Trachesotomy

Reza Furqon S

Trachesotomy
Indications
Technique

Open and percutaneous

Complications
Physiology

of a tracheotomy
Troubleshooting
Decannulation

Tracheotomy
Creation

of communication between the

trachea and the cervical skin with insertion of
a tube

Indications
Airway

obstruction
Pulmonary Secretions
Ventilation
Prolonged mechanical ventilation

May assist in weaning from mechanical

ventilation
Prevention of glottic stenosis/complication of
prolonged ett

Fixed Airway Obstruction

Tumours

Chronic airway obstruction up to 80% lumen

External

of upper aero digestive tract

compression by tumour

Anaplastic thyroid, massive lymphadenopathy

Foreign

Body
Glottic Stenosis/tracheal stenosis
Trauma upper airway

Non-Fixed Airway Obstruction

Trauma

Inflammatory

Expanding neck hematoma

Maxillofacial trauma
Laryngeal fracture
Inhalation injury
Anaphylaxis
Epiglottitis
Ludwigs Angina/Deep Neck space infection

Bilateral vocal cord paralysis

Fiberoptic Intubation can be successful

Pulmonary Secretion Clearance

Aspiration

/ dysphagia

COPD
Bronchiectesis
Stasis

of secretions

Poor cough

Poor

respiratory reserve

Ventilation
Neuromuscular

muscles

Reduced respiratory effort

Limited

respiratory depression

Reduced LOC

Severe

pulmonary reserve

COPD, Scoliosis, bronchiectesis

Central

disorder affecting respiratory

obstructive sleep apnea

Cor pulmonale, failure CPAP

Prolonged Intubation
7-10

days ett
Risk Factors for Glottic
Stenosis

Diabetes
Female
Size ETT and # ett
Hemodynamic
instability

Incidence

glottic
stenosis: 5% over 10
days (Whited 1984)

Example 1
Subglottic Stenosis

Example 3
Combined Glottic/Tracheal Stenosis

Prolonged Intubation
Weaning

from ventilator

Relative indication for tracheotomy

Modest gains in respiratory function after
tracheotomy may be enough to increase
chance of successful weaning from ventilator
Trend of patients ventilator requirements
5

day reversibility of common ICU admitting

diagnoses

Tracheotomy
Decision

made patient requires tracheotomy

Open or percutaneous technique
75% of tracheotomies done at SMH are done
percutaneously in ICU at bedside
Variations of open tracheotomy technique
General principles are the same

External approach through neck soft tissue

Creation of opening in trachea
Placement of tube to maintain airway

Technique

Diagrams from Lore, Surgical

Atlas 1988

Equipment
Tracheotomy

Right angles, cricoid hook, trach spreader

Tracheotomy

set
tube

Shiley most common

Select size (6, 8 most common)
Cuffed non-fenestrated for most ICU patients
Fenestrated if voicing expected (use non-fen
inner cannula during procedure)

Open Tracheotomy
1.

Position the patient

2.

3.

Neck extended
Roll under shoulders
4.
Arms tucked
On OR bed
5.

Palpate landmarks

Transverse incision half

way between cricoid
and sternal notch
Retraction
Divide strap muscles in
midline

Technique

Diagrams from Lore, Surgical

Atlas 1988

Technique cont
6.
7.
8.

9.
10.

Thyroid isthmus
Divide or retract
Identify cricoid and upper
tracheal rings using blunt
dissection
Blunt cricoid hook helpful
Retract cricoid in superior
direction

10.
11.
12.

13.
14.

Tracheotomy tube cuff

checked and obturator in
Deflate cuff of
endotracheal tube
Horizontal incision
between tracheal rings
(below the second ring)
Suction lumen if necessary
Spread rings apart with
spreader or scissors

Technique 2

DO NOT use cautery on the trachea

FIRE!

Technique 3

Technique
15.
16.
17.
18.
19.
20.

Endotracheal tube withdrawn until just above

the open tracheal site
Tracheotomy tube with obturator, pushed into
mid lumen of trachea, then directed inferiorly
Obturator withdrawn and inner cannula placed
Anaesthetic connector tubing passed over and
connected
Cuff inflated
DO NOT LET GO OF THE TUBE

Final
21.
22.
23.
24.

Anaesthesia: Check CO2, good breath

sounds
Sew in the trach tube shield to skin
Loosely approximate incision
Trach ties

Contraindications
Medically

well enough for GA

PEEP < 20 mm Hg
Uncontrolled coagulopathy
Airway pathology below tracheotomy site

Tracheotomy Tubes

Portex and Shiley common brands of trach tubes.

Shiley used as standard tube at St Michaels Hospital.

Tracheotomy Tubes

Tracheotomy Tubes

Bivona or foam cuff

Tracoe Cuffless
Speaking valve

Complications: Intraoperative
Bleeding

2.8%*
Recurrent laryngeal nerve injury
Tracheoesophageal fistula
Pneumothorax: rare
False passage

Anterior dissection most common

Incidence <1%

*Kost et al 1994

Odd Things That Can Happen

Trach tube place upside down
No CO2 tracing despite surgeon positive tube is in the
airway
Cut the pilot tube of the cuff while cutting the sutures
Trach tube coughed across table after correct
placement
Difficulty with air leak

Cuff leak/tube too short or not large enough /position tube

Blocked tube secondary to secretions/blood

Tracheotomy: Early
Complications
Bleeding

Minor common
Major tracheoinnominate fistula (<0.2%)*

Obstruction

of tube (2.5%)*
Dislodgement (1.4%)*
Pneumothorax (1 - 2.5%)*
Wound Infection

Local care, antibiotics (staph/pseudomonas)

Late Complications
Tracheal

stenosis
Tracheal chondritis
Subglottis stenosis- high tracheotomy
Tracheomalacia
Tracheoesophageal fistula
Failure of stoma closure when decannulated
Overall

complication rate 15-30% in ICU patients

largely minor with no long term morbidity

Tracheoinnominate Fistula
More

than 10 days post tracheotomy (as early

as 5 days)
Sentinel bleed
Angiogram/CTA for diagnosis
Surgical exploration
Interventional radiology-stent
Associated with low tracheotomy placement,
wound infection or aberrant artery

Late Complications/Stoma

Minor amount of bleeding common due to granulation tissue /dry mucosa

Stoma and Inferior View Vocal

Folds

Physiology of Tracheotomy
Neck

breathing
Bypass upper airway and nasal function
Loss of humidification/heat airflow
Dryness, thick secretions
Voicing possible with speaking valve
Loss of smell /reduced taste
Loss glottic closure function for cough

Physiology of Tracheotomy
Advantages
Respiration
Lower work of breathing (30%) c/w normal airway

Facilitates secretion clearance

Aspiration or thick secretions

Less dead space (100 mL)

Reduced airway resistance
Assists in patient independence from mechanical
ventilation
Patient comfort (better than ett)

Epstein 2005 Respiratory Care

Physiology of Tracheotomy
Respiration
increases turbulent airflow, secretions adhere inside tube

Disadvantages
Tube diameter and shape
Loss

of humidification/heat function of upper airway

Ciliary function affected

Biofilm colonization

Diminish

cough/loss glottic closure

Reduce laryngeal elevation during swallow
Patient comfort (better no tube at all)

Dysphagia
Common

issue in neurological impaired pt

Tube required for secretion management
particularly in patient with florid aspirate
Tube presence associated with limitation of
the cephalad excursion of larynx during
swallow and can contribute to
dysphagia/aspiration
Endoscopic / fluoroscopic assessment
Speech Therapy assessment!

Postoperative Tracheotomy Care

Humidification

via trach mask/Instill saline

Clear secretions, prevent crust
Inner cannula cleaning tid at least
If non-ventilated, change cuffed tube to noncuffed at 5-7 days
Ties changed 2 people if possible
Most hospital have nursing/RT protocol
Teach everyone trach care including patient,
family

Inner Cannula Care

Frequently

done tid or more

Saline and hydrogen peroxide (1:1) and trach
brush
Rinse with sterile water/saline and reinsert
Spare inner cannula and store in clean
covered container
Ties should be one finger tight and square
knot
Respiratory Therapy Protocol SMH

Troubleshooting Dislodgement
Causes

Ties too loose

Cough
cuff deflated
tube too short/wrong size for patient

Clinical signs
Difficulty in ventilating patient
Increased airway pressure
Suction catheter obstructed
Non Ventilated Patient
Poor

cough
Sudden voice change
Stridor, SOB
Suction catheter blocked

What to do: Dislodgement

Extend neck
Remove inner cannula
Use obturator to redirect tracheotomy
tube into lumen
If patient in distress and does not have
fixed obstruction above, pull out trach
tube
Ventilate with mask/intubate
Use flex bronchoscope or replace/OR

Troubleshooting Tube
Obstructed
Mucous

plug or blood clot most likely

Granulation tissue, particularly fenestrated
tubes
Remove inner cannula, suction, instill saline
Bronchoscopy
If no other recourse, pull out trach tube and if
necessary, replace new tube with obturator
Intubate/ventilate from above

Troubleshooting: Bleeding
Bleeding around trach stoma

Minor bleeding immediately

post-op
Moderate bleeding/venous
oozing often related to
thyroid
Examine wound
Pack, surgicel, if not
controlled, take back to OR

Bleeding from within lumen

Often related to suctioning

Broncoscopy exam
Dry mucosa
Granulation tissue
Coagulopathy
Rare innominate fistula

Decannulation
Goal is to ensure patient can tolerate
increased airway resistance/work of
breathing and secretion clearance
30% increase WOB transition from trach
breathing to upper airway breathing

Decannulation
Indication

for tracheotomy has

resolved/improved
Patient able to cope with secretions
Upper airway patent - examined if necessary
Appropriate vocal cord function
Good respiratory reserve/overall respiratory
status
Gag reflex present (5-10% no gag)

Decannulation
Stable

clinical condition

Hemodynamic stability
Absence of fever, sepsis infection

Adequate

swallowing

Gag

reflex, bedside swallowing assessment,

video fluoscopy

Maximum

expiratory pressure > 40 cm H2O

Ceriana et al 2003

Decannulation Protocol

Downsize tube to either 4 or 6 Shiley

Cuffless fenestrated tube

Gradually increase corking/cap of trach

Corked 24-48 hours before decannulation
Remove tracheostomy tube
Occlusive dressing for stoma
Persistent patent stoma

Occasionally requires local flap to close

Outpatient procedure under local, infection
common

Difficult to Decannulate
Granulation

Fenestra obstructed

Tracheal

mucosal edema/supraglottic edema

NG, aspiration

Laryngeal

tissue

pathology

Glottic stenosis, cord paralysis

Pulmonary

secretions
Increase airway resistance not tolerated

Tracheotomy: Summary
Safe

method of airway management

Open versus percutaneous technique
available
Complications largely minor
Mortality rare from procedure directly

0.3%* in last 30 years (grouped data)

Summary
Advantages/risks

of a tracheotomy for that

individual patient must outweigh the
disadvantages/risks without one.

Indication for Tracheotomy

Medical comorbidities
Respiratory /deglutition function
Ability to cope with secretions
Trial of corking/decannulation

Cricothyroidotomy
Prep

and position as for trach

Identify landmarks
Local anaesthetic
Incision over cricothyroid membrane
Placement of small tracheotomy tube, ETT or
large bore needle with attachment for
ventilation

Cricothyroidotomy
Advantages
Quick c/w open trach
No laryngeal injury
Failure of intubation
attempts in emergency
situation

Disadvantages
Can cause laryngeal
injury
Must be sure of
landmarks
Small tube required

Cricothyroidotomy

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