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Tracheostomy| indications, technique, types and complications

Definition: Creation of surgical opening, in anterior tracheal wall.

Indications:
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.
    tracheostomy

II. Lower respiratory tract obstruction

1. Secretory obstruction.

Value of tracheostomy:
  1. Frequent accurate aspiration of secretion. 
  2. Elimination of dead space.
  3. Avoids complications of prolonged intubation 
  4. Prevent aspiration.

Etiology:
A. Central
  • Head injury: contusion, laceration. 
  • Drug intoxication.
  • Uraemia, ketoacidosis. 
  • Brain tumors & abscess.
  • Stroke: Hge, embolism, thrombosis
B. Peripheral
  • Respiratory muscle paralysis. 
  • Chest injury e.g. ribs fracture.

2. Respiratory failure:

  • Chronic obstructive pulmonary disease 
  • Neurological disorders e.g. poliomyelitis, myasthenia.

III. Elective

A. Before laryngeal surgery.
B. Before major operations in head and neck e.g. angiofibroma, and maxillectomy.

Types: 

Technique:
 1. Anesthesia
  • Usually local infiltration, 
  • General: in elective cases, better in children.
  • No anesthesia in real emergency. (Better do cricothyrotomy).
2. Position
  • Supine with extended neck.
  • If patient distressed: sitting or semisitting.
3. Incision
  • 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:

  1. Metal or silastic. 
  2. Cuffed or non cuffed.
  3. Inner & outer tubes. 
  4. Tubes with expiratory valve.
Complications of Tracheostomy:
1. Anaesthetic complications local or general.
2. Apnea:
  • 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.
3. Bleeding
  • a. Primary: Anterior jugular vein, thyroid gland, innominate vein.
  • b. Reactionary: Slipped ligature, from previously collapsed vein (open the wound & ligate the
  • vessel).
  • 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.
5. Pneumomediastinum:

  • Due to: Excessive inferior dissection.
  • If mild: Resolve spontaneously.
  • If severe: Acute heart failure.
6. Crustation:
  • 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.
10. Injury:
  • 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.
11. Infection
  • Wound infection.
  • Chest infection.
12. Tube complications:
a) Slipped tube:
Due to low tracheostomy, wide stoma, short neck, or short tube.
Treatment: Reposition.
b) Blocked tube by dried secretions.
Treatment: Frequent suction, cleaning with NaHco3.

Post Operative Care.

  1. Patient lies in semi sitting position.
  2. Observation of vital signs.
  3. Observation for bleeding.
  4. Observation for respiratory distress (Known by recurrence of stridor, absence of air current, absence of mirror dimness, patient can speak without closing the tube).
  5. Humidification by steam inhalation.
  6. Antibiotics.
  7. Mucolytics.
  8. 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.

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