I. Name of Surgery A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube).

It is maintained open with a hollow tube called a tracheostomy tube. II. Indication In the acute setting, indications for tracheotomy include such conditions as severe facial trauma, head and neck cancers, large congenital tumors of the head and neck (e.g., branchial cleft cyst), and acute angioedema and inflammation of the head and neck. In the context of failed orotracheal or nasotracheal intubation, either tracheotomy or cricothyrotomy may be performed. In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet (e.g. comatose patients, or extensive surgery involving the head and neck). In extreme cases, the procedure may be indicated as a treatment for severe Obstructive Sleep Apnea seen in patients intolerant of Continuous Positive Airway Pressure (CPAP) therapy. A tracheostomy is usually done for one of three reasons: (1) to bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth to reach the lungs); (2) to clean and remove secretions from the airway; and (3) to more easily, and usually more safely, deliver oxygen to the lungs. III. Contraindication No absolute contraindications exist for tracheostomy. A strong relative contraindication to discrete surgical access to the airway is the anticipation that the blockage is a laryngeal carcinoma. The definitive procedure (usually a laryngectomy) is planned, and prior manipulation of the tumor is avoided because it may lead to increased incidence of stomal recurrence. Temporary tracheostomy may be performed just under the first tracheal ring in anticipation of a laryngectomy at a later time. End-of-life issues may also come to bear on the decision to perform a tracheostomy because it may represent further mechanization of the patient's care to family members. In fact, the performance of a tracheostomy does not affect the decision to extend or to withdraw care. Hygiene is improved, quality of life (speaking and eating, if relevant) is improved, and placement in long-term care is facilitated in some cases; however, dependence on mechanical ventilation may not be changed.

IV. Procedures: Pre-op, Operative, Post op Preop 5.1 This procedure can be a very frightening one and psychological preparation is essential for both the patients and relatives. It is preferable for the patient to be nursed in a side room where it is quieter, (Cherneeky et al. 1998). 5.2 The patient will be seen by the dietician and speech therapist if there are concerns regarding swallowing and nutritional intake. Physiotherapy referral can be made for deep breathing exercises and chest physiotherapy.

Operative The patient is made to lie down on their back with the neck & head extended by keeping a pillow under the shoulder and neck. Local anaesthesia or general anaesthesia is used for the procedure.

A horizontal cut is made across the neck above the 'sternal notch' using a knife. The skin is separated and surrounding tissues are dissected to expose the trachea. The 2nd or 3rd of the tracheal ring is incised for the tracheostomy tube to be placed. A suitable size tracheostomy tube is then introduced inside. While choosing the tube, the smallest feasible tube should be used. A general rule is that the tube should be three fourths of the diameter of the trachea. The cuff of the tube is inflated by using 2-5 ml of air and it is held in place by using a necktie. The incision is closed using skin sutures by the side of the tracheostomy tube. Dressing is applied for the wound to heal. Post op The "Obturator" that is used to pass the trach into the windpipe. An "Outer cannula" (tube). This Outer cannula has a plastic "trach plate" that lies against the skin on the neck and holds the trach in place. And an "Inner cannula" that fits inside the outer one and locks into place. Many of the patients need 1 to 3 days time to adapt themselves to breath through the tracheostomy tube. Painkillers and antibiotics are given as per the patients need. The patient will have to try and make adjustments to communicate. It would be very difficult for the patient to initially make any noise or sounds let alone trying to speak. Most patients can learn to speak with a tracheostomy tube after much training and practice. Once the underlying problem that caused the tracheostomy tube to be placed in the first place in healed then the tube would be removed.

A small scar would remain with the hole healing quickly. Long term care for tracheostomy tube Patients or attenders should learn how to take care of the tracheostomy if they are to be discharged home after the procedure. This will help them to take care of the tube at home. Normal lifestyles are encouraged and most activities can be resumed.

V. Nursing Responsibilities 7.1 Maintain a patent tracheostomy by:

Positioning: Sit the patient upright as soon as their condition permits Humidification: Humidification of gases is of paramount importance for patients receiving both short and long term ventilation (Ballard et al., 1992). 7.2 Tracheostomy patients must have humidification via a warmed humidifier for a minimum of 36 hours. The need for a particular type of humidification should be regularly assessed, as part of routine care planning and continued in use for as long as it is required. 7.3 Tracheostomy masks are for single patient use and can be washed in warm soapy water and dried with paper towels (Ronchetti 1998). 7.4 As some humidifiers are cumbersome, when a patient is fully mobile a Buchanan bib may be appropriate, although it is important to note that dampened or soiled Buchanan bibs may present an infection hazard. 7.5 A 'Swedish nose' type heat and moisture exchanger (Portex Trachvent or Platon Medical Trachphone) can be placed on the tracheostomy tube. Low flows of oxygen can be administered via a clip directly to the Swedish nose itself. The Swedish nose humidifier can become blocked by secretions and it therefore needs regular changes; the recommended maximum usage time is 24 hours, (but they may need changing more frequently). These devices do not provide a high level of humidification and may impose some extra work of breathing in use.

VI. Complications It is important to understand that a tracheostomy, as with all surgeries, involves potential complications and possible injury from both known and unforeseen causes. Because individuals vary in their tissue circulation and healing processes, as well as anesthetic reactions, ultimately there can be no guarantee made as to the results or potential complications. Tracheostomies are usually performed during emergency situations or on

very ill patients. This patient population is, therefore, at higher risk for a complication during and after the procedure The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. It is listed here for information only in order to provide a greater awareness and knowledge concerning the tracheostomy procedure.

Airway obstruction and aspiration of secretions (rare). Bleeding. In very rare situations, the need for blood products or a blood transfusion. Damage to the larynx (voice box) or airway with resultant permanent change in voice (rare). Need for further and more aggressive surgery Infection Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required Scarring of the airway or erosion of the tube into the surrounding structures (rare). Need for a permanent tracheostomy. This is most likely the result of the disease process which made the a tracheostomy necessary, and not from the actual procedure itself. Impaired swallowing and vocal function Scarring of the neck

VII. Prognosis Most patients need 1 to 3 days to adapt to breathing through a tracheostomy tube. It will take some time to learn how to communicate with others. At first, it may be impossible for the patient to talk or make sounds. After training and practice, most patients can learn to talk with a tracheostomy tube. Patients or family members learn how to take care of the tracheostomy during the hospital stay. Home-care service may also be available. You should be able to go back to your normal lifestyle. When you are outside, you can wear a loose covering (a scarf or other protection) over the tracheostomy stoma (hole). Use safety precautions when you are exposed to water, aerosols, powder, or food particles.