TRACHEOSTOMY

 

TRACHEOSTOMY
Tracheotomy , or tracheostomy, is a surgical procedure which consists of making an incision on
the anterior aspect of the neck and opening a direct airway through an incision in the trachea .

Indications
There are four main reasons why someone would receive a tracheotomy: [3]
1. Emergency airway access
2. Airway access for prolonged mechanical ventilation
3. Functional or mechanical upper airway obstruction
4. Decreased/incompetent clearance of tracheobronchial secretions


Surgical procedure
The best position for a tracheotomy was and still is one that forces the neck into the biggest
prominence . Usually, the patient is laid on their back on a table with a cushion placed under their
shoulders to prop them up . The typical procedure done is the open surgical tracheotomy .
Commonly a transverse (horizontal) incision is made two fingerbreadths above the sternal notch .
Alternatively, a vertical incision can be made in the midline of the neck from the thyroid cartilage to
just above the suprasternal notch. Skin, subcutaneous tissue, and strap muscles (a specific group of
neck muscles) are retracted aside to expose the thyroid isthmus, which can be cut or retracted
upwards. After proper identification of the cricoid cartilage and placement of a tracheal hook to
steady the trachea and pull it forward, the trachea is cut open, either through the space between
cartilage rings or vertically across multiple rings (cruciate incision). Occasionally a section of a
tracheal cartilage ring may be removed to make insertion of the tube easier. Once the incision is
made, a properly sized tube is inserted. The tube is connected to a ventilator and adequate
ventilation and oxygenation is confirmed. The tracheotomy apparatus is then attached to the neck
with tracheotomy ties, skin sutures, or both
 
Contraindications[ edit ]
There are a few absolute contraindications for percutaneous tracheostomy: [2]
 Active infection at the site of tracheostomy
 Uncontrolled bleeding disorder
 Unstable cardiopulmonary status (shock, extremely poor ventilatory status)
 Patient unable to stay still
 Abnormal anatomy of the tracheolaryngeal structures
Percutaneous tracheostomy is typically avoided in pediatric patients. Percutaneous tracheostomy
can be safely performed in the presence of: [20]
 Obesity
 Neutropenia
 History of  sternotomy
 Spinal cord injury

 Repeat tracheostomy


Risks/complications
Potential complication
A potential risk factor identified in a 2013 systematic review of the percutaneous technique was the
lack of  bronchoscopic  guidance. Use of the bronchoscope, an instrument inserted through a patient's
mouth for internal visualization of the airway, can help with proper placement of instruments and
better visualization of anatomical structures. However, this can also be dependent on the skills and
familiarity of the surgeon with both the procedure and the patient's anatomy
Hemorrhage[ edit ]
Hemorrhage is rare, but the most likely cause of fatality after a tracheostomy. It usually occurs due
to a  tracheoarterial fistula , an abnormal connection between the trachea and nearby blood vessels,
and most commonly manifests between 3 days to 6 weeks after the procedure is done. Fistulas can
result from incorrectly positioned equipment, high cuff pressures causing pressure sores or mucosal
damage, a low surgical trachea site, repetitive neck movement, radiotherapy, or prolonged
intubation.
Airway complications[ edit ]
There are a multitude of potential complications related to the airway. Main causes of mortality
during PDT include dislodgment of the tube, loss of airway during procedure and misplacement of
the tube. [21]  One of the more urgent complications include displacement or dislodgment of the
tracheotomy tube, either spontaneously or during a tube change. Although uncommon , the
associated fatality is high due to the loss of airway.Due to the seriousness of such a situation,
individuals with a tracheotomy tube should consult with their healthcare providers to have a specific,
written, emergency intubation and tracheostomy recannulation plan prepared in advance
Long-term- tracheal stenosis[ edit ]
Tracheal stenosis, is a possible long term complication. The most common symptom of stenosis is
gradually-worsening difficulty with breathing. However incidence is low, ranging from 0.6 to 2.8%
with increased rates if major bleeding or wound infections are present. A 2016 systematic review
identified a higher rate of tracheal stenosis in individuals who underwent a surgical tracheostomy, as
compared to PDT, however the difference was not statistically significant.
Complication rates[ edit ]
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of
10–15% and a procedural mortality of 0%,which is comparable to those of other series reported in
the literature from the Netherlands and the United States. A 2013 systematic review calculated
procedural mortality to be 0.17% or 1 in 600 cases. Multiple systematic reviews identified no
significant difference in rates of mortality, major bleeding, or wound infection between the
percutaneous or open surgical methods.