1. Tracheostomy DR. ISA BASUKI DEPARTMENT OF SURGERY AWS GENERAL HOSPITAL FACULTY OF MEDICINE MULAWARMAN UNIVERSITY

2. Etymology and terminology tracheotomy comes from two Greek words the root tom- (from Greek ) meaning "to cutthe word trachea (Greek )Tracheostomy meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itselfDefinition: surgical procedure to bypass the airway in the patient with upper airway obstruction, to make tracheobronchial toliet easier in the patient with decreased consciousness or for need of ventilator installation 3. Indicaton: General to bypass an obstructed upper airway; 2. to clean and remove secretions from the airway; 3. to more easily, and usually more safely, deliver oxygen to the lungs. 1. 4. Indications: Spesific Airway Bypass Severe inflammation of face, neck and larynx Tracheal injury Upper airway tumor Thyroid operation with complication of bleeding or bilateral recurrent nerve paralysis Neck radiotherapy Severe head and neck operating procedures Facial injury with multiple fractureBronchial Toilet Head trauma with consciousness disturbances, uneffective cough Tracheobronchitis with an edema and a lot of secretes Thoracic trauma with uneffective cough Post surgical procedure wtih inadequate coughEasier Ventilation Prolonged ventilator after intubation > 48 hours 5. ContraindicationNocontraindication especially for emergency case 6. Differential DiagnosisForupper airway obstruction: PneumoniaAcidosis 7. Radiologic Examination X-rayof the neck AP/Lateral 8. Anatomy of the Neck lies between the lower margin of the mandible above and the suprasternal notch and the upper border of the clavicle below. In the central region of the neck the respiratory system (the larynx and the trachea), and behind the alimentary system (the pharynx and the esophagus) At the sides of these structures are the vertically running carotid arteries, internal jugular veins, the vagus nerve, and the deep cervical lymph nodes 9. Contd Superficial Fascia thin layer that encloses the platysma muscle embedded in it are the cutaneous nerves, the superficial veins, and the superficial lymph nodesPlatysma a thin but clinically important muscular sheet embedded in the superficial fasciaSuperficial Veins External Jugular VeinTributariesAnterior Jugular Vein 10. Contd Deep Cervical Fascia Investing Layer Pretracheal Layer thin layer that is attached above to the laryngeal cartilages surrounds the thyroid and the parathyroid glands and encloses the infrahyoid musclesPrevertebral Layer thick layer that encircles the neck, splits to enclose the trapezius and the sternocleidomastoid musclesthick layer that passes like a septum across the neck behind the pharynx and the esophagus and in front of the prevertebral muscles and the vertebral columnCarotid Sheath local condensation of the prevertebral, the pretracheal, and the investing layers of the deep fascia that surround the common and internal carotid arteries, the internal jugular vein, the vagus nerve, and the deep cervical lymph nodes 11. SURGICAL ANATOMY 12. Algorithm and Procedures Dyspneu Upper Airway ObstructionPneumoniaChin lift, Jaw Thrust, Oropharyngeal/Nasopharyngeal AirwaySucceedUnsucceedTools not ready yetTools readyCricothyroidotomyTracheostomyAcidosis 13. Pre Operative Informed consent explain about: Operating proceduresLoss of voices when tracheostomy canule still in the tracheaComplication of operationShould be done in the operating theatre as much as possibleAdequate lightningOne assistant requiredTracheostomy set 14. Contd Plastic or metal canule preparation Prophylactic antibiotic: Cefazolin or combination of Clindamycin and Garamycin Anaesthetic preparation: Local or general anasthesia local anasthesia with lidocain (max dose 7 mg/kgBW)Patients position is supine with hyperextension of the head give a cushion below the shoulder trachea will be exposed to the anterior Give the head a doughnut cushion 15. Types of Tracheostomy TubesCuffed Tube with Disposable Inner CannulaCuffed Tube with Reusable Inner CannulaCuffless Tube with Disposable Inner CannulaUsed to obtain a closed circuit for ventilationUsed to obtain a closed circuit for ventilationUsed for patients with tracheal problemsUsed for patients who are ready for decannulation 16. ContdCuffed Tube with Reusable Inner Cannula Used for patients with tracheal problems Used for patients who are ready for decannulationFenestrated Cuffed Tracheostomy TubeFenestrated Cuffless Tracheostomy TubeUsed for patients who are on the ventilator but are not able to tolerate a speaking valve to speakUsed for patients who have difficulty using a speaking valve 17. ContdMetal Tracheostomy Tube Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes. 18. Steps of Procedures 1.Desinfection with povidone - iodine 10% or with Hibitane alcohol 70% at operating area (from lower lips chin neck until ICS 2, left and right until the anterior border of trapezius muscle)2.Operation area is narrowed by sterile linen3.Identification of trachea with palpation, starting from thyroid cartilage to jugular notch4.Perform a local anasthesia with lidocain 1% or 2% injection subcutaneously5.Vertical incision 3-4 cm (emergency case) or horizontal or collar incision (elective case), incision is deepened by cutting subcutis, fascia of neck superficial at the midline on the incision site 19. Contd 6.Hemostasis7.Put Langenbeck to the left and the right, balanced traction to mantain trachea in the midline. If theisthmus of the thyroid gland stand in the way, set aside the isthmus to the caudal and hold it with blunt hook. Identification of trachea, put sharp-one-tooth hook between cricoid and 1st tracheal ring8.Tracheal ring was cut vertically using No. 11 knife blade with a sharp edge facing up and direction of the incision to the cranial (2nd 3rd ring for high tracheostomy; 4th 5th ring for low tracheostomy) 20. Contd 9.Trachea maintained open with a blunt tooth hooks on the right and left side, clean the existing secretions by using a suction cannula and alternating with oxygenation10.secretions were taken for culture and sensitivity test (for diphteria patients)11.Insert the cannula tracheostomy carefully, at the time of inserting the tip, position of the axis perpendicular to the tracheal cannula, after entering surely turn the direction parallel to the axis of the trachea, proceed to thrust according the curve of cannula tracheostomy into the lumen of the trachea. 21. Contd 12.check cannula into the lumen of the trachea, feel the breath of the hole cannula tracheostomy, or use the end of the string that vibrates at the blast of breath13.the whole latch is released, assistant hold the cannula, cannula is fixed with sutures at the right and left lobes of cannula to the skin of the neck and installing a ribbon strap around the neck.14.If the incision is too wide, skin is sutured loosely (dont be too tight: can cause skin emphysem)15.Between cannula lobes and skin, put a sterile gauze cushion 22. Video 23. Complication Intraoperative BleedingReccurent laryngela nerve injury small riskPneumothoraxCricoid cartilage injuryEsophageal perforationTracheoesophageal fistulaVocal cord injury 24. Complication Post Operative Early Bleeding,Infection at operation site,Impaired swallowing function because of tracheostomy cuffSubcutaneous emphysema,Late GranulomaTracheoesophageal fistulaTracheocutaneous fistulaLaryngotracheal stenosis 25. Post Operative Management Observation for the first 24 hoursTreatment for primary diseaseTracheostomy cannula management: Suction of the secrete / hourCleanse the smaller cannula / 6 hoursNebulizer with warm air for 15 minutes /6 hoursTreat tracheostomy wound with gauze replacement every treatment 26. References Boldenham A, Whiteley S. Respiratory Emergencies. In Ellis BW, Brown SP eds. Hamilton Baileys Emergency Surgery 13th ed. Varghese Co. 2000, 43 45.Shires GT, Thal ER, Jones RC. Trauma in Principle of Surgery Schwartz 8th ed. McGraw Hill Inc. 2005, 338 339Cobb JP. Critical care: a system oriented approach. In Norton ed. Surgery Basic Science and Clinical Evidence. Springer, 2001, 282Zollinger, J.R., Ellison, E., 2010. Zollingers Atlas of Surgical Operations, Ninth Edition, 9th ed. McGraw Hill Professional. 27. Thank You