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A Tracheostomy is an artificially( usually)
surgically created airway fashioned by making
a hole in the anterior wall of trachea and the
insertion of a tracheostomy tube, which may
or may not be permanent.
Tracheotomy is the opening into trachea
where as tracheostomy is converting the
opening into stoma onto the skin surface.
Tracheostomy is one of the oldest surgical
A tracheotomy was portrayed by the Egyptians and
Indians in the early years.
Extensive history of tracheostomy can be best
divided into five periods:
1. The period of Legend (3100BC to AD 1546)-
The first elective tracheotomy by Asclepiadus of
Bithynia in AD100.
This operation ws described by Claudius Galen,
renowned physician in AD 131
References were made to tracheotomy, but was
considered both useless and dangerous due to
high risk of wound infection
Hippocrates condemned tracheostomy
2. The period of Fear(AD 1546-1833) in
the history of tracheostomy:
During this era, this procedure ws
considered as irresponsible and barbaric.
By early 1600s, it started getting
acceptable for few conditions like FBs etc.
Bcoz of fear and mistrust abt procedure, it
prevented therapatic use of it, for eg. In
1799,dec4th,first US president died of
acute(within 36 hours) upper airway
obstruction sec. to peritonsillar abscess
3.The period of Dramatisation(AD 1833-
It was considered as operation of life or
The operative technique of tracheostomy
was studied, refined and defined by
Chevalier Jackson in 1909.
He also designed the metallic double
4. The period of Enthusiasm(AD 1932- 1965)
Wherein saying “if u think tracheostomy……do it”
Indications for tr. Were actively sought for and both
surgical and medical world became strong advocates
5.The period of Rationalisation(AD 1965 to present):
In 1965, it became apparent tht oral or nasal
intubation was quicker and safer than tr. So began
this period wherein tr. Vs intubation ws debated.
Seldinger introduced PCT in 1953
PCT using guidewire introduced by Ciaglia et al.
In 1990 Griggs et al developed another guidewire
dilating forceps for PCT
The trachea begins at the
lower border of cricoid
cartilage(C6) superiorly to
the tracheal bifurcation at
the level of sternal angle(T5).
Made up of 16 to 22 C-
shaped cartilage anteriorly
joined by annular ligaments
and posteriorly by trachealis
Located in midline
position,but can be deviated
to right as in advanced age
or severe COPD.
The average distance from
cricoid to carina is approx
12-16 cm long,2.3 cm wide.
Anterior to the trachea in the neck is the
isthmus of the thyroid gland at about the level
of 2nd to 4th tracheal cartilages.
Below this is the inferior thyroid veins, lymph
nodes, and sometimes a thyroid ima artery.
Anterior to all of these are the strap muscles.
Lateral to trachea in the neck are the lobes of
thyroid gland, great vessels and recurrent
The innominate artery crosses the trachea
either behind the sternum or in the lower
portion of neck.
During tracheostomy the careful surgeon will
palpate this region to assess the presenceof
high riding innominate artery.
The jugular venous arch connecting two
anterior jugular veins lies superficial to the
strap muscles just above the suprasternal
The basic anatomical relationships need to
be kept in mind in performing a
High tracheostomies (above 2nd tracheal
cartilage) are generally associated with a
higher rate of tracheal stenosis and
perichondritis of cricoid cartilage.
Low tracheostomy (below 4th tracheal
cartilages) will encounter more vascular
structures such as thyroid veins, ant. Jugular
arch, or a high innominate artery.
Horizontal skin incisions tend to be more
cosmetic, although the ext. jugular veins and
lateral anatomic structures must be
considered during dissection.
Vertical skin incisions tend to be avascular.
Paediatric larynx and tracheal anatomy varies
from adult and has a great clinical
Arteries of central neck:
Common carotid A.
Internal carotid A
Ext. carotid A. and br.
Superficial veins of central neck:
Ext. Jugular vein and ant jugular vein
Deep veins of central neck:
Internal jugular vein
Nerves of central neck:
Tenth nerve and its br.
Twelfth nerve and ansa cervicalis
Visceral structures of neck
Trachea and esophagus
Facilitation of ventilation support
Inability of patient to manage secretions
Upper airway obstruction
Inability to intubate
Adjunct to major head and neck surgery
Adjunct to management of major head and neck trauma
Cummings: Otolaryngology: Head & Neck Surgery, 4th
Goldenberg D, et al Tracheotomy: changing indications and a
review of 1,130 cases, J Otolaryngol 31:211–215, 2002
Tracheostomy in a number of medical and surgical
Trauma to the chest.
C.C.F. & pulmonary edema.
Tetanus, Rabies, Poliomyelitis.
Before doing major head and neck surgery
tracheostomy is done to prevent post operative
Elective – therapeutic or prophylactic
Emergency: when airway is complete or
almost completely obstructing as in FBs or
Elective: planned unhurried procedure.Often
temporary and closed when indication is
Therapeutic: to relieve respiratory
secretions or gv assisted ventilation.
Prophylactic: in extensive surgeries of
tongue, floor of mouth, mandibular resection
Permanent tracheostomy: In b/l abd.
Above the level
2nd & 3rd rings
Below the level
-Trachea is deep
-close to vessels
Position: supine with a pillow under the
trachea. This brings trachea forward.
Anesthesia: mostly done under local with 2%
lignocaine with epinephrine. Sometimes GA
Incision:Vertical- midline of neck, from
cricoid above to sternal notch.
Most favoured incision. Can be used in both
elective and emergency. Rapid access with
minimum bleeding and tissue dissection.
Horizontal -2 fingers breadth above the
sternal notch. Used in elective procedure
only. Cosmetically better scar.
Strap muscles separated in midline and
Thyroid isthmus is displaced upwards or
Identification of tracheal rings by colour and
confirmation- 4% lignocaine loaded syringe
introduced, withdrawn to see for air
bubbles, also to suppress cough.
Vertical incision given in trachea from below
upwards in 3 or 4th tracheal rings
Tube of appropriate size used. Tied to neck
with reaf knot.
Skin sutures not required.
Incision 1 cm below the cricoid or
halfway between the cricoid and the
Retractors are placed, the skin
is retracted, and the strap
muscles are visualized in the
midline. The muscles are
divided along the raphe, then
One Fingertip Fits
Under the Adult Ties
Trachea –soft and compressible
Too much of extension- Pleural injury,
innominate , thymus injury
Silk sutures on either side of trachea to
secure it in midline
Not to incise deeply as it can cause
posterior tracheal wall injury.
Not to excise ant. Wall of trachea- only
incision is given
Avoid infolding of ant tracheal wall
Proper selection of T tube
Nursing: constant supervision of pt after
tracheostomy for bleeding, displacement or
blocking of tube and removal of secretions.
Removal of secretions: Suction
Prevention of crusting and tracheitis:
Humidification, use of normal or hypotonic
saline or RL. If tenacious secretions, use of N-
acetylcysteine to loosen crusts
Care of T.tube: Inner tube cleaning
Care of inflatable cuff
Dressing: to avoid maceration of skin from
Breathing exercises: recommeded to ventilate
the lungs fully and prevent pulmonary infections
A calling bell, slate and a pencil for
ICU Bed SideTracheostomy
Minimally invasive alternative to open
Use of guide wire and Dilators
Under the vision of Bronchoscope through
Less time ,Less Expensive
Not suitable for thick neck and in emergency
Bleeding and injury to big
Apnoea- due to sudden
washout of co2
Injury to recurrent laryngeal
Injury to tracheoesophageal
Pneumothorax- injury to
Bleeding, reactionary or secondary
Tracheostomy tube obstruction
Tracheostomy tube displacement
Tracheitis and tracheobronchitis with
crusting in trachea
Atelectasis and lung abcess
Local wound infection and
• Hemorrhage, due to erosion of major vessels
• Laryngeal stenosis, due to perichondritis of
• Tracheal stenosis, due to tracheal ulceration
• Tracheo –oesophageal fistula
• Problems of decannulation
• Persistant tracheocutaneous fistula
• Problems of T.scar- keloid formation
• Corrosion of tracheostomy tube and aspiration
of its fragments into tracheo bronchial tree
T. tube should not kept longer than necessary
To decannulate, it shud be plugged or corked
and the pt shud be able to sleep overnight
with the tube closed before decannulation
After tube removal , pt is closely monitored
for resp.distress and tachycardia
It may be:
Persistance of the condition for which
tracheostomy was done.
Obstructing granulations: around stoma or at
tip of tube
Tracheal oedema or subglottic stenoses
Incurving of tracheal wall at the site of
1. Increased patient mobility
2. More secure airway
3. Increased comfort
4. Improved airway suctioning
5. Early transfer of ventilator-dependent
patients from the intensive care unit (ICU)
6. Less direct endolaryngeal injury
7. Enhanced oral nutrition
8. Enhanced phonation and communication
9. Decreased airway resistance for promoting
weaning from mechanical ventilation
10.Decreased risk for nosocomial pneumonia
in patient subgroups
A tracheostomy tube
◦ Inserted through the
maintain a patent
◦ Secured in place by
tapes tied around the
◦ Ideal T.tube:
◦ Rigid enough to
maintain the airway.
◦ Yet flexible enough to
limit tissue damage
◦ Comfortable to the pt.
Outer cannula 1. Main body of the tube which passes into
2. Diameter – inner dia of this outer cannula
Inner cannula 1. Removable tube –passes into outer tube
2. A bit longer
3. Can be locked
Cuff 1. Balloon at the distal end
Pilot balloon 1. Ext balloon connected by a inflation line to
Flange – neck
1. Supports the tube
2. Straight strip- adults
3. Angulated- pediatric
4. Adjustable flanges- bulky neck
1. Beveled tip shaft
2. Smooth round dilating tip
3. Reduces trauma – insertion
Fenestrations 1. Single/ multiple
Passy Muir valve
Speaking valves are
one way valves that
but block exhalation
through the cannula
forcing exhaled gas
through vocal cords
tube seals the
oral or gastric
once aspiration risk
Increases airflow to
Long term T. pts
Pts who do not
require a seal
PVC- Most cost effective, for short term use ,
More prone to infections.
Silicone –soft material, unique characteristic of
reducing adherence of secretions and bacteria
Siliconised PVC- sufficient rigidity,
Thermosensitive, More pt. comfortable. Eg
Silver- 92.8% silver, Cu and P with silver lining,
For prolonged use. Eg Negus and Chavelier
Sialistic –silicon rubber, less rigid. Eg. Moore