A tracheostomy is an opening in the anterior wall of the trachea, which is converted into a stoma on the skin surface. The procedure can be done under local or general anesthesia; types include emergent, elective, or permanent.
Definition of Terms
| Term | Definition |
|---|---|
| Tracheotomy | The incision in the trachea |
| Tracheostomy | The opening between the trachea and the external environment, 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 |
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 |
- Functions of a tracheostomy
- Alternative pathway for breathing in case of upper airway obstruction
- Improves alveolar ventilation in cases of respiratory insufficiency
- It can protect the airway from aspirations (blood and pharyngeal secretions) by using a cuffed tube
- Permits removal of tracheobronchial secretions by suction in patients who are unable to cough
- Intermittent positive pressure respiration (IPPR) required beyond 72 hours
- To administer general anaesthesia in cases where endotracheal intubation is difficult or impossible
- Indications
- Prolonged intubation (>5 days) to prevent tracheal stenosis, mucosal ulceration, and granulomas
- Weaning off a ventilator
- Managing secretions: it is more efficient for pulmonary hygiene
- To bypass upper airway obstruction
- Inability to intubate
- Adjunct to head and neck surgery or trauma
- To protect from gross aspiration
- To eliminate dead space
- 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
- Mostly inflammatory or traumatic lesions in children:
- Acute laryngotracheobronchitis
- Epiglottitis
- Diphtheria
- Laryngeal edema (caustic ingestion or burn)
- External laryngeal trauma
- Prolonged intubation
- Juvenile laryngeal papillomatosis
- Infants below 1 year are mostly congenital lesions:
- Causes of upper airway obstruction
- Infections
- Acute laryngotracheobronchitis
- Acute epiglottitis
- Diphtheria
- Ludwig’s angina
- Peritonsillar abscess
- Retropharyngeal abscess
- Parapharyngeal abscess
- Tongue abscess
- Trauma
- Neoplasms
- Benign neoplasms of the larynx
- Laryngeal cancer
- Neoplasms of the pharynx, upper trachea, tongue, and thyroid
- Foreign body in the larynx
- Edema of the larynx
- Burns
- Caustic ingestion
- Steam
- Irritant fumes or gases
- Allergy (angioneurotic or drug sensitivity)
- Radiation
- Bilateral abductor paralysis
- Congenital anomalies:
- Laryngeal web
- Cysts
- Tracheoesophageal fistula
- Bilateral choanal atresia
- Infections
- Selecting 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)
- Selecting 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
- Intra-operative complications
- Bleeding
- Mucus plug:
- Apnoea
- Pneumothorax due to injury to apical pleura
- Pneumomediastinum
- Injury to recurrent laryngeal nerves
- Aspiration of blood
- Damage to the tracheoesophageal common wall
- Post-operative complications
- Bleeding: reactionary or secondary
- Postoperative 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
- 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
- Keloid or an unsightly scar
- Corrosion of tracheostomy tube and aspiration of its fragments into the tracheobronchial tree
- Tracheitis