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Tracheostomy

April 12, 2022 - read ≈ 2 min

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I. Introduction

Tracheostomy is a procedure used to support patients with obstruction of their airway at the level of the larynx or above the it. Additionally, tracheostomy can be used to support patients with chronic respiratory problems or those who would require prolonged intubation with an endotracheal tube.

II. Indications/Contraindications

Indications

  • Need for prolonged airway access in patient requiring mechanical ventilation
  • Uncontrolled secretions
  • Airway obstruction

Contraindications

Absolute contraindications

  • None

Relative contraindications

  • Coagulopathy

III. Equipment

  • Scalpel
  • 10cc syringe
  • Tracheostomy tube
  • Self-retaining retractor

IV. Preparation

  • Patient is placed supine
  • Neck is prepped with an anti-septic solution (e.g. betadine)
  • Towel roll can be placed underneath the shoulders to assist with neck extension

V. Steps

  1. Extend the neck.
  2. Palpate the trachea two fingerbreadths above the sternal notch (Figure 1).
  3. Make a vertical incision in the midline overlying the trachea.
  4. Place a self-retaining retractor (or use an assistant to retract).
  5. Divide the strap muscles vertically (Figure 2).
  6. Expose the trachea.
  7. Place a permanent suture on each side of the trachea at the level of the third tracheal ring.
  8. Avoid puncturing the balloon of the endotracheal tube (if one is in place).
  9. Make a vertical incision in the anterior tracheal wall.
  10. Use the previous placed sutures to retract while inserting the tracheostomy tube (Figure 3).
  11. Inflate the balloon with 10 cc of air
  12. Confirm placement of the tube using end-tidal carbon dioxide monitoring device
  13. Close the incision with nylon sutures. Secure the tracheostomy tube in place with four nylon sutures (one in each corner)

The stay sutures placed on the lateral parts of the trachea can remain in place for a few days to help replace the tube if it falls out.

VI. Complications

  • Bleeding
  • Tracheal or subglottic stenosis
  • Tracheoesophageal fistula
  • Tracheo-innominate fistula: Avoid placing the tracheostomy tube too low. If placed too close to the innominate artery, the patient can develop a fistulous tract between the innominate artery and trachea. This can lead to life-threatening bleeding and death.
  • Intra-operative fire: When performing the tracheotomy, lower the fraction of inspired oxygen as low as permitted if planning to use cautery. Avoiding the use of cautery can help lower the risk of intra-operative fire.
  • Dislodgement: The tract for a tracheostomy tube takes a few weeks to mature. During this time, if the tracheostomy tube falls out, it may not easily be replaced. If the tube is removed, the patient should be re-intubated orally with an endotracheal intubation.

References

  • Bernstein ML, Wang SC. Chapter 45. Tracheostomy and Emergency Cricothyroidotomy. In: Minter RM, Doherty GM. Eds. Current Procedures: Surgery. Ann Arbor, Michigan. McGraw Hill; 2010.

Figure 1

Source: Minter RM, Doherty GM: Current Procedure: Surgery. Copyright © The McGraw-Hill companies, Inc. All rights reserved.

Figure 2

Source: Minter RM, Doherty GM: Current Procedure: Surgery. Copyright © The McGraw-Hill companies, Inc. All rights reserved.

Figure 3

Source: Minter RM, Doherty GM: Current Procedure: Surgery. Copyright © The McGraw-Hill companies, Inc. All rights reserved.

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