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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