Tracheostomy

Indications for tracheostomy
A. Respiratory obstruction
1 . Infections
- Acute laryngo-tracheo -bronchitis, acute epiglottitis,
diphtheria
- Ludwig's angina, peritonsillar, retropharyngeal or
parapharyngeal abscess, tongue abscess
2. Trauma
- External injury of larynx and trachea
- Trauma due to endoscopies, especially in infants
and children
- Fractures of mandible or maxillofacial injuries
3. Neoplasms
- Benign and malignant neoplasms of larynx,
pharynx, upper- trachea , tongue and thyroid
4. Foreign body larynx
5. Oedema larynx due to steam, irritant fumes or gases,
allergy (angioneurotic or drug sensitivity), radiation
6. Bilateral abductor paralysis
7, Congenital anomalies
- Laryngeal web, cysts, tracheo -oesophageal fistula
- Bi lateral choanal atresia
B. Retained secretions
1. Inability to cough
- Coma of any cause, e.g. head in juries, cerebrovascular
accidents, narcotic overdose
- Paralysis of respiratory muscles, e.g. spinal injuries,
polio, Guillain- Barre syndrome, myasthenia gravis
- Spasm of respiratory muscles, tetanus, eclampsia,
strychnine poisoning
2. Painful cough
- Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
- Bulbar polio, polyneuritis, bilateral laryngeal
paralysis
C. Respiratory insufficiency
- Chronic lung conditions, viz. emphysema, chronic
bronchitis, bronchiectasis, atelectasis

Types of Tracheostomy
1. Emergency tracheostomy. It is employed when airway
obstruction is complete or almost complete and there

is an urgent need to establish the airway. Intubation or
laryngotomy are either not possible or feasible in such cases.
2. Elective tracheostomy (syn. tranquil, orderly or
routine tracheostomy ). This is a planned, unhurried
procedure. Almost all operative surgical facilities are
available, endotracheal tube can be put and local or general
anaesthesia can be given. It is of two types:
(a) Therapeutic: to relieve respiratory obstruction,
remove tracheobronchial secretions or give assisted
ventilation.

(b) Prophylactic, to guard against anticipated respiratory
obstruction or aspiration of blood or pharyngeal
secretions such as in extensive surgery of tongue,
floor of mouth, mandibular resection or laryngofissure.
Elective tracheostomy is often temporary and is closed
when indication is over.
3. Permanent tracheostomy. This may be required
for cases of bilateral abductor paralysis or laryngeal stenosis.
In laryngectomy or laryngopharyngectomy, lower trachea!
stump is brought to surface and stitched to the skin.

Tracheostomy has also been divided into high, mid or
low. A high tracheostomy is done above the level of thyroid
isthmus ( isthmus lies against Il, III and IV tracheal
rings). It violates the 1st ring of trachea. Tracheostomy at
this site can cause perichondritis of the cricoid cartilage
and subglottic stenos is and is always avoided. Only indication
for high tracheostomy is carcinoma of larynx because
in such cases, total larynx anyway would ultimately be
removed and a fresh tracheostome made in a clean area
lower down. A mid tracheostomy is the preferred one and
is done through the 11 or III rings and would entail division
of the thyroid isthmus or its retraction upwards or
downwards to expose this part of trachea. A low tracheostomy
is done below the level of isthmus. Trachea is
deep at this level and close to several large vessels; also
there are difficulties with tracheostomy tube which
impinges on suprasternal notch.
Technique
Whenever possible, endotracheal intubation should be
done before tracheostomy. This is specially important in
infants and children.
Position. Patient lies supine with a pillow under the
shoulders so that neck is extended. This brings the trachea
forward.
Anaesthesia. No anaesthesia is required in unconscious
patients or when it is an emergency procedure. In
conscious patients, 1-2% lignocaine with epinephrine is
infiltrated in the line of incision and the area of dissect ion.
Sometimes, general anaesthesia with intubation is used.
Steps of Operation
1. A vertical incision is made in the midline of neck,
extending from cricoid cartilage to just above the
sternal notch. This is the most favoured incision
and can be used in eme rgency and elective procedures.
It gives rapid access with minimum of bleeding
and tissue dissection. A transverse incision , 5 cm
long, made 2 fingers ' breadth above the sternal notch
can be used in elective procedures. It has the advantage
of a cosmetically better scar (Fig. 62.1) .
2. After incision, tissues are dissected in the midline.
Dilated veins are either displaced or ligated .
3. Strap muscles are separated in the midline and
retracted laterally.

4. Thyroid isthmus is displaced upwards or divided
between the clamps, and suture- ligated.
5. A few drops of 4% lignocaine are injected into the
trachea to suppress the cough when trachea is
incised.
6. Trachea is fixed with a hook and opened with a vertical
incision in the region of 3rd and 4th or 3rd and
2nd rings. This is then converted into a circular
opening. The first tracheal ring is never divided as
perichondritis of crico id cartilage with stenosis can
result.
7. Tracheostomy tube of appropriate size is inserted
and secured by tapes .
8. Skin incision should not be sutured or packed
tightly as it may lead to development of subcutaneous
emphysema.

Complications
A. Immediate (at the time of operation):
1. Haemorrhage.
2. Apnoea. This follows opening of trachea in a
patient who had prolonged respiratory obstruction.
This is due to sudden washing out of CO2 which
was acting as a respiratory stimulus. Treatment is to
administer 5% CO2 in oxygen or ass isted ventilation.
3. Pneumothorax due to injury to apical pleura.
4. Injury to recurrent laryngeal nerves.
5. Aspiration of blood.
6. Injury to oesophagus. This can occur with tip of
knife while incising the trachea and may result in
tracheo-oesophageal fistu lao
B. Intermediate (during first few hours or days):
1. Bleeding, reactionary or secondary.
2. Displacement of tube.
3. Blocking of tube.
4. Subcutaneous emphysema.
5. Tracheitis and tracheobronchitis with crusting in
trachea.
6. Atelectas is and lung abscess.
7. Local wound infection and granulat ions.
C. Late (with prolonged use of tube for weeks and
months):
1. Haemorrhage, due to erosion of major vessel.
2. Laryngeal stenosis, due to perichondritis of cricoid
cartilage.
3. Tracheal stenosis, due to tracheal ulceration and
infection.
4. Tracheo-oesophageal fistula, due to prolonged use of
cuffed tube or erosion of trachea by the tip of tracheostomytube.
5. Problems of decannulation. Seen commonly in
infants and children.
6. Persistent tracheocutaneous fistula.
7. Problems of tracheostomy scar. Keloid or unsightly
scar.
8. Corrosion of tracheostomy tube and aspiration of its
fragments into the tracheobronchial tree.