cough reflex, causing accumulation of secretions inside the alveoli and impairment of the exchange of gases leading to hypoxia and hypercapnea. The patient will be drowned in his own secretions.

Indications of Tracheostomy

2- Lower respiratory tract obstruction: (Secretoryobstruction, Wet lung syndrome).

Causes:1- Coma: a) Cerebral: Vascular accidents and oimours.b) Toxic: Exogenous as in barbiturate poisoning or

endogenous as in- uraemia and diabetes.

c) Traumatic: Fracture base and head injuries.

2- Paralysis of chest muscles poliomyelitis and diphtheria.

3- Myopaihies myasthenia gravis.4- Trauma multiple fractured ribs.

Indications of Tracheostomy

2- Lower respiratory tract obstruction: .

3- Pre-operative:

Before bleeding operations of the nasopharynx, maxilla and tongue to prevent inhalation of blood during the operation.

Indections Tracheostomy

Aim of tracheostomy:1- To by-pass upper respiratory obstruction.2- To overcome tracheal obstruction. Pass a

hard tube (Koenig's tube).3- To aspirate the accumulated secretions as

in secretory obstruction. 4- To maintain artificial respiration in cases of

central respiratory failure5- To reduce the dead space by about 75 to 90cc

(above the tracheostomy)

Types of tracheostomy:1- High tracheostomy;In the 1st and 2nd tracheal rings above the isthmus of the thyroid gland

2- Mid tracheostorny;In the 3rd and 4th trachea rings behind the isthmus (operation of choice).

3- Low tracheostomy in the 5th and 6th rings below the isthmus.

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Procedures of the operation:

1- Anaesthesia:a) No anaesthesia in cyanosed patients and urgent cases.

b) Local: Infiltration with 1% Novocain.

c) General: When there is no emergency (pre-operarive).

2- Position:Neck is extended and a sandbag is put under the

shoulders

Tracheostomy

Procedures of the operation:3- Incision:a) Midline incision from the lower border of

the thyroid to the manubrium sternib) Cut the skin, superficial fascia, platysma

and the deep fascia connecting the pretracheal muscles (sternohyoid and sternothyroid) of the two sides.

c) Separate the pretracheal muscles of bothsides by a retractor .

Tracheostomy

4- The thyroid isthmus

is divided between 2 kochers, transfixed by catgut to prevent bleeding and leak of thyroxin and then retracted.

5- Expose the trachea

and inject 1/2 c.c surface anaesthetic(pantrocaine 1%) in the trachea to diminish the cough reflex.

Tracheostomy

6- Fix the trachea and elevate it by acricoid hook.

7- Open the trachea by an incision or by removal of a circular part of the 3rdand 4th rings.

8- Insert a suitable tracheostomy tube9- Close the wound after ligating the

bleeding vessels.

Tracheostomy

Incision of tracheostomy Pretracheal musclesThyriod isthmus

Division & retraction

of the isthmus.Opening of the

trachea Insertion of the tube

How to Perform an Emergency Tracheotomy

Tracheostomy

Tracheostomy

Tracheostomy

Tracheostomy

Post-operative care:1- Room should be humidified by tinct. benzoin

Co. and well-ventillated.2- The patient should be semi-sitting to allow

for cough.3- Respiration: Ensure that air is coming out

from the tube by:

a) Patient cannot speak.b) No stridor.c) The expired air moves a piece of cotton

or condenses vapour on a mirror.

Tracheostomy

Post-operative care:

4- Retractors, tracheal dilator, electric sucker and oxygen should be beside the patient, also a well-trained nurse for the after-care.

5- Removal of causal factors i.e. treat the cause of obstruction.

Tracheostomy

6- Removal of:a)Secretions by suction to prevent blocking

of the tube.b) The inner tube and clean it with sodium

bicarb. solution if it is blocked.c) The whole tube (decannulation) after the

indication for tracheostomy is treated. This is done after closing the tube with a cork

for 2 days.

TracheostomyPost-operative care:

The tracheostomy is

permanent in case of

total laryngectomy or

inoperable cancer

larynx.

Tracheostomy

1- anaesthetic complications:Laryngeal or bronchial spasm.Aspiration of vomitusCardiac or respiratory arrest.

2- Haemorrhage:From subcutaneous veins, thyroid isthmus or innominate vein. It may be:

a) Primary.b) Reactionary (open the wound and ligate the

vessels).c) Secondary haemorrhage.

Complications of tracheostomy:

Complication of tracheostomy:3- Pulmonary complications:

a) Apnea Arrest of respiration due to sudden wash of CO2 and failure of

the respiratory center which is accustomed to a high CO2tension in the blood.

Treatment Apnea : a) Close the opening for a short time to allow accumulation of

CO2. b) Give O2 and C02 5%.

b) Pulmonary oedema: Due to sudden release of pressure inside the

lungs and exudation from the capillaries.

• It causes noisy respiration, froth and cyanosis.Treatment:

a) Respiratory and cardiac stimulants.

b) Connect the tube to an under-water seal system.

Complicadom of tracheoatomy3- Pulmonary complications:

c) Pueumothorax:Due to injury of the apex of the pleura in children. Treatment: Aspiration by an intercostal needle.

d) Surgical emphysema:a) Of the neck due to air leakage around

a small tube during inspiration.b) Mediastinal.

Complication of tracheostomy3- Pulmonary complications:

4- Injury of:a) Blood vessels.b) Pleura, especially in low tracheostomy.

c) Oesophagus:

Causing tracheo-oesophageal fistula.

d) Cricoid cartilage:

High tracheostomy causes perichondritis of the cricoid

cartilage and later obstruction of the larynx,

Complication of tracheostomy

5- Infection:

a) Bronchopneumonia.

b) Infection of the external wound.

Complication of tracheostomy

Compliationi of tracheoitomy tubeCompliationi of tracheoitomy tube

Proper size

in position

Long tube causing Injury of oesophagus

Long curve causing injury of both oesophagus& trachea.

Small tube causing slipping out & surgical emphysema of neck.

6- Tubal complications: a) Before extubation:

( i ) Small tube causes surgical emphysema of the neck due to leakage of air around

(ii) Long curve causes injury of the esophagus. (III) Short tube may slip out of the tracheostomy opening

b) After extubation:(i) Tracheal fistula: Excise the track and close the skin.(ii) Tracheal or laryngeal stenosis after high

tracheostomy.