Tracheostomy

1. Tracheostomy Dr. Vishal Sharma

2. Jackson’s metallic tube

3. Jackson’s metallic tube

4. Jackson’s metallic tube • Made of German silver (alloy of Ag + Cu + P) • Has obturator (pilot), inner tube & outer tube • Inner tube is longer than outer tube for its removal & cleaning. Outer tube maintains patency. Pilot is inserted into outer tube for smooth & non-traumatic insertion of tube • Lock prevents expulsion of tube during cough

5. Fuller’s bivalved metallic tube I O

6. Fuller’s metallic tube • Outer tube bi-valved. The 2 blades when pressed together, help in smooth entry of tube. • Inner tube is longer & has a vent for phonation • Pt phonates by closing main tube opening • Vent also helps in decannulation of tube

7. Phonation via vent

8. Portex cuffed tube

9. Portex cuffed tube • Made of siliconized PolyVinylChloride. It is thermolabile & prevents crusting. • Low pressure high volume cuff maintains an air-tight seal required for: • Prevention of aspiration of secretions • Positive pressure ventilation

10. Cuffed double lumen tube

11. Cuffed fenestrated tube

12. Portex uncuffed tube For tracheostomy patient receiving radiation

13. Uncuffed double lumen fenestrated tube

14. Hands free speaking valve

15. Mechanism of speaking valve

16. Adjustable flange tube Used in obese neck, oedema neck

17. Salpekar double cuff tube Prevents ischemic necrosis of tracheal cartilage

18. Cold & hot water humidifiers

19. Heat & moisture exchanger

20. Nebulization attachment

23. Functions of Tracheostomy 1. Relieves upper airway obstruction 2. Improves alveolar ventilation by ing dead space by 30-50% & ing airflow resistance 3. Prevention of aspiration of blood & secretions 4. Removal of airway secretions in patient with inability to cough or with painful cough 5. Administration of anesthesia

24. Indications for Tracheostomy

25. A. Respiratory obstruction  Trauma to airway : external, endoscopic  Infection: epiglottitis, croup, Ludwig’s angina, para-pharyngeal /retro-pharyngeal abscess  Neoplasm: laryngo-tracheal, pharyngeal  Foreign bodyin airway  Oedema of larynx: irritant, allergic, irradiation  Paralysis of larynx: B/L abductor palsy  Congenital: laryngeal web, cyst, choanal atresia

26. B. Retained airway secretions  Inability to cough: coma, respiratory muscle palsy or spasm, laryngectomy  Painful cough: chest injuries, pneumonia  Excessive secretions: pulmonary oedema C. Respiratory insufficiency  Chronic bronchitis, bronchiectasis, atelectasis, reatined airway secretions

27. D. Anesthesia administration in:  Laryngo-pharyngeal growths  Maxillo-facial trauma  Trismus  Severe Ludwig’s angina  Positive pressure ventilation for > 72 hrs

28. Types of Tracheostomy  Emergency  Elective  Temporary  Permanent  Therapeutic  Prophylactic • High (1st ring): above thyroid isthmus • Mid (2nd – 4th ring): behind thyroid isthmus • Low (below 4th ring): below thyroid isthmus

29. Mid tracheostomy preferred High tracheostomy leads to subglottic stenosis Low tracheostomy is avoided as:  Trachea is deeper  Displacement of tracheostomy tube is common  Proximity to great vessels  Surgical emphysema is common  Tracheostoma is close to tracheal bifurcation

30. Steps of Tracheostomy

32. Positioning Supine position with extension of neck. General anesthesia with endotracheal intubation.

33. Infiltration  Cricoid palpated & a 5 cm horizontal incision marked 2 cm below it  2 % lignocaine & 1 in 2 lakh adrenaline injected into incision line

34. Horizontal Incision A 5 cm horizontal incision made with # 15 blade & deepened below subcutaneous tissue

35. Vertical Incision A 5 cm midline vertical incision can be made below cricoid in emergency tracheostomy. This avoids injury to blood vessels.

38. Exposure of strap muscles Investing layer of deep cervical fascia opened vertically with artery forceps. Palpation for tracheal rings done regularly during the dissection.

40. Retraction of strap muscles

41. Exposure of thyroid isthmus Strap muscles retracted laterally with Langenbeck retractors to expose the trachea & thyroid isthmus

42. Isthmus separation from trachea Thyroid isthmus detached from tracheal surface & retracted with blunt tracheal hook.

43. Isthmus retraction to expose pre-tracheal fascia

44. Division of thyroid isthmus If required, thyroid isthmus is divided between clamps. Transfixion sutures applied at the ends.

45. Confirmation of trachea • 5 ml syringe containing 4 % Lignocaine taken, its needle inserted into trachea & aspirated. Air bubbles confirm presence of needle in trachea. • 2 ml of solution injected into trachea & needle removed quickly to avoid breaking of needle during violent cough movements.

46. Creation of tracheal window Sharp cricoid hook inserted below cricoid to steady trachea. Tracheal window created by excising anterior 1/3rd of 2nd & 3rd tracheal ring with No. 11 blade & Allis tissue forceps.

47. Cautery assisted window

48. Holding cartilage with Allis forceps

49. Tracheal window

50. Other options