ANATOMY OF TRACHEA

INDICATIONS & COMPLICATIONS OF TRACHEOSTOMY

Moderator:- Dr.VivekStudent:- Dr.Imran

Trachea

Trachea lies in midline of the neck

Cricoid cartilage (C6) to the tracheal bifurcation at the level of sternal angle (T5).

As it passes downwards, it follows the curvature of the spine, and courses slightly backward.

Near the tracheal bifurcation, it deviates slightly to the right.

General Characteristics Length: 9-15 cm

Outer diameter: 21-27 mm

Internal diameter: 12-18 mm

Distance infracricoid-carina about 11 cm

18-22 C-shaped cartilaginous rings

In adults the cartilages are 3 to 5 mm wide and up to 2mm thick.

There are 2.1 rings/cm.

Becomes intra-thoracic at 6th cartilaginous ring.

Intra-thoracic portion: 6-15 cm.

Cross-section area of women about 40% less than men.

Annular Ligament – bet. two rings.

Crico-tracheal ligament –upper end of trachea with the lower border of cricoid.

Larynx move up and down along with the larynxduring respiration and swallowing.

Trachealis muscle overlies esophageal muscle & forma the posterior wall of trachea.

The membranous posterior membrane allows esophageal expansion during deglutition

Contains glands, small arteries, nerves, lymph vessels and elastic fibers

Trachealis muscle overlies esophageal muscle and epithelium

Mucous membrane of trachea

Continuous with larynx

Pinkish in color

Stratified ciliated columnar in character

Mucous glands, ciliary epithelium & muscle fibers promotes moistening, cleansing of the contaminated air and liquefaction and expectoration of the sputum.

Tracheal dimensions

Average cross-sectional area of the male adult trachea is approximately 2.8 cm2

Transverse (lateral) diameter of 25 mm and sagittal (anteroposterior) diameter of 27 mm are the upper limits of normal (males)

The lower limit of normal for both transverse and sagittal diameters is about 13 mm in men and 10 mm in women

Morphologic normal variants

U-shaped trachea (27%)

C-shaped trachea (49%)

Tracheal morphologiesA saber-sheath or scabbard trachea is. The saber sheath trachea has been described in up to 5 % of elderly men.

Women - round configuration

Men - sagittal widening and transverse narrowing.

Saber-sheath trachea

Tracheal Index (TI) defined as (transverse/saggital diameter)<0.6

12% of elderly men with COPD.

Tracheal appearances

A

B

C

D

E

F

Saber sheath Dynamic collapse Crescent shape collapse

Normal shape Expansion during inhalation Circumferential collapse

Tracheal RelationshipsCervical Thoracic

Anterior Posterior LateralSkinSup. & Deep facia

Esophagus 2 Lateral lobes of Thyroid

Strap musclesSternocleidomastoidSternohyoidSternothyroid

Recurrnent Laryngeal Nerves

Comman Carotid Artery

Isthmus of Thyroid Prevertebralfascia

Internal Jugalar VeinVagus

Inferior Thyroid VeinThyroidea Ima Artery<10%

Omohyoid

Pre-tracheal faciaPlexus Thyroideus Impar

External jugularvein

Cervical Trachea

Anterior Posterior Lateral

Thymus Gland Esophagus VagusPhrenic Nerves

Left Branchiocephalic Vein

Recurrnent Laryngeal Nerves

Superiorvena cava antero-laterally on right side

Arch of Aorta Prevertebralfascia

Lungs covered by PleuraThe left common carotid and left subclavian arteries

ThoracicDuct on left sideAzygos vein on right side

Thoracic Trachea

Cervical Tracheal Relationships Esophagus lies

Posterior Note Trachealis

muscle

Cervical Tracheal Relationships-Posterior

Esophagus Recurrent

Laryngeal Nerves

18

Cervical Tracheal Relationships-Anterior

SkinSuperficial & Deep fascia.

2nd to the 4thrings are covered by the isthmus of the thyroid.

Cervical Tracheal Relationships-Anterior

Inferior Thyroid Veins Thyroidea Ima

Artery->10% Pretrachal Fascia

invests Trachea Thyroid Gland Larynx

Cervical Tracheal Relationships-Anterior

Note: Thyroidea Ima Vein Plexus Thyroideus

Impar

Cervical Tracheal Relationships-Lateral 2 Lateral

Lobes-Thyroid Gland

Cervical Tracheal Relationships-Lateral Carotid Sheath

and Contents Common

Carotid Artery Internal Jugular

Vein Vagus Nerve

Anterolateral View

Cervical Tracheal Relationships-Lateral Carotid Sheath

and Contents Internal Jugular

Vein (Lateral) Common

Carotid Artery (Medial)

Vagus Nerve (Posterior)

Posterior View

Tracheal Relationships

Thoracic

Thoracic Tracheal Relationships-Anterior

Thymus Gland (or Thymic Remnant in adults)

Thoracic TrachealRelationships-Anterior-Thymic Remnant Removed

Left Brachiocephalic Vein

Aortic Arch

Thoracic TrachealRelationships-Lateral

Vagus Nerves Phrenic Nerves Lungs covered by

Pleura

Trachea-Nerve Supply

• General Sensation- Vagus & Recurrent Laryngeal Nerves

Autonomic InnervationSympathetic-Decreases Secretions(T1,T2)

Parasympathetic-Increases Secretions(Vagus)

Trachea-Blood Supply

Inferior Thyroid Arteries- Cervical Portion

Bronchial Arteries- Thoracic Portion

Venous drainage & Lymphatics

Venous plexuses situated around trachea and oesophagus ultimately drain into inferior thyroid venous plexus.

lymph nodes located around trachea, the brachio-cephalic and right common carotid arteries.

Indications & Complications of Tracheostomy

What is “Tracheostomy”

The word “tracheostomy” is derived from the Latin “trachea” and “tomein” (to make an opening).

Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea .

What is this & what are its indications ???

Answer at the end of presentation

HISTORY

Tracheostomy is one of the oldest surgical procedures.

A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC.

Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC.

The first successful tracheostomy was performed by Brasovala in the 15th century. 

1932 to prevent pulmonary infection in neurologically impair patients secondary to infections (poliomyelitis).

1943 to remove bronchial secretions in cases of myasthenia gravis and tetanus.

1951 to reduce the volume of dead space, use in COPD and severe penumonia.

1950 positive pressure through tracheostomy for patients with poliomyelitis.

1955 obstruction secondary to infection: diphteria, Ludwig’s angina.

1961 Obstructions secondary to tumour, infectious disease and trauma.

Tracheotomy Indications To bypass obstruction

Tracheotomy IndicationsProlonged intubation

- Need for prolonged respiratory support, such as in Bronchopulmonary Dysplasia

- To reduce anatomic dead space and increase the chance for mechanical ventilation withdrawal

- To improve the patient`s quality of life (easier toilet, ability to speak and eat, increase the mobility)

- Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm

PROTECTION of AIRWAY Neurological Diseases(Polyneuritis, GBS) Coma (GCS<8, risk of aspiration)

Elective Tracheostomy as Adjunct to H&N surgeries <14 days on ETT(relative) >21 days on ETT

Tracheotomy IndicationsMiscellaneous

-Congenital abnormalities. (Pierre Robin, Triecher Collins syndromes)

- Obstructive Sleep Apnea Syndrome.

- Aspirations related to muscle or sensory problems.

-Prophylaxis (as preparation for extensive H&N procedures, before radiotherapy for H&N CA)

-Cervical spinal cord injuries with respiratory muscles paralysis.

Contraindications No absolute contraindications exist to

tracheostomy

RELATIVE Laryngeal CA(strong)

it may lead to increased incidence of stomal recurrence(a diffuse infiltrate of neoplastic

tissue at the junction of the amputated trachea and skin )

Preoperative workup

Physical assessment also surgical and anesthesiological

CBC

PT, PTT, INR

Patient/apotropus confirmation

Types of Tracheostomy

1) Open procedure a) High tracheostomy

(Cricothyroidectomy) b) Low tracheostomy

2) Percutaneous procedure

High tracheostomy (Cricothyroidectomy)

Cricothyroid membrane

Crycoid cartilageThyroid cartilage

Landmark

Emergency Cricothyrotomy Protocol

Indications:hA patient that requires intubation and Unable to intubate and Unable to adequately ventilate

Conditions:hPatient 40 kg and 12 years old

Contraindications:hSuspected fractured larynxhInability to localize the cricothyroid membrane

Techniques

1) Seldinger (Melker) Cricothyrotomy

2) Needle Cricothyrotomy

Low Tracheostomy

Skin Prep with povidine iodine, chlorohexidine(savlon)

Draping

Good light source and suction machine ready and tested to be functional

Transverse Incision

Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch.

Incision length=6cm/ anterior border of SCM msc lateral

Blunt dissection of subcut tissue

Transversely

Retracted as shown

Strap msc is divided longitudinally at midline

Thyroid ismuth is divided at midline by 2 haemostat and cut edge secured by 2/0 vicryl

Depending on the TT size abt 4cm longitudinal opening is made in trachea below 2nd ring

Tube is anchored

Percutaneous Dilational Tracheostomy

Benefits include elimination of need for operating room use or anesthesia, and significant reduction in cost.Should be done in carefully selected patients

Under fiber optic control

To be ready to switch to open procedure

Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin.[

Guidewire introduction, with removal of sheath

PERCUTANEOUS DILATIONAL TRACHEOTOMY

PERCUTANEOUS DILATIONAL TRACHEOTOMY

Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark

PERCUTANEOUS DILATIONAL TRACHEOTOMY

The tracheotomy tube is loaded onto a dilator and advanced into the trachea over the guidewire and catheter. The guidewire and catheter are removed, leaving only the tracheostomy tube in the trachea

Post-Op Managment

PCV check(pressure controlled ventilation)

Repeat X-Ray soft tissue neck

Strong Analgesia

Antibiotics

IV fluid until able to tolerate orally

Risk factors for complications

Age: infants and adults over 75

Obesity

Smoking

Poor nutrition

Recent illness, especially an upper-respiratory infection

Alcoholism

Chronic illness

Diabetes

Complicationsimmediate

Apnea due to loss of hypoxic respiratory drive. This is mainly important in the awake patient. Ventilatory support must be available.

False root Bleeding

Pneumothorax or pneumomediastinum

Complicationsimmediate

Damage to the vocal cords (direct) Injury to adjacent structures: recurrent

laryngeal nerves, the great vessels, and the esophagus.

Post-obstructive pulmonary edema Hypotension Arrhythmia

Complicationsearly

Early bleeding: This is usually the result of increased blood pressure as the patient emerges from anesthesia and begins to cough.

Plugging with mucus Tracheitis Cellulitis Tube displacement Subcutaneous emphysema Atelectasis

Complicationslate

Bleeding - tracheoinnominate fistula Tracheo- and laryngomalacia Stenosis Tracheoesophageal fistula Tracheocutaneous fistula Granulation Scarring Failure to decannulate

TRACHEOSTOMY

TUBE CARE Tube changes:

Indications: soiled, cuff rupture. Complications: insertion into a false

passage bleeding, and patient discomfort. Avoid within 1st week. First tube change by surgeon. Difficult cases (obese, short and thick neck),

be prepared for endotracheal intubation.

TRACHEOSTOMY TUBE CARE Tracheostomy tube cuff pressures ---20 to 25

mm Hg.

Overly low cuff pressures < 18 mm Hg, may cause the cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia.

Excessively high cuff pressures above 25 to 35 mm Hg exceed capillary perfusion pressure and can result in compression of mucosal capillaries, which promotes mucosal ischemia and tracheal stenosis.

Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube.

TRACHEOSTOMY TUBE CARE

Humidification of the inspired gas is a standard of care for tracheostomized patients.

Thermovent

•  Secretions in the trach

•  Suspected aspiration of gastric or upper airway secretions

•  Increase in peak airway pressures when on ventilator

•  Increase in respirations or sustained cough or both

•  Gradual or sudden decrease in ABG

•  Sudden onset of respiratory distress when airway patency is questioned

Indications For Suctioning

Tube exchange After the track is formed – 4-5 days

after the operation.

Rate of exchange depends on clinical situation of the specific patient – type of discharge, type of tube, medical status, age..

Usually every 14 days.

Should be done by experienced staff.

Types of tubes

Cuffed and uncuffed

Fenestrated and unfenestrated

Single and double lumen

Various diameters

Cuffs To protect airway

To allow ventilation

Uncuffed Cuffed

Fenestrated

Allow patient to ventilate past tube via upper airway

Allow speech

Single/Double lumen

Double lumen allows easy cleaning

Single lumen has a greater internal diameter

Montgomery T-TubeBivona Fome-Cuff Tracheaostomy Tube

Single Cannular Shiley Pediatric TT

Other Types of Tubes

SPEECH

SPEECHTracheostomy Speaking Valve

Passy-Muir

A tracheostomy speaking valve is a one-way valve, allows air in, but not outforces air around the tracheostomy tube, through the vocal cords and out the mouth upon expiration, enabling the patient to vocalize

NUTRITION Tracheostomy tube prevents normal upward

movement of the larynx during swallowing and hinders glottic closure.

Between 20% and 70% of patients with a chronic tracheostomy experience at least one episode of aspiration every 48 hours

Keep head elevated to 45° during periods of tube feeding

Decanulationwhen?

Resolution of pathology that necessitated the tracheotomy (upper airway obstruction, pneumonia)

Normal protective laryngeal mechanisms (no aspirations during normal swallowing, good coughing)

No planed further interventions (radiotherapy, H&N operations)

No mechanical ventilation

Answer

Jackson’s tracheostomy

Fuller’s tracheostomy tube