Tracheostomy and Other Procedures for Airway Management

Definition: Making an opening in the anterior wall of the trachea and converting it into a stoma on the skin surface.

*Differentiation: Tracheotomy is the act of opening the trachea (a step), whereas Tracheostomy is the outcome (stoma).

Functions

• Bypass Obstruction: Alternative pathway for breathing.
• IPPR: Superior to intubation if required for > 72 hours.
• Anaesthesia Delivery: When intubation is impossible (Trismus, Laryngopharyngeal growth).

Indications

Category	Examples
1. Respiratory Obstruction	Infections: Ludwig's angina, Acute epiglottitis, Diphtheria. Trauma: External injury, Maxillofacial fractures. Neoplasms: Carcinoma Larynx. Congenital: Laryngeal web, Choanal atresia. Other: Bilateral abductor paralysis, Foreign body.
2. Retained Secretions	Inability to cough: Coma, Head injury, Stroke. Muscle Paralysis: GBS, Polio, Myasthenia Gravis. Painful Cough: Chest injuries, Abdominal surgery.
3. Respiratory Insufficiency	Chronic lung conditions (Emphysema, Bronchitis, Bronchiectasis).

Types & Classification

A. Based on Urgency

• Emergency: Urgent airway needed; obstruction complete/near complete.
• Elective (Tranquil): Planned procedure.
  • Therapeutic: To relieve obstruction/secretions.
  • Prophylactic: Before major surgery (e.g., Mandibular resection).
• Permanent: e.g., Laryngectomy, Bilateral abductor paralysis.
• Others: Percutaneous dilatational, Mini tracheostomy.

B. Based on Site (Tracheal Level)

Ideally done below the Cricoid Cartilage.

• High Tracheostomy (Above Isthmus): Violates 1st ring. AVOIDED (Risk of Perichondritis & Stenosis). Only used in Ca Larynx.
• Mid Tracheostomy (Behind Isthmus): PREFERRED. Through 2nd or 3rd ring. Isthmus is retracted or divided.
• Low Tracheostomy (Below Isthmus): Difficult; trachea is deep and close to large vessels. Tube may impinge on suprasternal notch.

Surgical Technique

Pre-requisites

• Intubation: Should be done first if possible (esp. children).
• Position: Supine with pillow under shoulders (Neck Extended). Brings trachea forward.
• Anaesthesia: None (Emergency/Unconscious) OR Local (1-2% Lignocaine + Epinephrine).

Steps of Operation

Tracheostomy in Infants & Children

Common Indications by Age Group

Age Group & Etiology	Specific Conditions
Infants (< 1 Year) Mostly Congenital Lesions	Subglottic Haemangioma Subglottic Stenosis Laryngeal Cyst Glottic Web Bilateral Vocal Cord Paralysis
Children Mostly Inflammatory or Traumatic	Infections: Acute Laryngo-tracheo-bronchitis, Epiglottitis, Diphtheria. Trauma: External laryngeal trauma, Prolonged intubation. Oedema: Chemical or Thermal injury. Neoplastic: Juvenile Laryngeal Papillomatosis.

Surgical Guidelines (The Golden Rules)

• Anaesthesia: Preferably General Anaesthesia (GA).
• Identification: Trachea is soft/hard to find. Insert an Endotracheal tube or Bronchoscope beforehand to define the trachea and prevent injury to RLN or Carotid.
• Positioning: Do NOT extend the neck too much.
  • Risk: Pulls pleura/thymus into neck → Injury (Pneumothorax) or placing stoma too low.
• Incision:
  • Stay Sutures: Place silk sutures on either side of midline before incising (helps in tube re-insertion if displaced).
  • Technique: Simple vertical incision. NO excision of tracheal wall (unlike adults).
  • Depth: Don't go deep! Risk of injury to Oesophagus (Tracheo-oesophageal fistula).
• Tube Selection: Use soft Silastic or Portex tubes (Metal causes trauma). Avoid long tubes (hit carina).
• Post-op: Check X-ray for tube position.

Postoperative Care

1. Suction & Supervision

• Constant Supervision: Risk of blocking/displacement. Patient needs a bell/paper to communicate.
• Suction Technique:
  • Use sterile catheter with Y-connector.
  • CRITICAL: Apply suction ONLY when withdrawing the catheter. Suction during insertion damages mucosa.

2. Humidification (Preventing Crusting)

• Use Steam tent / Ultrasonic nebulizer.
• If crusting occurs: Instill drops of Normal Saline / Ringer's Lactate or Acetylcysteine (Mucolytic) into trachea every 2-3 hours.

3. Decannulation

Removal of the tube when indication ceases. Prolonged use leads to stenosis/infection.

Complications of Tracheostomy

Timing	Complications
Immediate (At operation)	Haemorrhage Pneumothorax: Injury to apical pleura (common in children). Injury to RLN Injury to Oesophagus: Causes TE Fistula. Apnoea: Sudden washout of CO2 removes respiratory drive. Rx: 5% CO2 in O2.
Intermediate (Hours to Days)	Tube Displacement / Blocking (Commonest cause of death). Subcutaneous Emphysema: If wound sutured too tight. Lung Abscess / Atelectasis Tracheitis / Crusting
Late (Weeks to Months)	Laryngeal/Tracheal Stenosis: Perichondritis or scarring. Tracheo-Oesophageal Fistula: Erosion by cuff or tip. Difficult Decannulation Keloid Scar

Scenario: Severe obstruction allowing no time for an orderly tracheostomy. Immediate intervention is required.

1. Non-Invasive Measures

• Jaw Thrust: Lifting jaw forward to displace soft tissues.
  • Warning: Avoid neck extension in spinal injuries.
• Oropharyngeal Airway: Displaces tongue anteriorly. Used with face mask/Ambu bag.
• Nasopharyngeal Airway (Trumpet):
  • Inserted transnasally to posterior hypopharynx.
  • Better tolerated in awake patients than oral airway.
• Laryngeal Mask Airway (LMA):
  • Fits over laryngeal inlet. Delivers O2 directly to trachea.
  • Use: Rescue device when standard mask/intubation fails.

2. Invasive "Bridging" Procedures

A. Transtracheal Jet Ventilation

• Procedure: 12 or 14 Gauge IV catheter inserted into Cricothyroid membrane (directed caudally).
• Ventilation: Jet ventilation attached.
• Crucial Step: Ensure Expiration of air to prevent Barotrauma (Pneumothorax, Surgical Emphysema).

B. Endotracheal Intubation (Fastest)

• Gold Standard: Most rapid method. No anaesthesia required in emergency.
• Benefit: Converts a "Hurried, dangerous" tracheostomy into an "Orderly" one.

C. Cricothyrotomy (Laryngotomy / Mini Trach)

Opening the airway through the Cricothyroid membrane (Space between Thyroid and Cricoid cartilages).

D. Emergency Tracheostomy

• Technique: Rapid vertical incision from thyroid to sternal notch. Trachea fixed by hand. Incision in 2nd/3rd rings.
• Haemostasis: Often achieved by packing due to lack of time.
• Risk: High complication rate (poor lighting, struggling patient). Intubation is always preferred first.

Setting: ICU (Bedside). Patient is already intubated and sedated.

Technique: Seldinger technique (Needle → Guide Wire → Dilators) usually under Bronchoscopic Guidance to ensure midline entry.

Advantages vs. Contraindications

Advantages	Contraindications (Avoid In)
No OT expenses/transport needed. Avoids nosocomial infection (from OT). Earlier discharge.	Children (< 12 years). Obesity / Short neck. Neck masses (Thyromegaly). Uncorrectable Coagulopathy. Difficult landmarks.

Complications

• Paratracheal entry: False passage (Dilator/Tube enters tissue, not trachea).
• Damage to Posterior Tracheal Wall: Perforation.
• Surgical Emphysema.
• Haemorrhage.