Tracheostomy

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 2^nd tracheal ring
Stoma fashioned between 3^rd and 4^th 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Endo-tracheal tube withdrawn to sub-glottis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

Callanan V, O'Connor A F F. Adult and paediatric tracheostomy - technique, complications and alternatives. Curr Pract Surg 1994; 6: 219-22.

Dulgucrov P, Gysin C, Perneger T V, Chevrolet J C. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999; 27: 1617-1625.

Freeman B D, Isabella K, Lin N, Buchman T G. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000; 118: 1412-1418.

Mirza S, Cameron D S. The tracheostomy tube change: a review of the techniques. Hosp Med 2001: 62: 158-163.

Prout J. Tracheostomy in the intensive care patient: surgical or percutaneous. Hosp Med 2001: 62: 379.

Susanto I. Comparing percutaneous tracheostomy with open surgical tracheostomy. Br Med J 2002; 324: 3-4.