Tracheostomy

Introduction

A tracheostomy is a surgical opening in the front wall of the trachea. Tracheostomy has traditionally been performed as an open surgical procedure, but safe and reliable percutaneous tracheostomy techniques have been developed, allowing tracheostomy to be performed at the bedside in many patients patients [1].

This 6 minute video explains what a tracheostomy is.

Percutaneous Tracheostomy

Percutaneous tracheostomy involves the Seldinger technique and interannular tracheodilation [2].

Percutaneous tracheostomy (PT) is usually performed on a hospital room. The doctor makes a small incision near the bottom of the front of the neck. A special lens is fed through the mouth so the surgeon can see inside the throat. Using this view of the throat, the surgeon guides A needle is inserted into the trachea to create a tracheostomy hole, which is then expanded to fit the tube [3]. Bedside PT offers significant cost savings by eliminating operating room and anesthesia expenses. Bronchoscopy is often used as a visual aid during PT. Ultrasound (US) guided PT Yes It is becoming more and more popular [4].

Surgical Tracheostomy

Surgical tracheostomy involves dissection and incision of the trachea under direct vision [2].

Tracheostomy with tube

A surgical tracheostomy can be performed in an operating room or on a hospital ward. With the patient lying there, place a rolled up towel (or similar) under your shoulders to help stretch the patient’s neck. A local anesthetic is injected into the targeted area and an incision (incision) is made in the skin production. The surgeon will then open the trachea (this is called a “tracheotomy”) or the cricothyroid membrane, the thinnest part of the airway below the throat (this is called a “cricothyrotomy”). Insert the airway into the windpipe and connect the human to the oxygen supply. The whole process is done as fast as possible [3].

Indications for a Tracheostomy[5]

Airway obstruction

• Securing and clearing obstructed airways in the upper airway
• Blockage usually caused by inflammation of the airway infection or cancerous swelling from trauma
• Where the airway is expected to get worse and may actually become obstructed after major head and neck surgery

Provide artificial airway for ventilation

• A tracheostomy is usually well tolerated and usually does not require sedation once inserted.
• In the medium to long term, this is the best way to invasively ventilate the patient, providing a safe airway without directly interfering with the larynx
• It promotes ventilated weaning.
• It can provide patients with long-term mechanical ventilation in emergency situations or on a long-term basis.

Protecting the airway

• Some patients are at high risk of aspiration of secretions or gastric contents into the airways. E.g. Neuromuscular disorders Head injury Loss of consciousness Stroke or after long-term disuse, such as after translaryngeal intubation (endotracheal intubation)
• A tracheostomy tube with an inflated cuff reduces risk and provides some protection against aspiration
• Subglottic suction system helps reduce secretions entering the airway

Respiratory secretion management

• Facilitates clearing of bronchial secretions with poor coughing and phlegm retention
• Tracheostomy allows manual insufflation-insufflation (cough assist) to be applied directly to the lungs
• Inhale directly into the trachea to help clear secretions. [5]

Other Reasons for a Tracheostomy[6]

• Neuromuscular disorders that paralyze or weaken the chest muscles and diaphragm
• Aspiration related to throat muscle or sensory problems
• Cervical Fracture Combined with Spinal Cord Injury
• Long-term unconsciousness or coma
• Disorders of breathing control, such as congenital central hypoventilation or central apnea
• Facial surgery and facial burns
• Anaphylaxis (severe allergic reaction)

Physiological Changes

• Up to 50% reduction in upper airway anatomical dead space. – This space does not participate in gas exchange and increases the work of breathing. Reducing that could help patients come off ventilators more easily.
• The natural warming, humidification and air filtration that normally occurs in the upper respiratory tract is lost
• The patient’s ability to speak is removed/reduced due to the cuff impairing the swallowing mechanism of the larynx
• ability to swallow is adversely affected
• Taste and smell may be lost, which can negatively affect appetite.
• Altered body image[5]

Complications

Perioperative period

• Haemorrhage
• Tube misplacement – around the trachea or within the tissue of the main bronchi
• Pneumothorax
• Tube occlusion
• Surgical emphysema
• Loss of the upper airway

Postoperative period < 7 days

• Tube blockage with secretions or blood
• Partial or complete tube displacement
• Infection of the stoma site
• bronchial tree infection (pneumonia)
• Tracheal ulceration and/or mucosal ulceration due to necrosis or tube migration
• Risk of tracheostomy tube blockage in obese or fatigued patients with difficulty in neck extension
• Tracheo-oesophageal fistula formation
• Haemorrhage

Late postoperative period >7 days

• Tracheal granuloma (massive granulation tissue) that may cause difficulty breathing when the tracheostomy tube is removed
• Tracheodilation narrowing or tracheomalacia (partial collapse of the trachea, especially with increased airflow)
• Scar formation-requiring revision
• Haemorrhage