ANATOMY OF TRACHEA, INDICATIONS & COMPLICATIONS OF TRACHEOSTOMY

1. Moderator:- Dr.Vivek
Student:Dr.Imran

7. 
Contains
glands, small
arteries,
nerves,
lymph
vessels and
elastic fibers

Trachealis
muscle
overlies
esophage
al muscle
and
epithelium

9.  Average cross-sectional
area of the male adult
trachea is approximately
2.8 cm2
Transverse (lateral)
diameter of 25 mm and
sagittal (anteroposterior)
diameter of 27 mm are the
upper limits of normal
(males)
 The lower limit of normal
for both transverse and
sagittal diameters is about
13 mm in men and 10 mm
in women

10. U-shaped trachea (27%)
C-shaped trachea (49%)

11. A saber-sheath or scabbard trachea is.
The saber sheath trachea has been
described in up to 5 % of elderly men.
Women - round configuration
Men - sagittal widening and transverse
narrowing.

12.  Tracheal Index (TI)
defined as
(transverse/saggital
diameter)<0.6
 12% of elderly men
with COPD.

13. Normal shape
A
B
Saber sheath
Expansion during inhalation Circumferential collapse
C
D
Dynamic collapse
E
F
Crescent shape collapse

14. Tracheal Relationships
Cervical
Thoracic

15. Cervical Trachea
Anterior
Posterior
Lateral
Skin
Sup. & Deep facia
Esophagus
2 Lateral lobes of Thyroid
Strap muscles
Sternocleidomastoid
Sternohyoid
Sternothyroid
Recurrnent Laryngeal
Nerves
Comman Carotid Artery
Isthmus of Thyroid
Prevertebral
fascia
Internal Jugalar
VeinVagus
Inferior Thyroid Vein
Thyroidea Ima
Artery<10%
Omohyoid
Pre-tracheal facia
Plexus Thyroideus Impar
External jugular
vein

16. Thoracic Trachea
Anterior
Posterior
Lateral
Thymus Gland
Esophagus
Vagus
Phrenic Nerves
Left Branchiocephalic Vein
Recurrnent Laryngeal
Nerves
Superior
vena cava anterolaterally on right side
Arch of Aorta
Prevertebral
fascia
Lungs covered by
Pleura
The left common
carotid and left
subclavian arteries
Thoracic
Duct on left side
Azygos vein on right
side

17. 

Esophagus lies
Posterior
Note Trachealis muscle

18. 

Esophagus
Recurrent Laryngeal
Nerves
18

19. Cervical Tracheal
RelationshipsAnterior
Skin
Superficial & Deep
fascia.
2nd to the 4th
rings are covered by
the isthmus of the
thyroid.

20. 


Inferior Thyroid Veins
Thyroidea Ima Artery>10%
Pretrachal Fascia invests
 Trachea
 Thyroid Gland
 Larynx

21. 
Note:
 Thyroidea Ima Vein
 Plexus Thyroideus Impar

22. 
2 Lateral LobesThyroid Gland

23. 
Carotid Sheath and
Contents
 Common Carotid
Artery
 Internal Jugular Vein
 Vagus Nerve
Anterolateral View

24. Posterior View

Carotid Sheath and
Contents
 Internal Jugular Vein
(Lateral)
 Common Carotid
Artery (Medial)
 Vagus Nerve
(Posterior)

26. 
Thymus Gland (or
Thymic Remnant in
adults)

27. 

Left Brachiocephalic
Vein
Aortic Arch

28.  Vagus Nerves
 Phrenic Nerves
 Lungs covered by Pleura

29. • General Sensation- Vagus & Recurrent
Laryngeal Nerves
 Autonomic Innervation
 Sympathetic-Decreases
Secretions(T1,T2)
 Parasympathetic-Increases
Secretions(Vagus)

30.  Inferior Thyroid Arteries- Cervical
Portion
 Bronchial Arteries- Thoracic Portion

31.  Venous plexuses situated around
trachea and oesophagus ultimately
drain into inferior thyroid venous
plexus.
 lymph nodes located around trachea,
the brachio-cephalic and right
common carotid arteries.

32. Indications & Complications of
Tracheostomy

33. What is “Tracheostomy”
The word “tracheostomy” is
derived from the Latin “trachea”
and “tomein” (to make an
opening).
Tracheostomy is an operative
procedure that creates a surgical
airway in the cervical trachea .

34. What is this & what are its indications ???
Answer at the end of presentation

36. 1932 to prevent pulmonary infection in
neurologically impair patients secondary
to infections (poliomyelitis).
1943 to remove bronchial secretions in
cases of myasthenia gravis and tetanus.
1951 to reduce the volume of dead space,
use in COPD and severe penumonia.

37. 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.

38. Tracheotomy Indications
To bypass obstruction

39. Tracheotomy Indications
Prolonged intubation
- Need for prolonged respiratory support, such as in
Bronchopulmonary Dysplasia
- To reduce anatomic dead space and increase the chance for
mechanical ventilation withdrawal
- To improve the patient`s quality of life (easier toilet,
ability to speak and eat, increase the mobility)
- Neuromuscular diseases paralyzing or weakening chest
muscles and diaphragm

40.  PROTECTION of AIRWAY
 Neurological Diseases(Polyneuritis, GBS)
 Coma (GCS<8, risk of aspiration)
 Elective Tracheostomy as Adjunct to H&N surgeries
 <14 days on ETT(relative)
 >21 days on ETT

41. Tracheotomy Indications
Miscellaneous
-Congenital abnormalities. (Pierre Robin, Triecher Collins
syndromes)
- Obstructive Sleep Apnea Syndrome.
- Aspirations related to muscle or sensory problems.
-Prophylaxis (as preparation for extensive H&N
procedures, before radiotherapy for H&N CA)
-Cervical spinal cord injuries with respiratory muscles
paralysis.

42. 
No absolute contraindications exist to
tracheostomy

RELATIVE
 Laryngeal CA(strong)

it may lead to increased incidence of stomal
recurrence(a diffuse infiltrate of neoplastic tissue at the junction of the
amputated trachea and skin )

43. 
Physical assessment also surgical and
anesthesiological

CBC

PT, PTT, INR

Patient/apotropus confirmation

44. Types of Tracheostomy
1) Open procedure
a) High tracheostomy (Cricothyroidectomy)
b) Low tracheostomy
2) Percutaneous procedure

45. High tracheostomy (Cricothyroidectomy)
Landmark
Thyroid cartilage
Cricothyroid membrane
Crycoid cartilage

46. Emergency Cricothyrotomy Protocol
Indications:
A patient that requires intubation and
Unable to intubate and
Unable to adequately ventilate
Conditions:
Patient  40 kg and  12 years old
Contraindications:
Suspected fractured larynx
Inability to localize the cricothyroid membrane

47. Techniques
1) Seldinger (Melker) Cricothyrotomy
2) Needle Cricothyrotomy

48. Low Tracheostomy
Skin Prep with povidine
iodine,
chlorohexidine(savlon)
Draping
Good light source and
suction machine ready
and tested to be
functional

49. Transverse Incision
Incision 1 cm below the cricoid or halfway between
the cricoid and the sternal notch.
Incision length=6cm/ anterior border of SCM msc
lateral

50. Blunt dissection of
subcut tissue
Transversely
Retracted as shown

51. Strap msc is divided
longitudinally at
midline
Thyroid
ismuth is
divided at
midline by 2
haemostat
and cut edge
secured by
2/0 vicryl

52. Depending on
the TT size abt
4cm longitudinal
opening is made
in trachea below
2nd ring

53. Tube is
anchored

54. Percutaneous Dilational
Tracheostomy
Benefits include elimination of need for
operating room use or anesthesia, and
significant reduction in cost.
Should be done in carefully selected patients
Under fiber optic control
To be ready to switch to open procedure

55. PERCUTANEOUS DILATIONAL TRACHEOTOMY
Guidewire introduction, with
removal of sheath
Guidewire and catheter are advanced
together into the trachea as far as the
skin positioning marks on the guide
catheter to the skin.[

56. Guidewire, guide
catheter, and dilator
unit are advanced
together into the
trachea to the skin
positioning mark

57. The tracheotomy tube is
loaded onto a dilator and
advanced into the trachea
over the guidewire and
catheter. The guidewire and
catheter are removed,
leaving only the
tracheostomy tube in the
trachea

58. PCV check(pressure controlled ventilation)
Repeat X-Ray soft tissue neck
Strong Analgesia
Antibiotics
IV fluid until able to tolerate orally

59. Risk factors for complications
Age: infants and adults over 75
Obesity
Smoking
Poor nutrition
Recent illness, especially an upper-respiratory infection
Alcoholism
Chronic illness
Diabetes

60.  Apnea due to loss of hypoxic respiratory drive.
This is mainly important in the awake patient.
Ventilatory support must be available
 False
root
 Bleeding
 Pneumothorax or pneumomediastinum

61. to the vocal cords (direct)
 Injury to adjacent structures: recurrent
 Damage
laryngeal nerves, the great vessels, and the
esophagus.
 Post-obstructive
 Hypotension
 Arrhythmia
pulmonary edema

62. 






Early bleeding: This is usually the result of increased
blood pressure as the patient emerges from
anesthesia and begins to cough.
Plugging with mucus
Tracheitis
Cellulitis
Tube displacement
Subcutaneous emphysema
Atelectasis

63. 







Bleeding - tracheoinnominate fistula
Tracheo- and laryngomalacia
Stenosis
Tracheoesophageal fistula
Tracheocutaneous fistula
Granulation
Scarring
Failure to decannulate

64. 
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.

65. 
Tracheostomy tube cuff pressures ---20 to 25 mm Hg.

Overly low cuff pressures < 18 mm Hg, may cause the cuff
to develop longitudinal folds, promote microaspiration of
secretions collected above the cuff, and increase the risk
for nosocomial pneumonia.

Excessively high cuff pressures above 25 to 35 mm Hg
exceed capillary perfusion pressure and can result in
compression of mucosal capillaries, which promotes
mucosal ischemia and tracheal stenosis.

Cuff pressure should be measured with calibrated devices
and recorded at least once every nursing shift and after
every manipulation of the tracheostomy tube.

66. 
Humidification of the inspired gas is a standard
of care for tracheostomized patients.
Thermovent

67. Indications For Suctioning
• Secretions in the trach
• Suspected aspiration of gastric or upper airway
secretions
• Increase in peak airway pressures when on ventilator
• Increase in respirations or sustained cough or both
• Gradual or sudden decrease in ABG
• Sudden onset of respiratory distress when airway
patency is questioned

68. 
After the track is formed – 4-5 days after the
operation.

Rate of exchange depends on clinical
situation of the specific patient – type of
discharge, type of tube, medical status, age..

Usually every 14 days.

Should be done by experienced staff.

69. 

Cuffed and uncuffed
Fenestrated and unfenestrated

Single and double lumen

Various diameters

70. 

Uncuffed
Cuffed
To protect airway
To allow ventilation

72. 

Allow patient to
ventilate past tube via
upper airway
Allow speech

73. 

Double lumen allows
easy cleaning
Single lumen has a
greater internal
diameter

74. Other Types of Tubes
Bivona Fome-Cuff
Tracheaostomy Tube
Montgomery T-Tube
Single Cannular Shiley
Pediatric TT

76. Tracheostomy Speaking Valve
Passy-Muir
A tracheostomy speaking valve is a one-way valve,
allows air in, but not out
forces air around the tracheostomy tube, through the
vocal cords and out the mouth upon expiration,
enabling the patient to vocalize

77. 
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

Keep head elevated to 45° during periods of tube
feeding

78. 



Resolution of pathology that necessitated the
tracheotomy (upper airway obstruction,
pneumonia)
Normal protective laryngeal mechanisms (no
aspirations during normal swallowing, good
coughing)
No planed further interventions (radiotherapy,
H&N operations)
No mechanical ventilation

79. Answer
Jackson’s tracheostomy
Fuller’s tracheostomy tube