د.حسين جاسم
L.5 Tracheostomy

           It's defined as creation of an opening in the trachea and converting this opening into a stoma with the skin.

Indications:
1. Relief of respiratory obstruction:
   - Congenital causes: bilateral choanal atresia, laryngeal web or cyst & tracheo- esophageal anomalies.
   -  Traumatic:
           External:  blows on the larynx, gunshots or cut throat. 
         Internal: Inhalation of steam or fumes, foreign body and swallowing of corrosives.
   -  Infections:  Acute epiglottitis, acute laryngotracheobronchitis and diphtheria.                          -  Tumors:  Malignant disease of the tongue, pharynx, thyroid, and larynx.
   -   Miscellaneous causes:  Haemophilia & Angioneurotic oedema.
   - Bilateral laryngeal nerve palsies: after thyroid surgery or bulbar palsy.
    -  Cord fixation due to rheumatoid arthritis.
2.  Protection of the tracheobronchial tree.
     In conditions that are leading to inhalation of saliva, food or gastric contents, stagnation of bronchial secretion as in CNS disorders, burns of the face and neck and head injury.
3. Tracheostomy aids respiration in artificial or intermittent positive pressure ventilation; in cases leading to respiratory insufficiency; as in chronic bronchitis, emphysema, post operative pneumonia and chest injury.
Types of tracheostomy tubes
A. Metallic tracheostomy tube (Silver-Jackson's tube):
      It is composed of inner and outer tube with trocar or introducer to insert the tube into the trachea.
     Advantages:
Composed of inner and outer tube; the inner tube collects the secretions on it        and can be removed while the outer is retained in position securing the airway.
     
Disadvantages: 
      1. More traumatic than the plastic tracheostomy tube.
2. Have no cuff so it can't be used in artificial ventilation.
B. Plastic tracheostomy   tube (portex)
 Advantages:
     1. Less traumatic. 
      2. Have cuff so it can be used in artificial ventilation.
 Disadvantages:
          1. Have no inner tube so it should, be removed totally to clean up the tracheostomy tube. 
     2. The cuff may produce pressure necrosis on the tracheal mucosa leading to ulceration and stenosis.

Procedure of tracheostomy
 1. In emergency conditions vertical incision is preferred while in elective cases we do transverse incision. 
2. Separation of subcutaneous tissues, strap muscles and pretracheal fascia in vertical line. 
3. Transaction of the thyroid isthmus & ligation of the pedicles. 
4. Vertical opening in the trachea between 2-4tn tracheal and insertion of the tube or make a circular window in the trachea. 
5. Loose closure of the skin & light dressing to prevent surgical emphysema from development.
Post operative management:
1. Nursing in the first 24 hours post operatively is of utmost importance.
2. Position: the patient must, be sitting upright- in bed  
3. Suction with sterile catheter into the trachea applied regularly with aseptic technique. 
4. Humidification either by using humidifier or moistened gauze over the tracheostomy.
5.  Prevention of apnea in cases of long standing obstruction, apnea may follow restoration of the airway, with lowering of pCO2, carbon dioxide 5-7% in oxygen is given through the tracheostomy.
6.  Care of the tube and changing it or cleaning by removal of the inner tube in case of metallic tracheostomy tube.
7.  Care of the wound of the tracheostomy with dressing and antibiotics.

Physiological changes after tracheostomy:
1.	A 10-50% reduction in anatomical dead space.
2.	Loss of voice due to bypassing the larynx during breathing.
3.	Difficulty in swallowing due to tethering of the trachea to the skin.
4.	Loss of humidification; cold dry air hits the tracheobronchial tree which interfere with the ciliary function allowing accumulation of secretion.
5.	Loss of glottic valve closure required for effective coughing.

Complications of tracheostomy:
Immediate: 
1. Hemorrhage from the thyroid isthmus, abnormally placed blood vessels, skin edges.
2. Recurrent laryngeal nerve injury.
3. Apnea secondary to loss of hypoxic drive.
4. Cardiac arrest secondary to the adrenaline surge and the     sudden rise in pH as CO2 is washed out.
5. Air embolism.
6. Pneumothorax.
7. Creation of a false passage.
Intermediate: 
1.  Cellulitis.  
2. Displacement of the tube with suffocation may occur if completely displaced outside the tracheal opening, the tube should be re-inserted at once.
3.   Tube obstruction. 
4.  Surgical emphysema.
5.  Tracheal wall ulceration or necrosis.
6.  Dysphagia due to tethering of the trachea to the skin.
7.   Pneumomediastinum.
Late:  
1.  Perichondritis & stenosis may develop in the subglottic region if the tracheostomy involves the 1st tracheal ring.
2. tracheo-oesophageal fistula can result from pressure of an ill-fitting tube against the posterior wall.
3. tracheo-arterial fistula can result from pressure of an ill-fitting tube against the great vessels in the neck especially in children.