TRACHEOSTOMY


BY
DR. MD. MANJUR RAHIM
ASSOCIATE PROFESSOR (ENT)
 DEFINITION

Tracheostomy is making an opening in the
anterior wall of trachea and converting it into
a stoma on the skin surface.
 FUNCTIONS OF
TRACHEOSTOMY

1. It bypasses and relieves the upper airway
obstruction.
2. Improves alveolar ventilation by decreasing the
dead space and reducing the resistance to
airflow.
3. Protects the lower respitory tract. By using
cuffed tube LRT protected from pharyngeal
secretion and traumatic bleeding.
4. Permits removal of tracheobronchial secretion.

5. Intermittent positive pressure ventilation. If
IPPR is required beyond 7 days, tracheostomy is
superior to intubation.
6. To administer anaesthesia in
laryngopharyngeal growth or trismus.
 INDICATIONS OF
TRACHEOSTOMY

A. Upper airway obstruction
1. Neoplasms: Malignant and benign neoplasm of
larynx, pharynx, tongue etc.
2. Foreign body larynx
3. Trauma: Fracture of mandible and maxillofacial
injury, external injury of larynx and trachea
4. Infections: Acute laryngotracheobronchitis,
acute epiglottitis, diphtheria. Ludwig’s angina,
retropharyngeal abscess.
5. Oedema of larynx due to steam, irritant
fumes or gases, allergy, radiation etc.

6. Bilateral vocal cords paralysis.
7. Congenital anomalies; Laryngeal web, cyst,
bilateral choanal atresia etc.
B. Tracheobronchial toileting
in retained secretion
1. Inability to cough:
a, coma of any cause: head injury,
cerebrovascular accident, narcotic overdose.

b, paralysis of respiratory muscles e,g. spinal
injuries, polio, Guillain-Barre syndrome,
myasthenia gravis.
2. Painful cough: Chest injuries, multiple rib
fractures.
 C. Protect lower
respiratory tract from
aspiration

Bubler polio
Polyneuritis
Bilateral vocal cord paralysis etc
 D. Respiratory
insufficiency
Chronic lung condition like bronchiectasis,
atelectasis, emphysema


Flail chest

Bulber polio
Polyneuritis
Guillain-Barre syndrome
myasthenia gravis
 Type of
Tracheostomy

Emergency tracheostomy
Elective tracheostomy
It may be temporary or permanent ( After
total laryngectomy)
 Procedure of
tracheostomy

Anaesthesia
Local anaesthesia in emergency cases
General anaesthesia in elective cases
 Position of the
patient

Patient lies supine with neck extension by
placing a pillow under the shoulder

 Skin incision

Midline vertical incision from lower border of
cricoid cartilage upto suprasternal notch in
emergency cases.
A transverse neck incision midway between above
two landmark.

Skin incision cuts the skin, subcutaneous and
deep fascia.
The infrahyoid muscles are exposed and
separated in the midline to expose the thyroid
isthmus and trachea.

The thyroid isthmus is either retracted upward
or cut to expose the tracheal rings

The cricoid cartilages is hooked up to stabilize

the trachea.

 An opening is made in the anterior wall of
trachea, usually at the level of the2nd ,3rd or 3rd
, 4th tracheal ring and the tracheostomy tube
is placed in position by tapes around the
neck



 Complications
Immediate (at the time of
operation)

1. Haemorage
2. Apnoea
3. Pneumothorax
4. Recurrent laryngeal nerve injury
5. Aspiration of blood
6. Injury to oesophagus
Intermediate(during first few
hours or days)
1. Bleeding, reactionary or secondary
2. Displacement of tube
3. Blockage of tube

4. Surgical emphysema
5. Tracheitis and tracheobrochitis
6. Atelectasis and lung abscess
7. Local wound infection and granulation
tissue formation
 Late (with prolong use of
tube for weeks or months)


1. Haemorrhage, due to erosion of major
vessels
2. Laryngeal stenosis, due perichondritis of
cricoid cartilage
3. Tracheal stenosis, due to tracheal infection
and ulceration
 4. Tracheo-oesophageal fistula, due to
prolong use of cuffed tube or erosion of
trachea by the tip of tracheostomy tube
5. Problems of decannulatoin. Seen
commonly in children


6. Persistent tracheo-cutaneous fistula
7. Ugly scar or keloid formation
8. Corrosion of tracheostomy tube and
aspiration of its fragments into the
tracheobronchial tree
Post Operative
Management

 Care of the patient

After tracheostomy constant supervision of the
patient for bleeding, displacement or blocking
of the tube and removal of secretion is essential.
A nurse or patient relative should be in
attendance. Patient is given a calling bell for
any emergency and paper and pencil to
communicate.
 Suction

Depending on the amount of secretion
suction may be required every half an hour
and so. A sterile catheter should be used with
a Y connector to break suction force.
 Humidification

Proper humidification is necessary to prevent
crusting and tracheitis by use of humidifier,
steam tent, ultrasonic nebulizer or keeping a
boiling kettle in the room.
 Humidification

If crusting occurs, a few drop of normal saline
is instilled into the trachea every 2-3 hours to
loosen crusts
 Care of
Tracheostomy Tube

Tube should be kept in situ at least 2- 3 days to help
tract maturation and subsequent easy changing of
tube.
If cuffed tube is used, it should be periodically
deflated to prevent pressure necrosis.
 Care of wound

Water proof dressing should be applied to
prevent maceration of surrounding skin. The
wound is properly dressed to avoid infection.
Dressing is changed when it is soaked.
 Physiotherapy

Patient is encouraged to ambulant as early as
possible. Coughing out is encouraged and
various breathing exercise are to be taught.
 Decannulation

It is the process of taking out the tube
permanently after the patient has settled
down from the disease for which
tracheostomy was performed.
 Decannulation

This is usually performed after prior
intermittent blocking of the tube. If the
patient can tolerate blocked tube for 24 hours,
tube can be removed and wound is closed.
Other procedures for
airway establishment

1. Endotracheal intubation
2. Cricothyrotomy or larygotomy
3. Percutaneous tracheostomy
