Tracheostomy

Definition

Tracheotomy is a surgical procedure used to cut a hole in the trachea through which a small tube is inserted.

Indications for tracheostomy

Tracheotomy is indicated when the airway is mechanically blocked, for example by a crushing blow to the neck, and efforts at both intubation and "popping" the trachea process back into shape with the thumbs have been unsuccessful.

  • Upper airway obstruction (like facial trauma, epiglottitis, laryngeal trauma, etc.)
  • Prolonged intubation
  • Bronchopulmonary toilet

Techniques

Emergency tracheostomy

The emergency tracheotomy is performed only by doctors qualified in emergency medicine or under their specific direction. Paramedics perform a needle cricothoracotomy instead, if local protocols permit.

  • Done very quickly; by slashing , find trachea, open it and insert tube
  • Obviously, higher incidence of complications
  • Basically, a puncture through the cricothyroid membrane

Elective tracheostomy

Sometimes a planned tracheotomy is indicated when a patient requires long-term mechanical ventilation, for example in throat cancer. Great care must be taken to avoid damaging the vocal cords.

  • Patient intubated from above (oral or nasal endotracheal intubation)
  • Careful dissection and control of bleeding
  • Coordinated insertion of trach tube and removal of endotracheal tube
  • Cricothyrotomy

Important issues

  • Cuffed: (cuff may reduce aspiration but also puts pressure on tracheal walls)
  • Inner cannula: (removable, helps prevent tube blockage because it can be cleaned)
  • Fenestrated: (has a hole in it for airflow through vocal cords and upper airway to allow phonation)

Tracheostomy Care

  • Deflate cuff at about 24 hr
  • Change tube at 5 days when tract is formed
  • Humidified air
  • Inner cannula removed and cleaned at least daily, more if needed
  • To decannulate patient:
    • Change to uncuffed fenestrated trach
    • Downsize trach to size 6 or 4
    • "Cork" (with plastic plug) at least 24 hr prior to removing trach tube
    • Occlusive dressing over tracheostomy site for about one week (it should heal up entirely)

Complications

Early complications

  • Damage to vessels, esophagus, recurrent laryngeal nerve
  • Damage to cupula of lung: pneumomediastinum/thorax (Do post-op CXR)
  • Apnea in patients with chronic hypoxia/CO2 retention

Delayed complications

  • Tube blockage
  • Tube displacement
  • Delayed decannulation
  • Persistence of stoma after decannulation
  • Hemorrhage: especially brachiocephalic artery erosion
  • Tracheomalacia
  • Dysphagia
  • Tracheal stenosis
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