Definition of tracheostomy :

Definition : Making an opening in the anterior wall of trachea & converting it into stoma on the skin surface is called tracheostomy.

Types of tracheostomy :

1. Emergency tracheostomy
2. Elective tracheostomy.
3. Permanent tracheostomy.
4. Percutaneous dilatational tracheostomy.
5. Mini tracheostomy (cricothyroidotomy).

Procedure of emergency tracheostomy :

1. Position : Tonsillectomy position (Supine with a pillow under the shoulder).
2. Anaesthesia : No anaesthesia is required in unconscious patient or when it is an emergency procedure. In conscious patient local anaesthesia on diamond shaped field of thyroid cartilage. Sometimes general anaesthesia with intubation is used.
3. Incision : A vertical midline incision is made from the inferior aspect of the thyroid cartilage to the suprasternal notch & continued down between the infrahyoid muscles.
4. Tissues are dissected in the midline.
5. Deep fascia is opened.
6. Dilated veins are either displaced or ligated.
7. Strap muscles are retracted laterally
8. Isthmus is divided or retracted below.
9. A few drops of 4% lignocaine are injected into the trachea to suppress cough when trachea is incised.
10. 2nd to 4th tracheal rings are opened (usually 3rd ring) but not above due to cricoid cartilage  not below due to pleura.
11. Circular opening is made
12. Appropriate tracheostomy tube is inserted.
13. Firmly secured by tapes
14. Closure of the wounds by silk.

Procedure of elective tracheostomy :

1. Anaesthesia : General anaesthesia
2. Incision : A transverse incision. 2cm below the cricoid cartilage.
3. The steps above (steps 4-13 of emergency tracheostomy).
4. Skin edges are sutured to the tracheal opening.

Aims/objectives of tracheostomy :

1. To relieve respiratory obstruction.
2. To retained secretions.
3. To improve alveolar ventilation.
4. To protect airways.
5. To remove tracheobronchial secretions.
6. For Intermittent positive pressure respiration (IPPR).
7. To administer anaesthesia.

Indication of tracheostomy :

Indications of emergency tracheostomy :

  Relief of respiratory obstruction :

1) Congenital:

• Bilateral choanal atresia.
• Laryngeal web or cyst.
• Upper tracheal stenosis.
• Tracheo-oesophageal fistula.

2) Acquired :

    a) Infections :

• Acute laryngotracheobronchitis.
• Acute epiglottitis
• Laryngeal diphtheria.
• Laryngeal oedema
• Ludwig’s angina
• Peritonsillar abscess
• Retropharyngeal abscess or Parapharyngeal abscess.
• Tongue abscess.

     b) Trauma :

• External injury of larynx & trachea.
• Trauma due to endoscopies, especially in infants and children.
• Fracture of mandible or maxillofacial injuries.

    c) Neoplasms :

• Benign & malignant neoplasms of larynx, pharynx, upper trachea. tongue & thyroid.

   d) Others :

• Foreign body larynx.
• Oedema larynx due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), radiation.
• Bilateral abductor palsy.

Retained secretions:

   a) Inability to cough :

• Coma of any cause: head injury, cerebrovascular accidents & narcotic overdose.
• Paralysis of respiratory muscles : Spinal injuries, Polio, Guillain-Barre syndrome, Myasthenia gravis.
• Spasm of respiratory muscles.
• Tetanus
• Eclampsia
• Strychnine poisoning.

  b) Painful cough :

• Chest injuries.
• Multiple rib fractures
• Pneumonia.

  c) Aspiration of pharyngeal secretions :

• Bulbar polio.
• Polyneuritis
• Bilateral laryngeal paralysis.

Respiratory insufficiency : Chronic lung conditions, viz emphysema, chronic bronchitis, bronchiectasis & atelectasis.

Absolute indications for tracheostomy :

1. Carcinoma of the larynx with stridor.
2. Multiple papilloma of larynx in children.
3. Laryngeal diphtheria.
4. Open or closed injury to the larynx.
5. Foreign body in the larynx.

Indications of tracheostomy in infants & children :

Infants below 1 year (most congenital lesions) :

1. Subglottic haemangioma.
2. Subglottic stenosis.
3. Laryngeal cyst.
4. Glottic web.
5. Bilateral vocal cord paralysis.

Children (most inflammatory or traumatic lesions) :

1. Acute laryngo-tracheo-bronchitis with respiratory obstruction.
2. Acute epiglottitis.
3. Diphtheria.
4. Laryngeal oedema.
5. External laryngeal trauma.
6. Prolonged intubation.
7. Juvenile laryngeal papillomatosis.

Head neck emergencies :

1. Acute laryngo tracheo bronchitis.
2. External injury of larynx & trachea.
3. Foreign body larynx.
4. Peritonsillar abscess
5. Retropharyngeal abscess.
6. Parapharyngeal abscess.
7. Ludwig’s angina.

Complications of tracheostomy :

Immediate / per-operative complications:

• Haemorrhage.
• Injury to paratracheal structures, particularly the carotid artery, recurrent laryngel nerve and oesophagus.
• Damage to the trachea.

Early / intermediate complications :

• Apnoea caused by a fall in the PCO2
• Haemorrhage.
• Subcutaneous emphysema, pneumomediastinum and pneumothorax.
• Accidental extubation, anterior displacement of the tube, obstruction of the tube lumen and tip occlusion against the tracheal wall.
• Infection
• Swallowing dysfunction.

Late complications :

• Difficult decannulation.
• Tracheocutaneous fistula.
• Tracheo-oesophageal fistula.
• Tracheoinnominate artery fistula with severe haemorrhage.
• Tracheal stenosis.

Level of tracheal rings where tracheostomy operation is done : 

• High tracheostomi : Above the level of thyroid isthmus.
• Mid tracheostomy : Behind the isthmus (Against 2nd 3rd & 4th tracheal rings commonly performed operation).

Complication of low tracheostomy :

1. Pneumothorax due to injury to apical pleura.
2. Injury to apex of the lung.
3. Atelectasis
4. Lung abscess
5. Injury to oesophagus.

Post-operative care of a tracheostomy :

•  Constant supervision :  Bleeding, Displacement or blocking of tube, Remobal of secretions.
• Regular suction and cleaning of the tube.
• Position of the patient : Propped up position.
• Prevention of crusting & tracheitis :
• Proper humidification by use of humidifier, steam tent, ultrasonic nebulizer or keeping a boiling kettle in the room.
• If crusting occurs : A few drops of normal saline or hypotonic saline or Ringer’s lactate are installed into the trachea every 2-3 hours to loosen crusts.
• Care of the tracheostomy tube :  Clean the inner cannula for first 3 days. After 3-4 days, outer tube can be removed & cleaned every day.
• Feeding : Proper nourishment is essential for the recovery of the patient. If the patient is unable to eat than naso-gastric feeding is to be started.
• Physiotherapy & change of posture : Patient should be encouraged to be ambulant as early as possible. In a non-ambulant patient, posture is to be changed frequently to avoid lower respiratory tract infection.
• Dressing : Water proof dressing should be applied to prevent maceration of surrounding skin.
• Decannulation : Tracheostomy tube should not be kept longer than necessary. Prolonged use of tube leads to tracheobronchial infections, tracheal ulceration, granulations, stenosis and unsightly scars.