Tracheostomy

Definition:
A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretionsfrom the lungs. This tube is called a tracheostomy tube or trach tube.

Purpose/Indication
There are broadly four groups of patients on whom tracheostomy needs to be performed: 1. To relieve breathing difficulties by any blockage in the airway passages for example Foreign body Impactation in the airways. Acute infection of the airways Edema of the airways Paralysis of vocal cords following injury Tumors of the vocal cords Trauma in the region 2. To improve respiratory functions by reducing the length of the airway, which may be required in special lung conditions like- Bronchopneumonia Bronchitis with Emphysema Chest injury In these conditions the tracheostomy tube also helps in aspiration of excessive secretion that may be caused due to infection or injury 3. Respiratory nerve damage temporary or permanent causing paralysis of chest muscles that assist in breathing. In these situations performing assisted or positive pressure respirations may be required in conditions like Unconsciousness associated with head injuries Barbiturate poisoning Poliomyelitis Tetanus These patients may also aspirate their gastric content into the lungs and a tracheostomy tube may be helpful for aspiration these secretions. 4. As a preliminary step in certain surgeries on the upper airway.

Contraindication
There are no absolute contraindications to tracheostomy. A strong relative contraindication to discrete surgical access to the airway is the anticipation that the blockage is a laryngeal carcinoma.

Reference Values
Normal results include uncomplicated healing of the incision and successful maintenance of long-term tube placement.

Abnormal Result
Immediate

Haemorrhage Tube misplacement/displacement Pneumothorax

Immediate

Tube occlusion by secretions and/or blood Infection -chest/local skin Cuff under/over inflation Surgical emphysema

Late

Tracheal ulceration Tracheo-oesophageal fistula Tracheo-cutaneous fistula Granulation tissue (skin/tracheal) Tracheal stenosis (at incision or cuff site) Scar formation

Materials/Equipments
Tracheostomy tubes of the appropriate type and size Tracheostomy tube (one size smaller) Trach tube ties or velcro strap Dressing supplies, gauze Hydrogen peroxide, sterile water, normal saline Water soluble lubricant such as Surgilube or KY Jelly Blunt-end bandage scissors Tweezers or hemostats Sterile Q-tips Trach care kits and/or pipe cleaners (double-cannula trach tubes) Luer lock syringes for cuffed trach tubes

Preparation
Emergency tracheotomy In the emergency tracheotomy, there is no time to explain the procedure or the need for it to the patient. The patient is placed on his or her back with face upward (supine), with a rolled-up towel between the shoulders. This positioning of the patient makes it easier for the doctor to feel and see the structures in the throat. A local anesthetic is injected across the cricothyroid membrane.

Nonemergency tracheotomy In a nonemergency tracheotomy, there is time for the doctor to discuss the surgery with the patient, to explain what will happen and why it is needed. The patient is then put under general anesthesia. The neck area and chest are then disinfected and surgical drapes are placed over the area, setting up a sterile surgical field.

Procedure
The patient is made to lie down on their back with the neck & head extended by keeping a pillow under the shoulder and neck. Local anaesthesia or general anaesthesia is used for the procedure. A horizontal cut is made across the neck above the 'sternal notch' using a knife. The skin is separated and surrounding tissues are dissected to expose the trachea. The 2nd or 3rd of the tracheal ring is incised for the tracheostomy tube to be placed. A suitable size tracheostomy tube is then introduced inside. While choosing the tube, the smallest feasible tube should be used. A general rule is that the tube should be three fourths of the diameter of the trachea. The cuff of the tube is inflated by using 2-5 ml of air and it is held in place by using a necktie. The incision is closed using skin sutures by the side of the tracheostomy tube. Dressing is applied for the wound to heal.

Pre-operative care
Patient preparation should include a realistic explanation of what to expect. The patients should be prepared about the altered breathing sensation and the care that this will require i.e: humidified oxygen therapy and suctioning. Due to the absence of airflow for phonation the patient must be given alternative methods of communication. The literacy of the patient must be considered to ensure the appropriate aides to be supplied i.e: pen and paper, picture charts and call system. To ensure the patient is nursed in a safe environment the immediate bed environment must include

Spare tracheostomy tubes (one same size /one size smaller) Tracheal dilators Scissors/stitch cutters Syringe Re-breath bag and tubing Suction equipment with appropriate size cathters Gloves

Peri-operative care
(For all types of tracheostomy) 1. 2. 3. 4. 5. 6. 7. 8. 9. Place a pillow under shoulders to permit full extension of head and neck. Control patient respiration with ventilator and sedation, as necessary. Endotracheal tube cuff to be deflated and tapes loosened (but not removed). Prep and drape the anterior neck area. Local anaesthesia may be required to surrounding area. Endo-tracheal tube will be withdrawn to prevent damage to tube during stoma formation. Procedure carried out either by formation of surgical window or dilatation. Position will be checked by positive air presence and by endoscopy. Endotracheal tube will be removed once tracheostomy tube has been successfully inserted and cuff inflated. 10. Suction via tracheostomy tube to remove blood and secretions. 11. Skin incision closed. 12. Tracheostomy tube is secured by the use of sutures through neck plate to skin and velcro tapes (unless contra-indicated).

Post-operative Care
A chest x ray is often taken, especially in children, to check whether the tube has become displaced or if complications have occurred. The doctor may prescribe antibiotics to reduce the risk of infection. For the first few days postoperatively, the patient should be kept in a room where the temperature and humidity can be maintained at optimum levels. Increased temperature and humidity will help to reduce the tracheal irritation that results when inspired air has bypassed the natural warming and moisturizing of the nasopharyngeal airway. The patient's room should be supplied with a variety of equipment necessary to the care of the patient. Such things include suction equipment, a spare tracheostomy tube set, and sterile dressing material. Always apply basic principles of aseptic technique when caring for the incision and the airway. When suctioning, use separate set-ups for pharyngeal and tracheostomy suctioning. Constantly observe the patient for signs of respiratory obstruction such as restlessness, cyanosis, increased pulse, or gurgling noises during respiration Watch closely for bleeding from the incision, and look for blood in the aspirated secretions when suctioning. Be alert for choking or coughing when the patient swallows. This may indicate damage to the esophagus with leakage of swallowed material into the trachea.

Precautions
Extra precautions should be taken when performing site care during the first few days after the tracheostomy is surgically created. The site is prone to bleeding and is sensitive to movement of the tracheostomy tube. It is recommended that another health care professional securely hold the tube while site care is performed. Tracheostomy care should not be done while the patient is restless or agitated, since this increases the chance that the tube may be pulled out and the airway lost.