Tracheostomy

 

Indications

-       Prevention of complications of prolonged endotracheal intubation

-       May facilitate airway suctioning and improve patient comfort during weaning

      -    Impending airway obstruction e.g. bulky tumour, caustic ingestion, trauma, infectious oedema.
 

Contraindications

 

Preoperative preparation

-       Consent
Prepare tubes - men us. take size 8; women size 6-7; cuffed with an inner tube that can be removed for cleaning.

 

Anaesthesia

-       General anaesthesia

-       Local anaesthesia

 

Position of the patient

-       Position carefully. Supine

-       Head ring; pillow under shoulders; head up and extended (drains venous system)

 

Special equipment

-       ECG, blood pressure and pulse oximetry monitoring

 

Incision

-       Horizontal skin crease incision placed halfway between the cricoid and suprasternal notch (aiming 3-4th tracheal rings)
Through skin and subcut fat and platysma with diathermy.  Keep in midline,
Then blunt dissection; relatively avascular; split strap muscles in midline and retract sideways.

 

Exploration

-       Separate the pretracheal muscles and divide the thyroid isthmus between clamps (usually can be lifted or pushed out way instead of dividing though; bleeds)

-       Pretracheal vessels just below the cricoid may need diathermy

-       Clean / skeletonize the anterior tracheal wall
Feel cricoid and count down to 3-4 ring. Now check tube, check lumen, check inflates.

-       When the trachea is palpated, the ETT is withdrawn to the sub-glottic region

-       1-2 cm  incision centred on the third or fourth ring/2nd – 3rd ring; will hear air escaping. No diathermy here as oxygen in airway. No 11 blade then enlarged with Mayo scissors.
For a temporary trache, make a horizontal incision.  Emergency - make a longitudinal incision.  If long term trachy, cut a small ring of cartilage out of the trachea (heals ok).

-       Do not excise segments or cut flaps (complications include subsequent stenosis)

-       Insert tracheal dilators, or 2-0 silk stitch through the cut tracheal edge on each border and leave the ends long
Pass tube (upwards to start with then turn it around).  Inflate cuff.  Then connect ventilator and look for CO2 trace.

-       Secure tube to skin; don't close the wound else may get surgical emphysema.

 

Complications

-       Bleeding

o   From thyroid isthmus or inferior thyroid vein

o   In young children the brachiocephalic vein may rise above the suprasternal notch.

- Pneumothorax / pneumomediastinum if cupula of lung violated; too much dissection.
- Perforating posterior tracheal wall can result in tracheoesophageal fistula or mediastinitis

- Airway fire; no diathermy near airway.
- Post-op bleeding from skin edge of isthmus; pack; if copious then tube may be eroding through tracheal wall or innominate vessel (disaster; 90% mortality).
- Obstruction; mucus or clots; remove, suction, humidify, clean.

Post-operative instructions

-       CXR



Tracheostomy

· Supine, neck extended, shoulder support, headring, reverse trendelenberg

· Head drape

· Check tracheostomy tube & cuff

· Incision 2cm above notch, skin crease, measure length, mark prior to incising

· Incision through platysma

· Subplatysmal flaps to thyroid prominence & jugular notch

· Joll’s retractor

· Open deep fascia in midline

· Expose 3rd – 6th tracheal rings

— Divide isthmus if necessary between Criles

· Suture in trachea

· Warn anaesthetist

· Incise trachea with inferiorly based U-shaped flap

— Replace suture if necessary with prolene, long loop

· Draw back ET tube

· Insert tracheostomy tube

· Inflate cuff & connect to ventilator

· Close platysma

· Close skin with interrupted sutures

· Secure tracheostomy tapes



Tracheostomy

What are the indications for tracheostomy?

   Relief of airways obstruction

Congenital

Subglottic stenosis, laryngeal cyst, tracheo-esophageal abnormalities

Aquired

            Trauma to larynx

            Infection – epiglotitis, laryngotracheobronchitis

            Burns to larynx

            Oedema from anaphylaxis

Tumour – carcinoma of larynx, tongue, pharynx, thyroid

            Bilateral vocal cord palsy

            Foreign body

            Sleep apnea syndrome

   Temporary and permanent protection of tracheo-bronchial tree

            Neurological disease – MS, myasthenia gravis

            Trauma – burns to face and neck

            Head and neck surgery – oropharynx resection or supraglottic laryngectomy

            Coma- from trauma or drug overdose

   Respiratory insufficiency

Tracheostomy has advantages in  reducing upper airways dead space by 70% and reducing work of breathing.

Tracheostomy allows easier swallowing mobility and speech compared with ET tube, allows patient to be nursed outside of ICU, allows easier suctioning

For all above reasons it is better when weaning a patient from ventilatory support.

Generally early tracheostomy (7-10 days of mechanical ventilation) is appropriate in patients for whom weaning is not likely before 14 days.

What is the role of early tracheostomy (<1 week)

Randomized studies suggest a benefit in terms of infection, hospital and ventilator days. There may also be a mortality benefit.

What different ways are there to perform tracheostomy?

Percutaneous or open.

Percutaneous dilatational Tracheostomy decreases the risk of wound infection and bleeding.

Complications in percutaneous tracheostomy are reduced if bronchoscopic guidance is used.

Relative contra-indications to percutaneous tracheostomy include: Age <15years, uncorrectable bleeding diasthesis, gross distortion of neck (haematoma, thyromegaly, scarring from previous neck surgery, short fat neck which obscures land marks.

 

 

How do you perform an open tracheostomy?

· Pre-operative: obtain consent from patient. If patient is ventilated discuss with family and treating team the risks and benefits of procedure

· Check coagulation and platelets pre-opertively.

· Blood for group and hold

· Withhold heparin if used

· Perform only in operating room with anaesthetist

· Perform under GA with ET tube in situ

· If patient is not intubated and procedure is emergent for airways obstruction perform cricothyroidotomy instead.

· Make sure that appropriate size tubes are available in theatre (sizes 6-9 for adult). Size 7 is appropriate for most adults.

· Supine, neck extended, folded sheet between shoulders, headring, reverse trendelenberg

· Head drape

· Check tracheostomy tube & cuff

· I make a vertical incision starting at the cricoid and continuing down for 4-5cm

· Incision through skin, fat and platysma and continue down directly over midline.

· Subplatysmal flaps to thyroid prominence & jugular notch

· Joll’s retractor

· Open deep fascia in midline  and separate the sternohyoid muscles

· Expose 3rd – 6th tracheal rings using scissor dissection

   Expose the capsule of the thyroid gland

   Clamp, ligated and divide all thyroid veins in the region with 2/0 Vicryl ties

   Identify the thyroid isthmus

   Slide Metz scissors under the thyroid isthmus and elevate it.

   Clamp the isthmus with Criles and divide.

   Suture-ligate the isthmus with 2/0 Vicryl suture ties

· Identify the second and third tracheal rings.

· Ensure complete haemostasis

You cannot get complete haemostasis. There is constant oozing which cannot be located despite optimizing light, retraction, extending the incision and getting an extra-assistant. What do you do?

Pack the wound and return in 48 hours after rechecking coags. I don’t opne the trachea until it is completely dry.

· Warn anaesthetist that air leak will soon occur

· Have sucker set up

· Suture in trachea

· Warn anaesthetist of an air leak and ask for a few minutes of pre-oxygenation with 100% O2.

· I make a vertical incision in the anterior tracheal wall of the second and third tracheal rings with a 15 blade.

· I suction the trachea and gently the spread the edges of the tracheotomy with curved haemostat. If the hole does not allow easy entrance of the tube I excise a 1cm segment of the third tracheal ring.

· I insert 2/0 prolene sutures in the 3rd tracheal rings either side of the tracheotomy and leave these long in haemostats

· I lubricate the trachesotomy tube and ask my assistant to gentle hold the prolene sutures whilst I slip the tube into the trachea whilst the ET tube is withdrawn to the supraglottic larynx.

· The tracheostomy tube cuff is inflated and a soft sucker introduced into the trachea.

·I connect to ventilator and confirm placement with end-tidal CO2 and chest movement.

· Close I approximate the sternohyoid above and below with 2/0 Vicryl

I loosly approximate platysma as above

· Close skin with interrupted 2/0 Nylon sutures

I suture the tracheostomy flanges to the skin using 0 Nylon

· Secure tracheostomy tapes round the neck

Post-op

· Humidified oxygen with 7% CO2 and regular suctioning

You are taking the patient back to ICU and tube dislodges

· Have the patient re-intubated and return to theatre. I would not attempt to blindly re-introduce the tube in ICU or the corridor even using the stay sutures.

What are the complications of tracheostomy?

Immediate:

· Tube dislodgement and asphyxia, aspiration, Bleeding with soiling of airway and aspiration, pneumothorax.

· The best way to deal with heavy bleeding is to re-intubate and return the patient to theatre for formal exploration

Early: infection in wound or trachea.

· Infection can usually be managed with IV Abx. Uncontrolled infection can lead to tracheal erosion.

· Atelectasis and pulmonary infection

Late: Fistulation into the inominate artery and exsanguination.

· Tracheal stenosis, vocal cord palsy, tracheo-esophageal fistula

What are the indications for cricothyroidotomy

· For an emergency airway when intubation is impossible

· Anasthesia: Local infiltration of lignocaine with adrenaline or none. This provides anesthesia and reduces bleeding.

· Preparation: Place a rolled sheet between the shoulders. Head ring. Sterile prep and drape.

· I grasp the thyroid cartilage between thumb and middle finger of left hand and use index finder to palpate the space between the thyroid and cricoid cartilages and infiltrate more local anesthetic.

· I make a transverse incision with a number 15 scalpel through the skin.

· I achieve haemostasis with pressure and diathermy.

· I make a stab incision in the membrane and then use a curved artery to dilate the tract.

· I insert a 7F cuffed tracheostomy tube. And suture it to the skin and secure with tracheosomy tape.