Tracheotomy

 is a surgical procedure which consists of

making an incision (cut) on
the anterior aspect (front) of the neck and
opening a direct airway through an incision in
the trachea (windpipe). The
resulting stoma (hole) can serve
independently as an airway or as a site for
a tracheal tube or tracheostomy tube  to be
inserted; this tube allows a person to breathe
without the use of the nose or mouth
Completed tracheotomy:
1 – Vocal folds
2 – Thyroid cartilage
3 – Cricoid cartilage
4 – Tracheal rings
5 – Balloon cuff
 Indications (general)

 1. to bypass an obstructed upper

 airway;
 2. to clean and remove secretions from
 the airway;
 3. to more easily, and usually more
 safely, deliver oxygen to the lungs.
 Airway Bypass
Indications (specific)
• Severe inflammation of face, neck and larynx
• Tracheal injury
• Upper airway tumor
• Thyroid operation with complication of bleeding or bilateral recurrent nerve
paralysis
• Neck radiotherapy
• Severe head and neck operating procedures
• Facial injury with multiple fracture
Bronchial Toilet
• Head trauma with consciousness disturbances, uneffective cough
• Tracheobronchitis with an edema and a lot of secretes
• Thoracic trauma with uneffective cough
• Post surgical procedure wtih inadequate cough
Easier Ventilation
• Prolonged ventilator after intubation > 48 hours
 Contraindications
 No contraindications especially for emergency case
Differential Diagnosis
For upper airway obstruction:
- Pneumonia
- Acidosis
 Preoperative

 Informed consent - explain about:

 Operating procedures
 Loss of voices when tracheostomy canule still in the trachea
 Complication of operation
 Should be done in the operating theatre as much as
 possible
 Adequate lightning
 One assistant required
 Tracheostomy set
 Plastic or metal canule preparation
 Prophylactic antibiotic: Cefazolin or combination of
 Clindamycin and Garamycin
 Anaesthetic preparation:
 Local or general anasthesia  local anasthesia with lidocain
(max dose 7 mg/kgBW)
 Patient’s position is supine with hyperextension of the
 Head: give a cushion below the shoulder trachea will be
exposed to the anterior
 Give the head a “doughnut” cushion
The surgical tracheostomy set: (A) general instruments (tissue tweezers,
mosquito forceps, Cooper scissors, muscle retractors, and Mayo needle
holder). The Portex percutaneous tracheostomy kit: (B) scalpel, (C) 14-gauge
sheath, (D) dilator, (E) guidewire, (F) guidewire dilating forceps, and (G)
tracheotomy tube.
 Steps of Procedures
 1. Desinfection with povidone - iodine 10% or
with Hibitane – alcohol 70% at operating area
(from lower lips – chin – neck until ICS 2, left
and right until the anterior border of trapezius
muscle)
 2. Operation area is narrowed by sterile linen
 3. Identification of trachea with palpation,
starting from thyroid cartilage to jugular
notch
 4. Perform a local anasthesia with lidocain 1%
or 2% injection subcutaneously
 5. Vertical incision 3-4 cm (emergency case) or
horizontal or collar incision (elective case),
incision is deepened by cutting subcutis,
fascia of neck superficial at the midline on the
incision site
6. Hemostasis
7. Put Langenbeck to the left and the right, balanced traction to
mantain trachea in the midline. If the isthmus of the thyroid
gland
stand in the way, set aside the isthmus to the caudal and hold it
with blunt hook. Identification of trachea, put sharp-one-tooth
hook between cricoid and 1st tracheal ring
8. Tracheal ring was cut vertically using No. 11 knife blade with a
sharp edge facing up and direction of the incision to the cranial
(2nd – 3rd ring for high tracheostomy; 4th – 5th ring for low
tracheostomy)
9. Trachea maintained open with a blunt tooth hooks on the
right
and left side, clean the existing secretions by using a suction
cannula and alternating with oxygenation
10. secretions were taken for culture and sensitivity test (for
diphteria patients)
11. Insert the cannula tracheostomy carefully, at the time of
inserting the tip, position of the axis perpendicular to the
tracheal cannula, after entering surely turn the direction
parallel to the axis of the trachea, proceed to thrust
according the curve of cannula tracheostomy into the lumen
of the trachea.
12. check cannula into the lumen of the trachea, feel the
breath of the hole cannula tracheostomy, or use the end
of the string that vibrates at the blast of breath
13. the whole latch is released, assistant hold the cannula,
cannula is fixed with sutures at the right and left lobes of
cannula to the skin of the neck and installing a ribbon strap
around the neck.
14. If the incision is too wide, skin is sutured loosely (don’t
be too tight: can cause skin emphysem)
15. Between cannula lobes and skin, put a sterile gauze
cushion
 Complication
Intraoperative
 Bleeding
 Reccurent laryngela nerve injury  small risk
 Pneumothorax
 Cricoid cartilage injury
 Esophageal perforation
 Tracheoesophageal fistula
 Vocal cord injury
Post Operative
 Early
 Impaired swallowing function because of tracheostomy cuff
 Bleeding,
 Infection at operation site,
 Subcutaneous emphysema,
Late
 Granuloma
 Tracheoesophageal fistula
 Tracheocutaneous fistula
 Laryngotracheal stenosis
 Post Operative Management
 Observation for the first 24 hours
 Treatment for primary disease
 Tracheostomy cannula management:
 Suction of the secrete / hour
 Cleanse the smaller cannula / 6 hours
 Nebulizer with warm air for 15 minutes /6 hours
 Treat tracheostomy wound with gauze replacement
every treatment