Definition: Creation of surgical opening, in anterior tracheal wall.
I. Upper respiratory tract obstruction. All causes of stridor
+ Extra laryngeal causes (injury, infection, edema, tumors)
- Injury: maxillofacial.
- Infection: retropharyngeal abscess.
- Edema: tongue & neck edema.
- Tumors: oral cavity, tongue, and pharynx.
II. Lower respiratory tract obstruction
1. Secretory obstruction.
Value of tracheostomy:
- Frequent accurate aspiration of secretion.
- Elimination of dead space.
- Avoids complications of prolonged intubation
- Prevent aspiration.
- Head injury: contusion, laceration.
- Drug intoxication.
- Uraemia, ketoacidosis.
- Brain tumors & abscess.
- Stroke: Hge, embolism, thrombosis
- Respiratory muscle paralysis.
- Chest injury e.g. ribs fracture.
2. Respiratory failure:
- Chronic obstructive pulmonary disease
- Neurological disorders e.g. poliomyelitis, myasthenia.
A. Before laryngeal surgery.
B. Before major operations in head and neck e.g. angiofibroma, and maxillectomy.
- Usually local infiltration,
- General: in elective cases, better in children.
- No anesthesia in real emergency. (Better do cricothyrotomy).
- Supine with extended neck.
- If patient distressed: sitting or semisitting.
- Vertical: rapid, lower border of thyroid cartilage to manubrium sterni
- Transverse: more cosmetic.
4. Incise fat, fascia, separate pretracheal muscles.
5. Dissect, incise & transfix thyroid gland isthmus.
6. Open the trachea as a flap.
7. Put a suitable tube. 8-Adequate haemostasis.
9. Close the wound not too tight, fix tube to skin.
Types of Tracheostomy tubes:
- Metal or silastic.
- Cuffed or non cuffed.
- Inner & outer tubes.
- Tubes with expiratory valve.
Complications of Tracheostomy:
1. Anaesthetic complications local or general.
- When operation done under L.A
- Due to rapid wash out of CO2 which is stimulus for respiratory center.
- Treatment: Close the opening for a short time, allow patient to breath 95% O2 in 5% co2 , or assisted ventilation.
- a. Primary: Anterior jugular vein, thyroid gland, innominate vein.
- b. Reactionary: Slipped ligature, from previously collapsed vein (open the wound & ligate the
- c. Secondary: Due to infection (antibiotics & fresh blood).
4. Pneumothorax (most common):
- Due to: pleural injury. Manifested by: dyspnea air entry, X ray.
- Treatment: intercostal tube connected to underwater seal.
- Due to: Excessive inferior dissection.
- If mild: Resolve spontaneously.
- If severe: Acute heart failure.
- Cause: No filtration of inspired air.
- Decreased mucociliary clearance.
7. Delayed complications:
- Subglottic stenosis: due to cricoid injury.
- Tracheal stenosis: due to erosion by tube or infection.
- Difficult extubation.
- Tracheoesophageal fistula.
- Tracheocutaneous fistula.
8. Emphysema (surgical):
- Air accumulation under skin.
- Due to: - Improperly fitting tube (small tube and large tracheal opening). -Excessive lateral neck dissection.
- Treatment: Remove a skin suture, Insert a more fitting tube.
9. Embolism (air embolism) :
- Due to injury of large neck vein.
- Treatment: -Pour saline into wound. -Compression of opened vein. - Elevate foot of bed. -Blood transfusion.
- Thyroid gland >> Hemorrhage.
- Apex of pleura >> pneumothorax.
- Cricoid cartilage >> subglottic stenosis.
- Posterior tracheal wall >> Tracheoesophageal fistula.
- Treatment: Ryle feeding, surgical repair.
- Big vessels >> Hemorrhage.
- RLN >> V.F paralysis.
- Wound infection.
- Chest infection.
12. Tube complications:
a) Slipped tube:
Due to low tracheostomy, wide stoma, short neck, or short tube.
b) Blocked tube by dried secretions.
Treatment: Frequent suction, cleaning with NaHco3.
Post Operative Care.
- Patient lies in semi sitting position.
- Observation of vital signs.
- Observation for bleeding.
- Observation for respiratory distress (Known by recurrence of stridor, absence of air current, absence of mirror dimness, patient can speak without closing the tube).
- Humidification by steam inhalation.
- Care of tube:
a) Frequent suction, NaHco3 to dissolve mucus.
b) Regular removal of inner tube for cleaning.
9. Extubation: tube is closed with cork for daytime, then day & night.