Tracheostomy

Preparation

• Review indications and imaging
• Consent patient
• GA, ivabx
• Position supine on shoulder roll with head ring, neck + head extended
• Mark thyroid and cricoid cartilages, midline, suprasternal notch

Surgery

• Horizontal incision over trachea
• Raise subplatysmal flaps and retract with 2x Joll’s retractors
• Separate straps in midline
• Divide isthmus of thyroid and ligate with 3-0 vicryl
• Identify 2nd and 3rd tracheal rings
• Ask anaesthetics to turn down O2 as much as possible and deflate ETT balloon
• Type
  • Bjork flap
    • Incise tracheal rings vertically and horizontal above to raise inferior Bjork flap
      • hold up and open with a hook retractor.
    • Suture flap to skin with silk sutures
  • Window
    • Incise tracheal rings vertically and horizontal over the 2-3 tracheal ring
    • Use scissors to complete the excision of the window
• Ask anaesthesia to withdraw ETT until end can be seen just above level of tracheotomy
• Immediately place tracheostomy tube with obturator
• Inflate cuff, and swap ventilator tubing onto tube
• Check misting + CO2
• Haemostasis
• Layered closure with absorbable sutures, suture tracheostomy cuff to neck and secure with tie around neck

Postop

• Confirm adequacy of ventilation by checking CO2, chest rise, auscultate

• Haemostasis

• Regular suction

• Plan for trache removal/permanence

• Indications for Surgical Airway in trauma

  • Laryngeal #
  • Penetrating throat and neck injuries
  • Severe maxfax injuries with bleeding, deformity, oedema
  • Airway burns/inhalation injuries
  • Can’t intubate can’t ventilate

• Complications

• Immediate complications

  • Airway loss
  • Bleeding
    • Can be anterior jugular, carotid, IJV, innominate, isthmus of the thyroid.
  • Air leak
    • subcutaneous emphysema
  • Tube falling ou

• Late complications

  • Lack of spontaneous closure or healing of the tracheostomy once it’s removed
    • Requiring surgical repair
  • Infection
  • Scarring
  • Erode into large veins
    • Inominate vein
      • Can have herald bleed just prior to life-threatening hemorrhage.
      • Iinsert a gloved finger into the tracheostomy stoma and occlude the vessel against the sternum and call for help.
  • Tracheosophageal fistula
  • Tracheal stenosis.