Elective Tracheostomy

Indications

  • Long-term ventilation – to reduce dead space, prevent subglottic stenosis and allow bronchial toilet
  • To allow weaning from ventilation (patient does not require sedation)
  • Airway obstruction
  • Very rarely, to protect the airway from aspiration

 

NB Straightforward tracheostomies are increasingly performed using the Seldinger technique on ITUs.  ENT surgeons are, however, asked to perform surgical tracheostomies where the anatomy is less favourable (short, fat necks, overlying vessels).

 

Procedure

A horizontal incision is made midway between the cricoid and the suprasternal notch. The straps are divided in the midline. The thyroid isthmus is identified and divided. Either a square window or a (Bjork) flap is made in the trachea at the level of the third or fourth rings and a tracheostomy tube is inserted and the cuff inflated.  Once ventilation is established, the skin is either closed loosely or left (depending on the size of the incision). The tracheostomy tube is secured with tapes and sutures.

 

Length of procedure

Approximately 40 minutes.

 

Complications

Pain 

Bleeding  May be mild, around the wound, or due to granulation tissue in the trachea, but rarely there can be serious delayed bleeding due to vascular erosion.

Infection  Common – the tracheostomy site requires diligent nursing care.

Airway obstruction  The tube can become blocked by secretions (this is why some have an inner cannula which can be withdrawn in this scenario). See below.

Dislodgement  In the first few days after tracheostomy, this can be catastrophic as the tract is not well-developed – this is why the tracheostomy tube should be double-secured. See below. 

Pneumothorax  The lung apex can be higher than expected – however this is rare.

Recurrent laryngeal nerve injury  If the surgeon is careful to stay in the midline, this should really not occur.  Some surgeons do not consent for this.

Persistent tracheocutanous fistula  The tract may fail to heal soon after removal of the tube – however this resolves with occlusive dressings and conservative management in the vast majority of cases.

 

Post-operative management

NBTracheostomy care is a large topic and is only covered briefly.  

  • The patient must be cared for by nurses experienced in tracheostomy care.
  • The tracheostomy tube inserted initially should have an inner cannula, and be suctioned regularly. The patient should have warmed, humidified oxygen with intermittent nebulised saline. This is to prevent mucus plug occlusion, which is a particular problem in the initial week or two.

 

Tube obstruction or dislodgement/loss of airway

  • Preparation is key. You should always have: 
    • A plan for emergencies 
    • One or more spare tubes at the bedside
    • Tracheal dilators
    • Working suction with assorted catheters
    • Oxygen: tracheostomy and face masks
    • A good light, ideally a headlight
    • Visor-face masks for your protection
    • The airway/crash trolley nearby including gum elastic bougie  
  • Tube dislodgement does happen. If this occurs, lie the patient flat with their neck extended as far as possible. Use the tracheal dilators to part the soft tissue overlying the tracheostomy, suction and insert a new tube and inflate the cuff. Have an assistant call a senior ENT surgeon and the anaesthetist immediately.
  • If there is obstruction of the tube, use a suction cannula to remove secretions or plugs.  If there is blockage, remove the inner cannula. If this doesn’t work, call a senior ENT surgeon and the anaesthetist immediately. Consider deflating the cuff – if the patient does not have upper airway obstruction this may improve the airway. To assess further you can pass a flexible nasendoscope into the tube. Occasionally, partial dislodgement can result in the tip of the tube lying in the soft tissues – the tube may need to be re-sited or advanced (this should be performed carefully to avoid creating a false passage).
  • If, as in most cases, tracheostomy is not done for airway obstruction do not forget that oronasal intubation is still possible if the tracheostomy tube cannot be reinserted.

 

 

 

 Page last reviewed: 23 September 2016