A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs.

1. OTORHINOLARYNGOLOGY
Dr Kuku Kapenda Kapasu
Bsc.HB, MBChB UNZA,
MBA-HCM UNILUS
(understudy)
Cert. DPPPR ZIDIS
www.similima.com 1

2. TRACHEOSTOMY
ANATOMICAL RELATIONS
OF TRACHEA
www.similima.com 2

3. Before considering the operative procedure
some important anatomical relations are
reviewed.
Anteriorly the trachea is covered by skin,
superficial and deep fascia, sternohyoid and
sternothyroid muscles. The isthmus of the
thyroid gland lies deep to the strap muscles
and covers the trachea from the second to
the fourth ring. Below the isthmus lies the
inferior thyroid vein.
www.similima.com 3

4. On each side of the trachea are thyroid
lobes enclosed in the pretracheal fascia,
carotid sheath and other greater vessels
and nerves of the neck.
Posteriorly the trachea lies on the
oesophagus and the recurrent laryngeal
nerves ascend on each side between the
trachea and the oesophagus.
www.similima.com 4

5. Tracheostomy
This is a procedure wherein an opening
is made in the anterior tracheal wall
which is brought to skin by inserting a
tube or iatrogenic tracheo- cuteneous
fistula.
www.similima.com 5

6. Indications for Tracheostomy
1. Tracheostomy may be needed to
relieve respiratory obstruction which
may be due to the following:
a) Inflammatory diseases of the
upper respiratory tract like acute
laryngotracheobronchitis,
laryngeal diphtheria and acute
epiglottitis.
b) Impacted foreign bodies in the
larynx or trachea.
c) Trauma such as laryngeal injury,
maxillary and mandibular
fractures, inhalation of irritant
fumes or corrosive poisoning
causing laryngeal oedema.
www.similima.com 6

7. d)Angioneurotic oedema.
e)Tumours and cysts of the
larynx and laryngopharynx.
f)Bilateral vocal cord paralysis.
www.similima.com 7

8. 2. Tracheostomy may be needed to
prevent aspiration of fluids, pus or blood
from the trachea. Diseases like bulbar
paralysis leads to pharyngeal paralysis
and incompetenceof the laryngeal
sphincteric mechanism which leads to
overspill of oral secretions into the larynx.
Hence tracheostomy is required to
separate the lower respiratory tract from
the pharynx.
www.similima.com 8

9. 3. Tracheostomy is indicated in certain
diseases which lead to retention of
secretions in the lower respiratory tract.
Inadequate clearance of secretions from
the tracheobronchial tree produces
hypoxia and hypercapnia, further, these
secretions serve as an ideal culture
medium for bacteria. These conditions
include bronchiectasis, lung abscess,
chronic bronchitis, etc. Tracheostomy
may be needed in various conditions like
head injury and diabetic coma for proper
suction of secretions in the lower
respiratory tract.
www.similima.com 9

10. 4.Tracheostomy is indicated in certain
conditions leading to respiratory
insufficiency. Tracheostomy with a cuffed
tracheostomy tube enables intermittent
positive pressure respiration. The
diseases which cause respiratory
insufficiency are poliomyelitis,
polyneuritis, chest injuries (flail chest),
etc.
5.Muscular spasms and recurrent
laryngeal nerye spasm as in tetanus
necessitate a tracheostomy.
www.similima.com 10

11. Types of Tracheostomy
The urgency with which a tracheostomy
may be done is used to classify this
operation.
Emergency tracheostomy: This type of
operation is done when the laryngeal
obstruction is acute and demanding an
urgent relief. Under such circumstances
the patient’s head and neck are extended
and the trachea palpated. An incision is
given with a knife deep in the midline and
trachea opened for restoring respiration
through tracheostomy
www.similima.com 11

12. Elective tracheostomy: This is a
planned operation. The patient and
surgeon are both prepared. Proper
instruments and anaesthesia are
arranged. The incision given may be
(i) prophylactic, or (ii) therapeutic.
Permanent tracheostomy: This may be
required for patients with bilateral
abductor paralysis, laryngeal stenosis,
laryngectomy or laryngopharyngectomy,
Lower tracheal stump is brought, to
surface and stitched to the skin.
www.similima.com 12

13. Operative Technique
A vertical incision is given in the
suprasternal space extending down from
the cricoid cartilage through the skin,
subcutaneous fat and deep cervical
fascia. The infrahyoid muscles are
exposed and separated in the midline to
expose the thyroid isthmus and trachea.
The thyroid isthmus is either retracted or
cut to expose the tracheal rings. An
assistant pulls the soft tissues and
muscles laterally with retractors. The
cricoid cartilage is hooked up to stabilize
the trachea.
www.similima.com 13

14. An opening is made in the tracheal wall,
usually at the level of the third or fourth ring
and the tracheostomy tube is placed in
position and secured by tapes around the
neck. A tracheostomy is called high when
the tracheal opening is made above the
thyroid isthmus, i.e. through the first ring.
There are chances of damage to the cricoid
cartilage and subsequent subglottic
stenosis. A low tracheostomy means,
making the tracheal opening below the
thyroid isthmus. Care of such tracheostomy
becomes difficult. Mid tracheostomy is the
ideal procedure where the opening is made
behind the isthmus on the third ring.
www.similima.com 14

15. Complications of Tracheostomy
• Various complications may arise during
or after the operation. Complications that
can arise during surgery include
hemorrhage mainly due to trauma to the
thyroid veins.
• Trauma during surgery may be to thyroid
gland, esophagus, recurrent laryngeal
nerve, great vessels of the neck or the
domes of the pleura.
• Sudden decrease in PCO2 in the blood
and correction of hypoxia may lead to
apnoea.
www.similima.com 15

16. Postoperative Complications
1. Surgical emphysema of the neck and
chest may occur as the air may leak
into the cervical tissues.
2. Displacement of tube: Improper
opening in the trachea, improper size
and securing of the tube may lead to
displacement of the tube with the
formation of a false passage.
3. A high tracheostomy may damage
the cricoid cartilage with resultant
subglottic stenosis.
4. Damage to tracheal rings can lead to
tracheomalacia.
www.similima.com 16

17. 5. Difficult decannulation: The removal of
tracheostomy tube is known as
decannulation. Decannulation is usually
difficult in infants and young children
perhaps because the young child has no
airway reserve. It is better to use
expiratory valve to begin with, thus
restoring physiological expiratory thrust
and stimulating the reflex for vocal cord
abduction. Once this is tolerated well the
cannula should be gradually blocked and
reduced in size.
www.similima.com 17

18. Factors causing difficult
decannulation are the following:
• Persistence of the condition that
originally necessitated the
tracheostomy
• Granulation around stoma
• Oedema of the tracheal mucosa
• Inability to tolerate upper airway
resistance on decannulation
• Emotional dependence on
tracheostomy
• Subglottic stenosis
• Tracheomalacia
www.similima.com 18

19. • Incoordination of the laryngeal opening
reflex
• Impaired development of the larynx as a
result of long- standing tracheostomy.
6. Pulmonary infection: Lack of proper
defence mechanism of the upper air
passages and improper care of the
tracheostomy may lead to pulmonary
infection.
7. Tracheal stenosis
8. Fatal haemorrhage might occur due to
erosion of a great vessel (innominate
artery) by the tube end.
www.similima.com 19

20. Types of Tracheostomy Tubes
A tracheostomy tube may be metallic or
nonmetallic.
A metallic tracheostomy tube has an
inner and an outer tube. The inner tube is
longer than the outer one so that secretions
and crusts form in it can be removed and
the tube reinserted after cleaning without
difficulty. However, they do not have a cuff
and cannot produce an airtight seal.
A nonmetallic tracheostomy tube can be
of the cuffed or non-cuffed variety, e.g.
rubber and PVC tubes. Silastic cuffed PVC
tubes are of special use and allow
intermittent positive pressure respiration
and prevent aspiration into the trachea.
www.similima.com 20

21. Care of Tracheostomy
1. Proper attention is given to the correct
positioning of the tracheostomy tube by
selecting a proper sized tube and
securing it with tapes around the neck.
2. Removal of secretions: In addition to the
original pathology, the tube itself irritates
the mucosa and thus produces copious
secretions. The removal of secretions is
done by using a sterile catheter for
suction. Instillation of a few drops of 5
per cent sodium bicarbonate or saline
may cause thinning of secretions.
www.similima.com 21

22. 3. Cleaning of tracheostomy tube:
Secretions deposited on the tube, dry up
and form crusts thereby causing difficulty
in breathing. The inner tracheostomy
tube is periodically removed and
cleaned, so is the outer tube, if
necessary.
4.The tracheostomy wound is properly
dressed to avoid infection.
5.If a cuffed tube has been used, the cuff
should be periodically deflated to prevent
necrosis of the mucosa and tracheal
stenosis.
www.similima.com 22

23. 6.Humidification and prevention of crusting:
The tracheostomy bypasses the upper air
passages. Therefore, the function of air
conditioning done by the nose is prevented
which produces crusting in the trachea. To
overcome this difficulty, a piece of moist gauze
is put over the outer opening of the tube so that
air takes up the moisture. A boiling water kettle
in the room provides humidified air for such
patients. Better techniques are available for
humidifying the inspired air and include a
condenser humidifier, ultrasonic humidifier, etc.
7.A tracheostomised patient cannot shout or
call for help. So a call bell or nurse should be
available and set of tracheostomy instruments
should always be kept ready at bedside.
www.similima.com 23

24. Other procedures for immediate airway
establishment: When airway obstruction
is so marked as to allow no time to do an
orderly tracheostomy following measures
can be taken:
Endotracheal intubation: This is the
most quick method using a direct
laryngoscope, laryngeal inlet is visualized
and an endotracheal tube of correct size
is inserted between the vocal cords,
which makes patient to breath freely. No
anaesthesia is needed, but it is a
temporary procedure. After intubation, if
need is there a planned tracheostomy
can be performed.
www.similima.com 24

25. Cricothyrotomy or laryngotomy: Here
patient is made to lie on table with head
and neck extended to identify lower
border of thyroid cartilage and cricoid
ring. The skin over here is incised
vertically and then circothyroid
membrane is cut with a transverse
incision, which is kept open with a small
tracheostomy tube or handle of small
knife by turning it at right angle. This
again is a temporary procedure.
www.similima.com 25

26. www.similima.com 26