This is an artificial opening into the trachea through the neck in order to bypass an obstruction of the airway and/or to provide access to the lower airway to facilitate ventilatory support. This procedure should only be performed at level 4 and above.
Indications for this procedure include:
- Emergency tracheostomy: Foreign bodies (in the upper airway), maxillofacial trauma(patient cannot breath and endotracheal intubation impossible), inflammatory conditions such as epiglottis, Ludwig’s angina, retropharyngeal and other oropharyngeal abscesses with respiratory obstruction, tumours of head and neck with acute obstruction to airway (due to oedema, bleeding, infection, etc.).
- Elective tracheostomy (ventilation likely to continue for more than 2 weeks): Surgery for tumours of head and neck, major reconstructive facial surgery, prolonged ventilatory support surgery, e.g., in flail chest, acute respiratory distress syndrome, pneumonia, Guillain -Barre syndrome.
Methods
- In case of complete acute upper respiratory tract obstruction:
- Give oxygen through a big bore needle or a cannula inserted through cricothyroid membrane (Cricothyrotomy).
- Quickly extend the neck over a rolled up towel or pillow.
- Feel for the cricoid prominence (Adam’s apple) and the depression just distal to its membrane.
- Insert a big bore needle or cannula to the trachea (with or without local anaesthesia depending on circumstances).
- Tracheostomy technique:
- Ideally performed in theater, with patients properly cleaned and draped.
- Position patient supine with neck extended over a pillow and head stabilized in tracheostomy position.
- Anaesthesia:
- General anaesthesia through a tracheal tube if possible.
- Local anaesthesia (lignocaine 1% with adrenaline), in extreme circumstances.
- Incision and fixing of endotracheal tube:
- Transverse incision, 2cm below the upper angle of cricoid cartilage. Incision made through the skin, subcutaneous fat, and deep cervical fascia.
- Blunt dissection, then expose the anterior jugular vein, infrahyoid muscles and occasionally thyroid isthmus (which should be ligated and divided).
- A cruciate incision or a circular window is then made through the third and fourth tracheal rings.
- A tracheostomy, endotracheal, or other tube is then inserted.
- The skin incision is closed loosely around thye tube.
- Fix the tube securely with well tied tapes.
Tracheostomy Care: What You Need To Know About This Life-Saving Procedure
NB: Use as short a time as possible through this simple procedure. Humidification of the gases/air and frequent section through the tub must be done. When a clear passageway has been established and ventilation restored, refer the patient. For continued care of the tracheostomy, decannulation, etc., refer to tracheostomy for more details