Tracheostomy: As. Univ. Dr. Andrei Cristian Bobocea As. Univ. Dr. Serban Radu Matache

Tracheostomy
as. univ. Dr. Andrei Cristian Bobocea

as. univ. Dr. Serban Radu Matache
History
 Tracheostomy is one of the oldest surgical procedures.

 A tracheotomy was portrayed on Egyptian tablets
dated back to 3600 BC.
 Asclepiades of Persia is credited as the first person to
perform a tracheotomy in 100 BC.
 Antonio Musa Brasavola, an Italian physician,
performed the first documented case of a successful
tracheotomy.
 He published his account in 1546. The patient suffered
from a laryngeal abscess and recovered from the
procedure.
Tracheostomy
History and indications
 1932 prevent pulmonary infection in neurologically impair patients

secondary to infections (poliomyelitis).
 1943 remove bronchial secretions in cases of myasthenia gravis and

tetanus.
 1951 reduce the volume of dead space, use in COPD and severe
pneumonia.
 1950 positive pressure through tracheostomy for patients with

poliomyelitis.
 1955 obstruction secondary to infection: diphteria, Ludwig’s angina.
 1961 Obstructions secondary to tumour, infectious disease and

trauma.
Current indications
 Endotracheal intubation rather than tracheostomy is now used

to establish an emergency airway
 Even in difficult anatomic situations, intubation can usually be

accomplished over a flexible intubating laryngoscope or
bronchoscope.
 In 1909 Dr. Chevalier Jackson standardized the technique of

tracheostomy
Tracheostomy
Indication Contraidications
 Upper airway obstruction (in
children –epiglottitis, in adult –  Anatomic defects
trauma, laryngeal cancer, benign
tracheal stenosis)  Severe soft tissue infections
 Airway protection
 Severe hypoxemia
 Prolonged ventilatory support for

respiratory insufficiency – severe
brain injury, posttraumatic
respiratory distress syndrome,
respiratory infections, COPD
Tracheostomy
 Very stable platform for ventilatory access
 Very low incidence of accidental extubation
 Limited damage of the tracheal mucosa
 Better oral hygiene
 Eliminating much dead space may improve the chance of weaning a

patient with marginal pulmonary function from the ventilator
Technique
 The incision is located with reference
to the cricoid cartilage and not the
 Tracheostomy is preferably done in an sternal notch
operating room
 A more cosmetic transverse incision
is used
 A short incision is made 1 cm below
 The patient is supine on the table with
the cricoid cartilage, which can
the neck moderately extended
usually be palpated, even in obese
patients
 An inflatable bag placed beneath the  It is carried through the platysma, the
patient’s shoulders is helpful flaps elevated, and the strap muscles
are separated in the midline. (The
 Brief general anesthesia is preferred, thyroid isthmus overlies the second
but local anesthesia may be used tracheal cartilage in most patients)
Incision 1 cm below the cricoid or
halfway between the cricoid and the
sternal notch.
Retractors are placed, the skin

is retracted, and the strap
muscles are visualized in the
midline. The muscles are
divided along the raphe, then
retracted laterally
Technique
 Dissection is begun at the
lower border of the cricoid
cartilage and the trachea is
identified above and below the
isthmus
 Isthmus is divided and suture
ligated, providing a clean
exposure of the upper trachea
from the lower border of the
cricoid cartilage down to the
fourth ring
 A vertical midline incision is
made through the second and
third rings, which are
identified precisely
The thyroid isthmus lies in the field of the dissection.
Typically, the isthmus is 5 to 10 mm in its vertical dimension,
mobilize it away from the trachea and retract it,
then place the tracheal incision in the second or third tracheal
interspace.
Technique
 The tracheal lumen is exposed.
 The endotracheal tube is withdrawn proximally
to a point just above the incision in the trachea,
but is not yet removed
 Thyroid pole retractors are slipped into the
tracheal lumen and the stomal edges retracted
laterally. If the opening is not large enough,
part or all of the fourth ring may also be
divided vertically.
 The tracheostomy tube is slipped into the
trachea using a small amount of water-soluble
lubricant.
 With the tube in place, the cuff is inflated just
enough to provide a seal.
 The tracheostomy tube should be no larger in
diameter than is needed.
Technique
 A swivel adaptor is attached to the
tube and ventilation continued
through the tracheostomy tube.
 Only when the tracheostomy tube is
functioning satisfactorily, is the
endotracheal tube removed.
 Traction sutures in the cartilaginous
margins of the stoma are acceptable,
but unnecessary.
 The skin is closed loosely with 3-0
nylon monofilament vertical mattress
sutures.
 The flange of the tracheostomy tube
is sutured to the skin with four
additional sutures to prevent
inadvertent extubation
postoperatively.
 A tracheostomy tape is also tied.
TRACHEOSTOMY TUBE CARE
 Securing tracheostomy around

patient’s neck.
TRACHEOSTOMY
TUBE CARE
 Tube changes:
◦ Indications: soiled, cuff rupture.
◦ Complications: insertion into a false
passage bleeding, and patient discomfort.
◦ Avoid within 1st week.
◦ First tube change by surgeon.
◦ Difficult cases (obese, short and thick
neck), be prepared for endotracheal
intubation.
TRACHEOSTOMY TUBE CARE
 Humidification of the inspired gas is a
standard of care for tracheostomized
patients.
Thermovent
SPEECH
NUTRITION
 Tracheostomy tube prevents normal upward movement of

the larynx during swallowing and hinders glottic closure.
 Between 20% and 70% of patients with a chronic

tracheostomy experience at least one episode of aspiration
every 48 hours
 Evaluation by speech therapist.
 Keep head elevated to 45° during periods of tube feeding.

Complications - Immediate
 Apnea
 Mediastinal intubation
 Bleeding
 Pneumothorax
 Adjacent structure injury
 Postobstructive pulmonary edema
Complications -Early
 Bleeding
 Mucous plugging
 Tracheitis
 Cellulitis
 Displacement
 Subcutaneous emphysema
 Wound infection
Complications - late
 Bleeding
 Granulationtissue
 Wound infection
 Stenosis
 Tracheomalacia
 Tracheoesophageal fistula
 Tracheoinnominate fistula
 Tracheocutaneous fistula
CONCLUSION
 The most common indications for tracheostomy is
mechanical ventilation with prolonged tracheal
intubation.
 Tracheostomy: emergency and elective, improve

quality of life.
 Meticulous surgical technique.
 Appropriate postoperative tracheostomy care to

reduce complications.

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Tracheostomy

as. univ. Dr. Andrei Cristian Bobocea

 Tracheostomy is one of the oldest surgical procedures.

 1932 prevent pulmonary infection in neurologically impair patients

 1943 remove bronchial secretions in cases of myasthenia gravis and

 1950 positive pressure through tracheostomy for patients with

 1955 obstruction secondary to infection: diphteria, Ludwig’s angina.

 1961 Obstructions secondary to tumour, infectious disease and

 Endotracheal intubation rather than tracheostomy is now used

 Even in difficult anatomic situations, intubation can usually be

 In 1909 Dr. Chevalier Jackson standardized the technique of

 Prolonged ventilatory support for

 Very low incidence of accidental extubation

 Limited damage of the tracheal mucosa

 Better oral hygiene

 Eliminating much dead space may improve the chance of weaning a

Retractors are placed, the skin

 Securing tracheostomy around

 Tracheostomy tube prevents normal upward movement of

 Between 20% and 70% of patients with a chronic

 Evaluation by speech therapist.

 Keep head elevated to 45° during periods of tube feeding.

 Tracheostomy: emergency and elective, improve

 Meticulous surgical technique.

 Appropriate postoperative tracheostomy care to

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