Tracheostomy

1. DEFINITION

• Tracheotomy: A surgical incision made below the cricoid cartilage between the second and fourth tracheal rings.
  
  

• Tracheostomy: The creation of a permanent opening (stoma) between the trachea and the cervical skin.
  
  

  • The two terms are often used interchangeably.
    
    

  • Types:
    
    

    • Temporary: Elective or emergency.
      
      

    • Permanent: Usually done during other surgeries such as total laryngectomy.
      
      

2. ANATOMY OF THE TRACHEA

• A cartilaginous and membranous tube approximately 11 cm in length, extending from the lower border of the cricoid cartilage to the carina.
  
  

• Bifurcates at the level of thoracic vertebra five.
  
  

• Moves during respiration and swallowing.
  
  

• Lies in the midline of the neck and deviates slightly to the right within the chest.
  
  

• D-shaped: cartilaginous rings are incomplete posteriorly (where the trachealis muscle lies).
  
  

• In children: smaller, more mobile, and bifurcates higher.
  
  

• First cartilage is broader and connected to the cricoid cartilage by the cricotracheal ligament.
  
  

Vascular and Neural Supply:

• Arterial supply: Superior and inferior thyroid arteries.
  
  

• Venous drainage: Tracheal veins into the thyroid venous plexus.
  
  

• Nerve supply: Recurrent laryngeal nerve and sympathetic fibers from the middle cervical ganglion.
  
  

Anatomical Relations:

• Anteriorly: Skin, superficial and deep fascia, sternohyoid and sternothyroid muscles, isthmus of thyroid (at 2nd–4th tracheal rings), and possibly the left brachiocephalic vein.
  
  

• Laterally: Thyroid lobes, carotid sheath, and recurrent laryngeal nerve.
  
  

• Posteriorly: Oesophagus.
  
  

3. PHYSIOLOGICAL PROS AND CONS OF TRACHEOSTOMY

Advantages:

• Reduces anatomical dead space by up to 150 ml (50%).
  
  

• Reduces work of breathing.
  
  

• More comfortable than endotracheal tubes.
  
  

• Requires less sedation.
  
  

Disadvantages:

• Loss of natural humidification, filtration, and warming functions.
  
  

• Increased mucus production.
  
  

• Disruption of mucociliary clearance.
  
  

• Inability to speak.
  
  

• Impaired cough reflex and altered swallowing mechanism.
  
  

4. INDICATIONS FOR TRACHEOSTOMY

Main Categories:

1. Mechanical upper airway obstruction.
   
   

2. Airway protection in at-risk patients.
   
   

3. Respiratory failure.
   
   

4. Retention of bronchial secretions.
   
   

5. Elective use (e.g., ICU patients).
   
   

Specific Conditions:

• Neurological disorders (e.g., Guillain-Barré syndrome, tetanus, myasthenia gravis).
  
  

• Comatose patients (Glasgow Coma Scale < 8).
  
  

• Facial trauma.
  
  

• Pulmonary diseases (emphysema, asthma).
  
  

• Flail chest or chest trauma.
  
  

ICU Considerations:

• Prolonged intubation (>14 days): consider tracheostomy.
  
  

• No patient should be intubated for more than 21 days due to complications.
  
  

5. PREOPERATIVE ASSESSMENT

• Obtain informed consent.
  
  

• Explain to the patient about loss of speech and communication aids.
  
  

• Ensure clotting profile is normal, anticoagulants stopped.
  
  

• Platelets ideally above 100 × 10⁹/L (minimum 50 × 10⁹/L).
  
  

• Examine for difficult neck anatomy.
  
  

• Introduce patient to someone with a tracheostomy for reassurance.
  
  

6. TYPES OF TRACHEOSTOMY TUBES

• With/without cuff
  
  

• Single or double barrel
  
  

• Short or long
  
  

• Fenestrated or non-fenestrated
  
  

• With/without flange
  
  

• With/without speaking valve
  
  

• Materials: Silicone, polyvinyl chloride, silastic, metal (not used for radiotherapy or CT scan)
  
  

• Flexible or rigid
  
  

Indications for Cuffed Tubes:

• Risk of aspiration.
  
  

• Positive pressure ventilation.
  
  

• Freshly formed stoma in adults.
  
  

• Unstable conditions.
  
  

Contraindications:

• Children under 12 years.
  
  

• High risk of tracheal damage.
  
  

Flange: Adjusts tube length, helps bypass obstructions.
Fenestration: Assists phonation and airflow.

7. PAEDIATRIC TRACHEOSTOMY

Anatomical Considerations:

• Cricoid and hyoid cartilages lie higher.
  
  

• Difficult palpation due to pretracheal fat pad.
  
  

• Important surrounding structures include the innominate artery/vein and apices of lungs.
  
  

• Developing trachea—extra caution required.
  
  

Technique:

• Vertical skin incision, one fingerbreadth above suprasternal notch.
  
  

• Use stay sutures labelled for side and purpose.
  
  

• Use uncuffed tubes.
  
  

8. POSTOPERATIVE CARE AND EQUIPMENT

Essential Equipment:

• Spare tracheostomy tubes.
  
  

• Tracheal dilators.
  
  

• Suction kits.
  
  

• Sterile water and humidification devices.
  
  

• Syringes and cuff monitors.
  
  

• Communication aids and stoma dressings.
  
  

Humidification Methods:

• Heat and Moisture Exchangers (HME).
  
  

• Cold or hot water humidifiers.
  
  

• Stomal protectors.
  
  

• Nebulisation.
  
  

Suctioning:

• Based on clinical need (e.g., abnormal secretions, breath sounds, patient distress).
  
  

• Use catheter of appropriate size: Internal diameter of tube + 3 = French gauge.
  
  

• Use twirling motion, 10–15 seconds, limited to 3 passes per session.
  
  

Inner Cannula Care:

• Clean 2–3 times daily or more depending on secretions.
  
  

• First tube change: after 5–7 days (or 48 hours in some cases).
  
  

Complications:

• Peristomal hypergranulation: managed with 95% silver nitrate or surgical excision.
  
  

9. DECANNULATION (REMOVAL OF TUBE)

Definition: Permanent removal of tracheostomy tube.

Selection Criteria:

• Resolution of initial indication.
  
  

• Alert, able to protect airway.
  
  

• Tolerating cuff deflation and speaking valve.
  
  

• Able to expectorate secretions.
  
  

Steps:

• Gradual process over days to weeks.
  
  

• In children: recommended to do under diagnostic endoscopy.
  
  

• Downsize tube, then proceed to monitored capping and spigoting.
  
  

• Monitor vital signs.
  
  

• If not tolerated, rule out causes like granulomas or subglottic stenosis.
  
  

10. SWALLOWING DIFFICULTIES

Causes:

• Overinflation of cuff compressing oesophagus.
  
  

• Tube interfering with laryngeal motion.
  
  

Management:

• Use longer or more flexible tubes.
  
  

• Deflate cuff.
  
  

• Use smaller-sized tube if needed.
  
  

11. CRICOTHYROIDOTOMY / MINITRACHEOSTOMY

Emergency Procedure:

• Entry through cricothyroid membrane above the cricoid cartilage.
  
  

• Midline incision with blade or intravenous cannula.
  
  

• Cannula can be connected to bag-valve mask.
  
  

• Temporary procedure; convert to formal tracheostomy quickly.
  
  

Risks:

• High risk of subglottic stenosis.
  
  

12. COMPLICATIONS OF TRACHEOSTOMY

• Bleeding
  
  

• Infection
  
  

• Tube displacement
  
  

• Subcutaneous emphysema
  
  

• Tracheal stenosis
  
  

• Tracheoesophageal fistula
  
  

• Swallowing and speech problems
  
  

• Formation of granulation tissue