What is a tracheostomy?

A tracheostomy is a surgical procedure where an opening is created through the front of the neck into the trachea so a tube can be inserted to help the patient breathe. If necessary, the tube can be connected to an oxygen supply or a ventilator. Breathing is done through the tracheostomy tube rather than the nose or mouth. The stoma that is created can either be temporary or permanent.

How a tracheostomy is performed:

Percutaneous tracheostomy

The percutaneous tracheostomy is the most frequently performed type of tracheostomy in the intensive care unit. This is because it is simple, quick and can be performed at the bedside with the use of some local anaesthetic.

It utilises a seldinger technique which involves inserting a needle into the trachea, pushing a wire through the needle and then using a series of dilators over the wire making a hole big enough for the insertion of the tracheostomy tube.

All this is aided by the use of a fibreoptic scope down the endotracheal tube to ensure that the needle is entering the trachea. In skilled hands this is a procedure that can be done in under 30 minutes. See below video that demonstrates the percutaneous insertion:

Surgical tracheostomy

A surgical tracheostomy is carried out in an operating theatre using a general anaesthetic. A surgical tracheostomy is usually performed on an intensive care patient who may have difficult neck anatomy, possibly a short, wider neck where the anatomy may be unclear or some vessels which with a percutaneous technique might be difficult to avoid.

See below a surgical tracheostomy insertion video:

Components of the larynx

Legend:

  1. Hyoid bone

  2. Thyroid ligament

  3. Cricoid cartilage

  4. Thyroid cartilage

  5. Tracheal cartilages

Indications for insertion

There are a number of indications for a tracheostomy. Here are some of the most common reasons:

  • Failure to wean from mechanical ventilation.

  • Copious Secretions.

  • Upper airway obstruction.

  • Chronic neuro muscular disorders eg. muscular dystrophy and spinal cord injury.

  • Airway protection for patients that are at risk of aspiration.

Laryngectomy:

A laryngectomy is the surgical removal of the larynx, usually completely and permanently. The trachea is mobilised and detached from the upper airways, then the open end is stitched to the front of the neck. As a result, there is no connection from the nose or mouth to the lungs.

Airway management using the upper airways (facemasks, supraglottic airway devices or oral/nasal intubation) will not work. The only airway that the patient has is on the front of the neck.

 A laryngectomy is usually performed due to cancer of the larynx.

  • Types of tracheostomies

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  • Physiological changes

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