Indications for tracheostomy, technique
Tracheostomy is a surgical procedure to create an artificial opening in the trachea to allow air to enter the respiratory tract through it if this natural process is difficult or stopped. This is not just a hole - a special device (called a “cannula”) is inserted into the trachea or the walls of the trachea are sutured to the skin at the site of the hole.
When a tracheostomy is performed
Every doctor should know the indications, contraindications, and complications of tracheostomy.
Indications for tracheostomy
- airway obstruction that has already developed or is threatening to develop;
- maintenance of respiratory function in patients who are on mechanical ventilation (artificial lung ventilation) for a long time.
Airway obstruction can be
- super-acute - occurs literally in seconds against the background of absolute well-being;
- acute - occurs in a few minutes;
- subacute - develops up to several hours;
- chronic - forms gradually, from several days to several years.
The choice of tracheostomy technique depends on the form of airway obstruction.
Superacute obstruction is diagnosed when the airway is blocked by foreign bodies.
Pathological conditions with acute airway obstruction
- ingestion of foreign bodies into the airways;
- true croup in diphtheria (blockage by accumulation of films);
- Quincke's edema.
Causes of subacute airway obstruction:
- false form of croup;
- laryngeal sore throat;
- chemical burns (the indication for tracheostomy is edema that occurs with such burns).
Diseases and pathological conditions with chronic airway obstruction:
- perichondritis;
- narrowing of the trachea due to scars;
- cancerous lesions of the larynx.
Tracheostomy is used to maintain respiratory function in patients on long-term mechanical ventilation in the following cases
- severe traumatic brain injury;
- Toxic effects of barbiturates;
- various degrees of burn disease.
Types of tracheostomy
According to the level of dissection of the trachea relative to the isthmus of the thyroid gland, there are upper, middle and lower types of tracheostomy.
According to the urgency, tracheostomy can be
- planned - if at this moment the patient's life is not in danger and there is time to prepare for its implementation;
- Urgent - if there is a threat of respiratory failure due to airway obstruction;
- Immediate - if a person is in danger of suffocation due to airway obstruction that occurs unexpectedly.
According to the direction of the tracheal incision, tracheostomy is distinguished:
- longitudinal
- transverse;
- U-shaped (according to the Bjork method).
Adult patients undergo upper tracheostomy, children - lower tracheostomy. The main stages of emergency tracheostomy in newborns are practically the same as in adults. Middle tracheostomy is very rarely practiced.
Necessary tools
A set of instruments for tracheostomy, including tracheostomy tubes (cannulas), should be available in every clinic. In addition to cannulas, it includes
- scalpel
- forceps
- tweezers
- hemostatic clamps;
- scissors
- tracheal dilators;
- hooks
- probes
- catheter
- syringe or aspirator;
- needle holders;
- a set of surgical needles.
The most commonly used tracheostomy cannula is the Luer cannula, which consists of an external and internal tube.
Technique of percutaneous tracheostomy
During the tracheostomy, the patient lies on his back with a roller under his shoulders and his head tilted back. The operation is performed under local or general anesthesia, in emergency cases it is performed without anesthesia.
The technique of percutaneous tracheostomy depends on its type.
Upper tracheostomy technique
A 4-6 cm long tissue incision is made downward from the cricoid cartilage of the larynx, the upper cartilage of the trachea is exposed, and the third (sometimes fourth) cartilage of the trachea is crossed. Respiratory arrest occurs, followed by a sharp cough - only after that a tracheal dilator is inserted, then a tracheostomy cannula is inserted through the wound across the trachea (its shield should be adjacent to the neck), the dilator is removed, the cannula is fixed by fixing it with a bandage around the neck, and the soft tissue wound is sutured.
Lower tracheostomy technique
An incision is made from the cricoid cartilage to the sternum, the trachea is freed from soft tissues, then its fourth and fifth cartilages are cut. Further manipulations are the same as with an upper tracheostomy.
Alternatively, a conicotomy can be performed. Differences between conicotomy and tracheostomy: in the first case, the hole is made in the laryngeal wall, in the second - in the tracheal wall.
Conicotomy technique
The soft tissues are cut along the midline of the neck below the cricoid cartilage, the arch of the cricoid cartilage is crossed, and a clamp is inserted into the wound to expand it so that air can enter the airways.
A doctor must be able to perform a conicotomy under any circumstances. Tissue dissection is performed with any sharp objects at hand; instead of a tracheostomy cannula, any hollow elongated object is inserted - a ballpoint pen “case”, cocktail straw, or a teapot spout from a set.
Errors and complications
Indications for tracheostomy may be urgent. In these cases, tracheostomy is often performed in difficult conditions and its negative consequences can be observed:
- cosmetic defects;
- damage to blood vessels with subsequent bleeding;
- blood leakage into the respiratory tract with subsequent asphyxiation (suffocation);
- injury to the esophagus;
- if the cannula is inserted into the submucosal layer rather than into the tracheal lumen, asphyxia may be aggravated;
- perforation of the posterior wall of the trachea;
- fractures of the tracheal rings;
- subcutaneous emphysema;
- pneumothorax;
- death.
Late complications may also occur:
- purulent tracheobronchitis
- tracheal stenosis;
- tracheal fistula (fistula);
- change in voice;
- rough scars.
On our website Dobrobut.com, you can make an appointment for a consultation with our specialists who will tell you more about tracheostomy - for example, what should be the care after puncture dilatation tracheostomy, what are the long-term consequences of the procedure, etc.
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