Tracheostomy

Read More from the Source PDF

Procedure Snapshot

• Indication: Airway obstruction, need for prolonged ventilation, pulmonary hygiene, elimination of dead space, obstructive sleep apnea.¹
• Expected duration: 20–40 minutes.¹
• Special instruments: Tracheal hook, cuffed tracheostomy tube with introducer, bipolar cautery, suction, scissors, Langenbeck retractors.¹

---

Step Workflow

1. Preparation & Anesthesia
   • Ideally performed in OR with lighting, suction, diathermy, skilled assistance.¹
   • If intubation is unsafe → perform awake tracheostomy under local anesthesia.¹
   • Surgeon must be present during induction in high-risk airways.¹
2. Positioning
   • Supine with neck extended using shoulder roll; aim to “deliver” trachea out of thorax.¹
   • Patients with airway obstruction may require semi-upright positioning.¹
3. Surface Landmarks
   • Identify thyroid notch → cricothyroid membrane → cricoid cartilage.¹
   • Tracheostomy is created below the 1st tracheal ring to avoid subglottic stenosis.¹
4. Skin Incision
   • Transverse incision one fingerbreadth below cricoid (preferred cosmetically).¹
   • Avoid anterior jugular veins — retract laterally.¹
5. Strap Muscles
   • bluntly separate sternohyoid → sternothyroid in midline.¹
   • Retract laterally to expose thyroid isthmus.¹
6. Thyroid Isthmus
   • Usually overlies 2nd–3rd tracheal rings.¹
   • Retract superiorly; rarely divide/ligate unless obstructing access.¹
7. Expose Trachea
   • Bluntly clear soft tissue; avoid inferior thyroid veins.¹
   • Ensure bloodless field — hemostasis is difficult once tube is inserted.¹
   • If uncertain, aspirate air with needle to confirm trachea.¹
8. Create Tracheostoma
   • Inject lignocaine into tracheal lumen (awake patient).¹
   • Use tracheal hook to stabilize and lift trachea.¹
   • Safest adult technique: inferiorly based flap through 3rd–4th tracheal rings.¹
   • Pass a traction suture through the flap and secure to skin—prevents false-tract reinsertion.¹
9. Insert Tracheostomy Tube
   • Select the largest cuffed tube that fits comfortably.¹
   • Test cuff; insert introducer.¹
   • If intubated → withdraw ETT under vision.¹
   • Insert tube while applying traction on the flap suture; verify not in false passage.¹
   • Inflate cuff and ventilate; confirm with EtCO₂, chest rise, breath sounds.¹
10. Secure Tube
    • Tie tapes with neck flexed; should admit only 1 finger beneath.¹
    • Many surgeons suture tube to skin for first 48 hours until tract matures.¹

---

Key Pimp Questions

• Q: Why must tracheostomy be placed below the 1st ring?
  A: To avoid post-op subglottic stenosis.¹

• Q: Why avoid low tracheostomy?
  A: Risk of erosion into innominate artery → fatal hemorrhage.¹

• Q: Most dangerous error during tube insertion?
  A: Creation of false paratracheal tract.¹

• Q: Why avoid diathermy when entering the airway?
  A: Risk of airway fire in oxygen-rich environment.¹

• Q: Why are traction sutures important?
  A: Facilitate reinsertion and prevent false-tract placement during early post-op period.¹

---

Critical Anatomy

• Thyroid isthmus overlies 2nd–3rd rings.¹
• Anterior jugular veins superficial to strap muscles.¹
• Innominate artery lies anterior to lower trachea — low tracheostomy risk.¹
• Pleural domes may be injured → pneumothorax, especially in thin or ventilated patients.¹

---

Informed Consent Highlights

Risk	Approximate Incidence	Notes
Bleeding / Hematoma	Common¹	Risk ↑ with coagulopathy
False tract / failed ventilation	Serious complication¹	Hypoxia, high pressures
Pneumothorax / pneumomediastinum	Uncommon¹	Higher in children & ventilated patients
Innominate artery erosion	Rare but fatal¹	From low tracheostomy
Subglottic stenosis	If placed too high¹	Avoid 1st ring
Surgical emphysema	Common if skin sutured too tight¹	Monitor with CXR if extensive
Airway fire	Rare¹	Avoid diathermy when entering airway

---

Post-op Considerations

• Humidification essential (HME, humidifier, bib).¹
• Pulmonary toilet: suction frequently, ensure aseptic technique.¹
• Inner cannula cleaning prevents increased airway resistance.¹
• Cuff pressures: keep <25–30 cm H₂O to prevent ischemia & stenosis.¹
• Tube security: monitor tapes frequently; accidental decannulation is life-threatening, especially in first 48 h.¹
• CXR for pneumothorax if ventilated or symptomatic.¹
• Respiratory arrest risk after relieving obstruction → monitor closely.¹

---

Clinical Pearls

• In borderline airways: infiltrate trachea with local anesthetic before induction.¹
• Never enter the trachea with cautery.¹
• Always confirm true lumen with EtCO₂ + chest rise.¹
• For obese/short-necked patients: expect challenging exposure—maximize neck extension.¹
• Speaking valves allow phonation; fenestrated tubes allow airflow through larynx.¹

---

Quick Reference Table

---

Quick-Reference Cards

---

References

1. Fagan J. Tracheostomy. In Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery.
   :contentReference[oaicite:1]{index=1}