Overview

This is making an opening in the anterior wall of the trachea converting it into a stoma on the skin surface. Whenever possible, endotracheal intubation should be attempted first. Tracheostomy can be done under local or general anesthesia. Types of tracheostomy include emergent, elective, or permanent tracheostomy.

Definition of Terms

Term	Definition
Tracheotomy	The incision in the trachea
Tracheostomy	The opening between the trachea and the external world, derived from the Greek “stoma”
Tracheostomy tube	The tube placed through the tracheal opening
Trach	A colloquial term for all above related terms
Cricothyroidotomy	An incision in the cricothyroid membrane typically employed during an airway emergency

• Functions of a tracheostomy
  • Alternative pathway for breathing in case of upper airway obstruction
  • Improves alveolar ventilation in cases of respiratory insufficiency
  • Protects the airway from aspirations (blood, pharyngeal secretions) when using a cuffed tube
  • Permits removal of tracheobronchial secretions by suction: in patients unable to cough (coma, respiratory paralysis, head injuries) / feels pain when coughing (chest injury, upper abdominal surgery)
  • Intermittent positive pressure respiration (IPPR) required beyond 72 hours
  • To administer general anaesthesia in cases where endotracheal intubation is difficult or impossible
• Indications for tracheotomy
  • Prolonged intubation (>5 days) to prevent tracheal stenosis, mucosal ulceration and granulomas
  • Ventilation weaning
  • Managing secretions. It is more efficient for pulmonary hygiene
  • To bypass upper airway obstruction in: stridor, air hunger, retractions, obstructive sleep apnea with documented arterial desaturation, bilateral vocal cord paralysis, tumor
  • Inability to intubate
  • Adjunct to head and neck surgery/ trauma
  • To protect from gross aspiration
  • To eliminate dead space e.g. promoting weaning from a ventilator, in neuromuscular disorders
• Common indications in infants and children
  • Infants below 1 year are mostly congenital lesions: Subglottic hemangioma, subglottic stenosis, laryngeal cyst, glottic web, bilateral vocal cord paralysis
  • Children are mostly inflammatory or traumatic lesions: Acute laryngo-tracheo-bronchitis, epiglottitis, diphtheria, laryngeal edema (chemical/thermal injury), external laryngeal trauma, prolonged intubation, Juvenile laryngeal papillomatosis
• Causes of upper airway obstruction
  1. Infections: Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria, Ludwig’s angina, peritonsillar, retropharyngeal or parapharyngeal abscess, tongue abscess
  2. Trauma
  3. Neoplasms: Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue, and thyroid
  4. Foreign body in the larynx
  5. Edema of the larynx due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), radiation
  6. Bilateral abductor paralysis
  7. Congenital anomalies: Laryngeal web, cysts, tracheo-oesophageal fistula, bilateral choanal atresia

High, mid- and low tracheostomy

Tracheostomy	Description
High-tracheostomy	Done at the level of the thyroid isthmus via the 1st tracheal ring. It can cause perichondritis of the cricoid cartilage and subglottic stenosis. Only indicated in carcinoma of the larynx where the total larynx will be removed.
Mid-tracheostomy	Done between the 2nd and 3rd tracheal rings. Most preferred
Low-tracheostomy	Done below the level of the isthmus. Risk of injury to several large blood vessels

Types of tracheostomy tubes

Tube type	Description
Cuffed vs uncuffed	Cuffed tube has an inflatable cuff that prevents aspiration of pharyngeal secretions and prevent air leak. Used for patients with increased risk of aspiration
Single vs double lumen	Single lumen has one cannula. Double lumen has an inner and outer cannula.
Fenestrated vs non-fenestrated	Fenestrated has single or multiple holes situated at the upper curvature for speech production or weaning. Used in children for decannulation

Procedure

• How to select the size of a tracheostomy tube in an adult
  • Selected by size (or number) of the tube
  • The larger the size (number) the greater the inner diameter
  • In adults, tubes of inner diameter varying between 6 and 9 or 10 mm are used
  • The size of the tube may be expressed in French gauge (FG), which is 3.14 times the outer diameter of the tube FG = outer diameter × π (π = 3.14)
• How to select the size of a tracheostomy tube in a child
  • Size of tube (internal diameter in mm) = (age/4) + 4
  • Length of tube (in cm) = size of tube x 3
  • The size of a tube is roughly the size of the child’s little finger
• Pre-operative preparation
  1. Informed consent from the patient
  2. Baseline investigations- CBC, UECs, RBS
  3. Tracheostomy tubes preparation: cuffed vs. uncuffed, correct sizing
  4. Neck examination
• Procedure
  1. Position the patient to lie supine with a pillow below the shoulders so that the neck is extended
  2. Clean the neck
  3. Anesthesia: in conscious patients 1-2% lignocaine with epinephrine in the line of incision and area of dissection or general anesthesia with intubation
  4. Vertical incision is made from below the cricoid cartilage to just above the suprasternal notch
  5. Tissues are dissected in the midline with ligation or displacement of any dilated veins
  6. Strap muscles are separated in the midline and retracted laterally
  7. Thyroid isthmus is displaced upwards or divided between the clamps and suture ligated
  8. Few drops of 4% lignocaine are injected into the trachea to suppress cough when trachea is incised
  9. Trachea is fixed with a hook and opened with a vertical incision in the region of the 3rd and 2nd rings. This is then converted into a circular opening
  10. Tracheostomy tube of appropriate size is then inserted and secured with tape
  11. Gauze dressing is placed between the skin and flange of the tube around the stoma
• Special considerations for paediatric tracheostomy
  • The trachea is soft and compressible and its identification may become difficult. It may easily be displaced, and the surgeon may go deep or lateral to it injuring recurrent laryngeal nerve or even the carotid. It is therefore always useful to have an endotracheal tube or a bronchoscope inserted into the trachea before the operation.
  • Tracheostomy in infants and children is preferably done under general anesthesia.
  • During positioning, do not extend the neck too much as this pulls structures from chest into the neck and thus injury may occur or the tracheostomy opening may be made too low near suprasternal notch.
  • Before incising trachea, silk sutures are placed in the trachea, on either side of midline.
  • Trachea is simply incised, without excising a circular piece of tracheal wall.
  • The tracheal lumen is small, should not insert the knife too deep; it will injure posterior tracheal wall or even esophagus causing tracheo-oesophageal fistula.
  • Avoid infolding of anterior tracheal wall when inserting the tracheostomy tube
  • Selection of tube should be of proper diameter, length and curvature. A long tube impinges on the carina or right bronchus. With high curvature, lower end of tube impinges on anterior tracheal wall while upper part compresses the tracheal rings or cricoid
• Post-operative care
  • Keep cuff for first 2 days, then deflate
  1. Humidification via trach mask by instilling saline
  2. Clear secretions to avoid crusting
  3. Inner cannula cleaning
  4. If non-ventilated, change the cuffed tube after 5-7 days
  5. Change ties every 2 days
  6. Provide caretaker and patient education

Complications of Tracheostomy

• Immediate complications (intra-operative complications)
  1. Bleeding: Apply pressure
  2. Mucus plug: push saline with suction, if it does not work, remove the tube
  3. Apnea
  4. Pneumothorax due to injury to apical pleura
  5. Pneumomediastinum
  6. Injury to recurrent laryngeal nerves
  7. Aspiration of blood
  8. Damage to the tracheoesophageal common wall
• Immediate post-op complications (during the first few hours or days)
  • Bleeding, reactionary or secondary
  • Post-op pulmonary oedema (from release of pressure)
  • Acute obstruction from a mucus plug or blood clot
  • Tracheostomy tube displacement
  • Blocking of tube
  • Subcutaneous emphysema
  • Tracheitis and tracheobronchitis with crusting in trachea
  • Atelectasis and lung abscess
  • Local wound infection and granulations
• Long-term complications (with prolonged use for weeks and months)
  • Laryngeal stenosis, due to perichondritis of cricoid cartilage
  • Subglottic stenosis
  • Tracheal stenosis due to tracheal ulceration and infection
  • Tracheal-innominate artery fistula
  • Problems of decannulation: commonly in infants and children
  • Tracheo-oesophageal fistula, due to prolonged use of cuffed tube or erosion of trachea by the tip of tracheostomy tube
  • Persistent tracheocutaneous fistula
  • Problems of tracheostomy scar (Keloid, unsightly scar)
  • Corrosion of tracheostomy tube and aspiration of its fragments into the tracheobronchial tree
  • Tracheitis