Tracheostomy Operative Procedure

 

General Indications

There are four main indications or goals for a tracheostomy. The procedure may be required to achieve any one or combination of these four.

Heading the list is the assurance of a patent airway. As long as the tracheostomy tube itself is not blocked and it extends below the level of any site of blockage, the upper airway is virtually assured of being open. Obstruction in the upper airway caused by edema of the glottis or by carcinoma of the larynx are just two of many indications for tracheostomy.

Another important goal is protection of the lungs from potential threats such as obstruction or aspiration.

Tracheostomy may be indicated for more effective removal of secretions from the trachea and lower airways. Patients with sputum retention may be candidates for standard or mini-tracheostomy.

A final and very common indication for tracheostomy is to permit long-term ventilatory support. There are several advantages: the anatomical dead space is reduced, the ventilator may be easily attached directly to the tracheostomy tube, the airway is protected, a convenient access to the airway for suctioning is available, ventilatory support or tracheostomy tube dependency can be reduced, improved communication and nutritional support is also provided.

The Procedure

Tracheostomy should rarely be considered for emergency access and control of the airway. It is best performed with access gained to the trachea with an endotracheal tube in place. Rapid access to the airway is possible in less than one minute via oral or nasal intubation of the trachea, or cricothyrotomy. Little equipment is required for these routes; most emergency cricothyrotomy need only a large bore needle or scalpel.

 

Tracheostomy, on the other hand, is a procedure that requires more sophisticated skills and equipment. Tracheostomy is used infrequently as the initial route to gain access to the airway.

Surgical tracheostomy is usually performed in the operating room or less commonly in an intensive care unit under general or local anesthesia.



With the patient positioned with the neck hyperextended, the skin area is prepared and an incision is made below the cricoid cartilage. The trachea is located with blunt dissection, bleeding is controlled if necessary, and an incision (one of many types) is made through the 2nd, 3rd, or 4th tracheal cartilage. A cuffed tracheostomy tube of proper size and length is inserted through the anterior wall of the trachea as the endotracheal tube is slid above the ostomy site. The tracheostomy tube is gently positioned and ventilation is confirmed
through the tube. The tube is secured and the skin incision may be loosely sutured or left open.

 

 

Surgical Complications of Tracheostomy

Tracheostomy has definite surgical risk associated with it. The four most important immediate surgical complications are:

1. Bleeding from the operative site

2. Subcutaneous emphysema, mediastinal emphysema, and pneumothorax

3. Aspiration of blood in the airway

4. Cardiac arrest secondary to hypoxia, acidosis, or sudden electrolyte shifts.

Most of these complications can be avoided by establishing an airway prior to the procedure and by correcting hypoxia and hypercarbia prior to surgery. Meticulous control of bleeding is essential.

Percutaneous Tracheostomy

With the advent of the percutaneous approach to tracheostomy, many of the complications associated with surgical tracheostomy have been avoided. This technique offers both the clinician and the patient many advantages. Because this procedure is most frequently performed at the patient's bedside, there are no delays often associated with scheduling a surgical procedure. Significant bleeding is rare, post-procedural infections are almost nonexistent, and costs are drastically reduced. When compared to prolonged transtracheal intubation or surgical tracheostomy, the risks and complications are low. Many clinicians now favor early tracheostomy with two to three days post-transtracheal intubation over prolonged maintenance of an endotracheal tube.

The Procedure

Percutaneous tracheostomy is not indicated for gaining access to the airway in emergency situations and should not be confused with cricothyroid puncture.

the bedside in the intensive care unit with the patient sedated and fully monitored. The patient does not have to be transported to the surgical suite with all the equipment and monitoring systems required for critically ill patients. This is a distinct safety advantage.

At the bedside the patient is placed in the supine position with a blanket roll or pillow positioned beneath the shoulders to extend the neck as much as possible. The skin of the anterior neck is prepped with an antiseptic soap.

Most patients will benefit from intravenous sedation with a narcotic and/or benzodiazepine agent. The procedure is performed under local anesthesia with the drug of choice being lidocaine with epinephrine.

Ideally the procedure involves three clinicians: the physician performing the tracheostomy, a nurse assistant, and a respiratory therapist to manage the airway during the procedure.

Following setup, skin prep, administration of medications, and anesthesia, the airway is prepared by withdrawing the endotracheal tube to the level just below the cords where the cuff is inflated and the airway maintained during the tracheostomy. A large bore needle is inserted into the trachea and a Seldinger-type guide wire is placed into the lumen of the airway. The stoma is then created by passing a series of dilators over the wire and a guiding catheter. The tracheostomy tube is then placed on a obturator/dilator and passed into the trachea. With the removal of the obturator/dilator, the guiding catheter, and the

Per-fit™ percutaneous tracheostomy technique.

 

 

guide wire, the procedure is complete. The average time to perform a percutaneous tracheostomy varies from 3-15 minutes.

Complications of Percutaneous Tracheostomy

As previously mentioned, complications of percutaneous technique are not common but may include false passage of the tracheostomy tube, pneumothorax, delayed bleeding, puncture of the posterior tracheal wall, or premature extubation during the procedure and loss of the airway. A clinical guide and Per-fit video is available for review. Contact customer service or your SIMS Portex Inc. sales representative.