Tracheostomy

Tutorial Pra Bedah Dasar

Narasumber: dr. Suprayitno Wardoyo, Sp. BTKV, Subsp. JPK (K)
 Tracheostomy

Trachea Stoma

the word trachea tom- (from Greek τομή tomḗ)

 from Greek τραχεία tracheía. meaning "to cut“
 stom- (from Greek
Windpipe στόμα stóma) meaning "mouth"

Tracheostomy  surgical
procedure that creates an opening
(stoma) in the windpipe (trachea).
 Trachea

1. Passage for air and playing

a vital role in breathing
2. A hollow, tube-like
structure that runs from the
larynx (voice box) to the
bronchi.
 Trachea Anatomy

1. Average length and width

11.8 cm (10 – 13cm) and 1.5 – 2 cm
*wider in males
2. 18 to 22 “C” shaped cartilaginous
rings
3. Lower edge of cricoid cartilage
(C6)
to carina (T4)
4. One-third: extrathoracic
two-thirds: intrathoracic
 Trachea Anatomy
Blood supply:
1. Branches of inferior thyroid artery –
cervical trachea
2. Bronchial arteries – thoracic trachea
and carina
 Trachea Anatomy
Blood supply: Microcirculation of
trachea
1. Tracheoesophageal artery
2. Primary Tracheal Artery
a. Lateral Longitudinal
Anastomosis
b. Anterior Transverse
Intercartilaginous artery
c. Posterior Transverse
Intercartilaginous artery
3. Primary Esophageal Artery
4. Submucosal capillary Plexus
Anatomic Relationship
1. Thyroid Gland
2. Recurrent Laryngeal
Nerve
3. Esofagus
4. Aorta
5. Arteries and Veins
Anatomic Relationship
 History

1. The oldest and most commonly performed

operation on the airway
2. Tracheostomies have been performed since
ancient times and  Rig Veda, the sacred Hindu
scripture which dates back to 2000 BC.
3. In 1620 Habicot published the first book on
tracheostomies.
 History

1. In the 1800s tracheostomy

gained in popularity,
treating patients with
Diphtheria.
2. Chevelier Jackson in 1923 nd
was the first person to
recognise that dividing the
cricoid cartilage during a
‘high’ tracheostomy leads to
stenosis.
 Definition

1. Tracheostomy  opening anterior wall of

trachea either Permanent or temporary, held
open by a tube, with the consequence of
diverting airflow from the larynx  providing an
alternative airway for breathing
2. Tracheotomy  incision in the trachea during the
course of an operation
 Tracheostomy

Tracheostomy is considered superior to

endotracheal intubation in certain situations due to
several factors:
1. Comfort
2. Safety
3. Prolonged ventilation
4. Independence
5. Access
 Indications

The indications for tracheostomy

include:
1. Mechanical upper airway
obstruction.
2. Protection of tracheobronchial tree
in patients at risk of aspiration.
3. Respiratory failure.
4. Retention of bronchial secretions.
5. Elective tracheostomy for major
head and neck surgery
Mechanical Upper Airway Obstruction
 Tracheostomy

1. is often performed in the anesthetized patient with

a controlled airway.
2. Conversely, imminent airway compromise may
necessitate tracheostomy in the awake patient.
3. Elective tracheostomy usually replaces prolonged
endotracheal ventilation after 7 to 10 days.
Tracheostomy
in the ICU
Respiratory
failure
Type I and II
 Tracheostomy

Main goals 
• reduces patient discomfort,
• reduces the risk of endotracheal tube plugging,
• reduces the likelihood of laryngeal damage from
prolonged endotracheal intubation, and
• provides flexibility and safety during weaning from
assisted ventilation
 Tracheostomy

Tracheostomy is contraindicated in:


Patients requiring high levels of ventilatory support
(including high PEEP and fraction of inspired oxygen),
in whom brief periods of apnea during the procedure
will be poorly tolerated.
 Neck Trauma

Blunt or penetrating injury to the neck

can cause disruption of the larynx or
trachea
 airway obstruction and/or severe
bleeding into the tracheobronchial tree.
A definitive airway is urgently required
in this situation.
 Operative Step
1. The patient should be positioned on the operating
table with the neck extended.
2. The trachea and laryngeal cartilages should be
palpated  This should be a horizontal incision
halfway between the sternal notch and the cricoid
cartilage
3. The incision should be at least 6 cm long in the adult
and should extend to the anterior border of the
sternocleidomastoid muscles on either side.
*experienced surgeons may choose to make a smaller incision
but the wider the exposure, the easier the operation is to
perform
 Operative Step
1. The incision is made through the subcutaneous tissue
and platysma, down to the deep cervical fascia.
2. A self-retaining retractor can now be inserted, and the
dissection continued until the strap muscles are
encountered.
3. The thyroid isthmus should be divided between two
haemostats and the cut ends transfixed with 2/0
Vicryl suture.
4. Do not dissect lateral to the anterior surface of the
trachea in order to avoid injury to the recurrent
laryngeal nerves and other important lateral
structures
 Operative Step
1. After dividing the isthmus, carefully count the tracheal
rings. Meticulous haemostasis is essential at this
stage as it is difficult to visualise the depths of the
wound once the tube is in situ.
2. The tracheostomy should be sited over the 2nd and 3rd
or 3rd and 4th tracheal cartilages.
3. Make a longitudinal incision through these cartilages in
the midline. If heavily calcified, create a window in the
anterior aspect of the tracheal cartilages large
enough for the tube.
 Operative Step
1. Alert the anaesthetist before making the
tracheal incision to prepare for tube
withdrawal.
2. Ensure all equipment is functional and the
correct tube size is selected.
3. The anaesthetist should confirm that there is
good CO2 return and that thepatient is
oxygenating well and that the air-pressures
are adequate. Check the cuff on the
tracheostomy tube is staying inflated as it can
be punctured by a sharp edge of calcified
cartilage.
 Operative Step
1. Wait until a tract forms between the trachea
and the skin, typically after 48–72 hours, before
changing the tube.
2. Avoid replacing the tube earlier, as there is no
need to change a well-functioning tube.
3. Perform the first tube change on day 5 when a
stable tract has formed, minimizing any
potential issues during replacement
Complications
PERCUTANEOUS DILATATIONAL TRACHEOSTOMY

Standard Surgical
Tracheostomy
(SST)
Tracheostomy
Percutaneous
Dilatational
Tracheostomy
(PDT)
PERCUTANEOUS DILATATIONAL TRACHEOSTOMY
1. PDT involves placing a tracheostomy tube using a
commercially available set and a series of dilators.
2. PDT is an elective procedure commonly performed in the
ICU.
3. The popularity of PDT is attributed to its greater
availability and fewer constraints compared to SST.
4. PDT is preferred due to
a. reduced restrictions related to theater availability,
b. accessing surgeons,
c. cost, and
d. time required for coordinating patient transfer.
 Surgical Tracheostomy
• Advantage
• Traditional procedure with
longterm experience with
techniques and outcome
• Low early complication rates for
critically ill patient
• Direct access to deep cervical
structures to control bleeding
and ensure proper placement
• Disadvantage
• Most performed in the
operating room, high cost and
transport risk
• Procedure delay because
operating room availability
• Stoma infection and bleeding
 Percutaneous Tracheostomy

• Advantage • Disadvantage
• Low early complication rates • Airway misplascement when
in critical setting if performed performed without
by experienced operator bronchoscopy
• Avoids deep neck dissection • Few long term outcome study
• Non surgeon can perform to define late airway
• Can be performed bedside complication
 Tracheostomy Tubes
1. Outer cannula
2. Inner cannula
3. Cuff
4. Pilot balloon
5. Flange/neck plate
6. Introducer/obturator
7. Fenestrations
8. 15 mm adaptor
 Decannulation
1. the deliberate and permanent removal of the
tracheostomy tube. It should only be considered when the
indication for the insertion of the tracheostomy has
resolved.
 Indications
1. Reason for the tracheostomy resolved.
2. Patient alert, responsive and consenting.
3. Patient tolerating cuff deflation for a minimum of 12 h.
4. Patient managing to protect their airway and have a clear
chest.
5. Patient maintaining oxygen saturations.
6. Patient tolerating the use of a speaking valve and/or digital
occlusion.
7. Patient able to expectorate around the tube into their
mouth.
8. Tracheostomy tube type and size is appropriate.
 Troubleshooting

1. Respiratory insufficiency
2. Airway obstruction
3. Retention of secretions
4. Evidence of blood in secretions
5. Patient anxiety
 Long Term Tracheostomy
1. If clinical indications suggest that the patient will continue
to require their tracheostomy tube after their discharge,
plans to accommodate this should be instigated.
 When is a long-term tracheostomy tube required?
1. To provide ongoing mechanical ventilatory support
2. To bypass a long-term or permanent upper airway
obstruction to facilitate airflow (e.g. congenital
abnormalities)
3. To provide access to chest secretions in the event of
respiratory insufficiency (i.e. impaired cough
reflex/weakened respiratory muscles)
4. To protect from aspiration in the event of impaired swallow
reflex (e.g. neuromuscular disorders)
Thank You