Indications for tracheostomy
- To relieve upper airway obstruction
- Foreign body
- Trauma
- Acute infection - acute epiglottitis, diphtheria
- Glottic oedema
- Bilateral abductor paralysis of the vocal cords
- Tumours of the larynx
- Congenital web or atresia
- To improve respiratory function
- Fulminating bronchopneumonia
- Chronic bronchitis and emphysema
- Chest injury and flail chest
- Respiratory paralysis
- Unconscious head injury
- Bulbar poliomyelitis
- Tetanus
Advantages of tracheostomy over endotracheal intubation
- Reduces patient discomfort
- Reduces need for sedation
- Improves ability to maintain oral and bronchial hygiene
- Reduces risk of glottic trauma
- Reduces dead space and reduces work of breathing
- Augments process of weaning from ventilatory support
Tracheostomy technique
- Patient positioned supine with sandbag between scapulae
- Transverse cervical skin incision 1 cm above sternal notch
- Incision should extend to the sternomastoid muscles
- Dissect through fascial planes and retract anterior jugular veins
- Retract the strap muscles
- Divide thyroid isthmus and oversew to prevent bleeding
- Place cricoid hook on 2nd tracheal ring
- Stoma fashioned between 3rd and 4th tracheal rings
- Anterior portion of tracheal ring removed
- No advantage in creating a tracheal flap
- Endo-tracheal tube withdrawn to sub-glottis
- Tracheostomy tube inserted using obturator
- When confirmed that in correct position the ET tube removed
- Tube secured with tapes
Complications of tracheostomy
- Immediate
- Haemorrhage
- Surgical trauma - oesophagus, recurrent laryngeal nerve
- Pneumothorax
- Intermediate
- Tracheal erosion
- Tube displacement
- Tube obstruction
- Subcutaneous emphysema
- Aspiration & lung abscess
- Late
- Persistent tracheo-cutaneous fistula
- Laryngeal and tracheal stenosis
- Tracheomalacia
- Tracheo-oesophageal fistula
Post-operative tracheostomy care
- Maintain patent airway
- Frequent atraumatic suction
- Humidification of inspired air and oxygen
- Mucolytic agents
- Coughing and physiotherapy
- Occasional bronchial lavage
- Prevent infection and complications
- Aseptic tube suction, handling and tube changing
- Prophylactic antibiotics
- Deflate cuff for 5 minutes every hours
- Avoid tube impinging on posterior tracheal wall
Percutaneous tracheostomy
- Indicated in patients likely to require ventilatory support for more than 2 weeks
- Usually performed at the bedside in an ITU
- Has significant cost benefits compared to open procedure
- Performed using a guide-wire and dilators
- Bronchoscopic guidance may reduce the complication rate
- May be associated with a reduced risk of bleeding and infection
- Success rates of 98% have been reported
- Mortality related to the procedure is less than 0.5%
- Complications occur in 5-15% of patients
- Complications are similar to those following the open procedure
- Re-insertion of a displaced tube may be more difficult
Bibliography
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