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Tracheotomy is a surgical procedure used to cut a hole in the trachea through which a small tube is inserted.
Indications for Tracheotomy
The indicationsfor Tracheotomy are as follows :
1. Acute setting - maxillofacial injuries, large tumors of the head and neck, congenital tumors e.g. branchial cyst, acute inflammation of head and neck
2. 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 emergent settings, in the context of failed endotracheal intubation or where intubation is contraindicated, cricothyrodotomy or mini-tracheostomy may be performed in preference to a tracheostomy.
How to Perform a Tracheostomy
- Curvilinear skin incision along relaxed skin tension lines (RSTL) between sternal notch and cricoid cartilage
- Midline vertical incision dividing strap muscles
- Division of thyroid isthmus between ligatures
- Elevation of cricoid with cricoid hook
- Placement of tracheal incision. An inferior based flap or Bjork flap (through 2nd and 3rd 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.
- Insert tracheostomy tube (with concomitant withdrawal of endotracheal tube), inflate cuff, secure with tape around neck or stay sutures.
- Connect ventilator tubing
Complications of Tracheostomy
- 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 & mucus plugging, disloged tube, respiratory arrest and post obstructive pulmonary edema (when tracheostomy is performed in a patient with longstanding upper airway obstruction, and is dependant on hypoxia drive for respiration)
- 3. Late - Bleeding from tracheoinnominate fistula (can be torrential), tracheal stenosis (from ischemia induced by a cuffed tracheostomy tube)
See also
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