Tracheotomy

Tracheotomy and tracheostomy are surgical procedures on the neck to open a direct airway through an incision in the trachea (the windpipe). They are performed by paramedics, emergency physicians and surgeons.

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Terminology

Tracheotomy, from the Greek root tom- meaning "to cut," refers to the procedure of cutting into the trachea and is an emergency procedure.

A tracheostomy, from the root stom- meaning "mouth," refers to the making of a semipermanent or permanent opening, and to the opening itself.^[1]

Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma at the time it is created.^[2]

Uses of tracheotomy

The conditions in which a tracheotomy may be used are:

• Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors, e.g. branchial cyst, acute inflammation of head and neck, and
• Chronic / elective setting - when there is need for long term mechanical ventilation and tracheal toilet, e.g. comatose patients, surgery to the head and neck.

In emergency settings, in the context of failed endotracheal intubation or where intubation is contraindicated, cricothyroidotomy or mini-tracheostomy may be performed in preference to a tracheostomy.

Tracheotomy procedure

1. Curvilinear skin incision along relaxed skin tension lines (RSTL) between sternal notch and cricoid cartilage.
2. Midline vertical incision dividing strap muscles.
3. Division of thyroid isthmus between ligatures.
4. Elevation of cricoid with cricoid hook.
5. Placement of tracheal incision. An inferior based flap or Björk flap (through second and third tracheal rings) is commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision (pediatric) or excision of an ellipse of anterior tracheal wall.
6. Insert tracheostomy tube (with concomitant withdrawal of endotracheal tube), inflate cuff, secure with tape around neck or stay sutures.
7. Connect ventilator tubing.

It is also possible to make a simple vertical incision between tracheal rings (typically 2nd and 3rd) for the incision. rear end flaps may produce more intratracheal granulation tissue at the site of the incisions, making it less favorable to some surgeons.

Complications

1. Immediate - pneumothorax or pneumomediastinum, tracheoesophageal fistula, injury to great vessels or recurrent laryngeal nerves, bleeding, e.g. from divided thyroid isthmus.
2. Early - secretions and mucus plugging, dislodged tube, respiratory arrest and post obstructive pulmonary edema (when tracheostomy is performed in a patient with longstanding upper airway obstruction, and is dependent on hypoxic drive for respiration).
3. Late - bleeding from tracheoinnominate fistula (can be torrential), tracheal stenosis (from ischemia induced by a cuffed tracheostomy tube), tracheoesophageal fistula, tracheocutaneous fistula and cosmetic deformity must be considered upon decannulation.

Problems

1. Immune problems - air inhaled through a stoma is not filtered or moistened like it is when inhaled through the nose, or even the mouth.
2. Drowning - as little as two teaspoons of water in the stoma can drown the person; therefore, they cannot swim and bathing must be done with extreme care.
3. Suffocation - if the stoma is covered, the person will suffocate, as in some cases they cannot breathe through their nose or their mouth.

See also

• Cricothyroidotomy
• Intubation
• Mechanical ventilation

References