TRACHEOSTOMY is the opening in the anterior wall of the trachea through which the tracheostomy tube is inserted. It allows you to breathe freely, bypassing the upper respiratory tract. The surgical procedure to create a tracheoSTOMY is called a tracheoTOMY. It can be a pre-planned procedure or it can be performed suddenly in order to save life.

Tracheostomyand considerations about it appeared even before our era. Asclepiades believed that in the case of a suffocating patient, time is of the essence and one should cut the trachea below the sick place as soon as possible with a firm hand. This procedure was also performed by Areteus from Cappadocia in the 1st century. On the other hand, the first detailed description of the tracheotomy procedure was made by Paweł of Aegina. It should be remembered that these were times when no one even heard about the principles of asepsis, so most tracheotomies ended in the patient's death. In the Middle Ages, when the development of medicine was actually standing still, tracheotomy was abandoned. It was believed that cutting the trachea was a punishment for sins, and was put on a par with cutting off the head or limbs. During the Renaissance, attention was drawn to the subject again. Paris surgeon Nicolas Habicot, an ardent supporter of the use of tracheotomy, wrote even a 108-page monograph describing: indications, technique and tools for the procedure. In the 18th century it was noticed that tracheotomy was of particular importance in the case of drowned and suffocated people. The discovery and description of the ligament of the thyroid gland by Morgagni allowed for the modification of the tracheotomy technique and a significant reduction of bleeding complications. In the 19th century, Trousseau constructed a tracheostomy tube and a dilator for a cut trachea, which is still used today. Until now, upper tracheotomy has been performed, while Trousseau introduced lower tracheotomy. Unfortunately, due to anatomical conditions, such a location resulted in the risk of bleeding from large vessels during the procedure or as a result of pressure ulcers caused by compression of the tube. Malgaigne proposed a middle tracheotomy after cutting the ligament of the thyroid gland. Tracheal stenosis was a frequent complication. The recipe for this was to be a model of a fireplace pipe introduced by Pieniazek.

Tracheostomy: division

Due to the patient's hypoxia, the following are distinguished:

  • sudden (urgent) tracheostomy - the patient is suffocating and the tracheotomy must be performedimmediately to save life
  • planned tracheostomy - the patient breathes well (or relatively well), so it is time to perform the tracheotomy

Division by tracheostomy location:

  1. upper dissection of the trachea (tracheotomy superior) - above the ligament of the thyroid gland
  2. medial dissection of the trachea (tracheotomy media) - in the ligament of the thyroid gland
  3. lower dissection of the trachea (tracheotomy interior) - below the ligament of the thyroid gland

Tracheostomy: indications

Tracheostomy as part of elective tracheotomy is performed on patients who require long-term ventilation and a restroom of the trachea, e.g. before major neurosurgery or neck and thoracic surgery. During extensive procedures within the throat and larynx, it protects against bleeding into the lower respiratory tract. In patients with inoperable laryngeal neoplasms undergoing radiotherapy, a tracheostomy is performed to protect against shortness of breath. Increasingly, in such patients, instead of intubation, a tracheostomy is chosen. Benefits of a tracheostomy compared to an endotracheal tube:

  • reduction of breathing effort associated with self-breathing
  • reducing the need for analgesic and sedative drugs needed to achieve Tracheal Tube tolerance
  • simplification of hygiene procedures in the area of ​​the mouth and throat
  • improving the patient's own comfort
  • facilitating communication with the patient

Although it seems like an extreme therapy now, tracheotomy has been performed on patients with severe obstructive sleep apnea (OSA). Fortunately, in the 1980s, Colin Sullivan introduced the first non-invasive method of OSA treatment using positive airway pressure, the so-called CEPAP, which today is the basis in the treatment of this disease. The main indication for short-term tracheotomy is the state of sudden laryngeal dyspnea, which may be the result of: laryngeal edema, a wedged foreign body, neoplastic tumors or injuries narrowing its lumen. Other indications include: dyspnoea of ​​central origin, intoxication with sleeping pills, a foreign body in the lower respiratory tract that cannot be removed by tracheobronchoscopy.

Perform a tracheostomy

In the case of elective tracheotomy, premedication with drugs and oxygen can be administered. Due to time pressure, in urgent cases, drugs are abandoned, but oxygen administration is necessary: ​​oxygen shower, through an endotracheal or bronchoscopic tube before and afterduring the procedure.

For the best visibility of the larynx, the patient is placed on his back and the head is tilted back. Depending on whether or not time allows, anesthesia may be used. Usually, local infiltration anesthesia is sufficient. The exceptions are small children for whom mixed anesthesia is indicated.

Rapid opening of the airways can be achieved by:

  • CICOTOMY - involves cutting the cricothyroid ligament within the larynx, so it is not actually a tracheotomy, but is usually an introduction to upper, middle or lower tracheotomy
  • INTUBATION followed by TRACHEOTOMY - it is possible when the obstacle is below the glottis; the endotracheal tube allows for the suction of secretions, improves lung ventilation and allows for controlled breathing
  • TRACHEOPRONCHOSCOPY followed by TRACHEOTOMY

In elective mode, an upper, middle or lower tracheotomy is performed. The choice of method depends on the anatomical conditions. In children, the larynx and trachea are higher than in adults. With age, the larynx and trachea, along with the bronchi and lungs, move downwards. That is why the upper cut is performed in adults and the lower cut in children.

Tracheotomy process:

  • skin incision in the midline from the upper edge of the cricoid approximately 5-6 cm downwards; in cosmetic terms, the cross cut is more favorable, but requires more operator experience
  • fascia cut
  • hooking the trachea - maneuvering technique is important to avoid cutting the back wall of the trachea and esophagus, which can lead to a tracheoesophageal fistula
  • thyroid dissection
  • dissection of the trachea - sudden opening of the trachea stimulates the patient from coughing; in the case of an conscious patient, he exposes the secretion himself, while in an unconscious or undergoing general anesthesia, the secretion should be suctioned
  • tracheal window excision - should be performed on adult patients who are going to wear the tracheotomy tube for a longer period or permanently
  • possible tracheobronchoscopy
  • tube insertion
  • wound closure

Factors that make tracheotomy difficult

  • short and thick neck
  • thyroid gland hypertrophy
  • defects of the cervical and thoracic spine
  • inflammatory infiltration of the anterior wall of the neck
  • subcutaneous emphysema
  • extensive crushing wounds to the neck

Management of the patient withtracheostomy

Proper patient care is very important. Care should be taken to maintain the patency of the tracheostomy tube and the tracheobronchial tree, and to provide the patient with adequate pulmonary ventilation. Recommended:

  • frequent suctioning of secretions from the respiratory tract, if necessary, even once every 20-30 minutes, especially when the patient cannot cough up himself
  • bronchial flushing in cases of thick discharge forming plugs; this operation can be performed during bronchoscopy by injecting 4-5 ml of saline solution, 3% baking soda solution or one of the agents reducing the surface tension of the secretions
  • humidifying the inhaled air, because as a result of tracheotomy, the air bypasses the upper levels of the respiratory tract which properly warm and moisturize it
  • reduction of the density of secretions from the lower respiratory tract
  • relieving bronchospasms by administering bronchodilators
  • reducing swelling of the bronchial mucosa
  • drying of the lower respiratory tract
  • oxygen treatment
  • careful wound care, changing dressings frequently enough to keep them dry all the time; if necessary, antibiotics are given and the sutures are usually removed 6-7 days after the procedure

Removal of tracheostomy tube

In cases where the cause of the airway obstruction persists, the tubing is not removed at all. On the other hand, if the obstacle has been removed and the patient has endured the obstruction of the tube for at least 24 hours (this is achieved by inserting the so-called tube with a window), the tube is removed in the dressing room. After such a procedure, the patient must remain under control for another 24 hours. Factors that may delay the planned removal of the tube include: swelling of the tracheal mucosa, granulation tissue formation around the tracheostomy, and softening of the tracheal cartilages.

Complications while inserting a tracheotomy

  • apnea - patient positioning, which is to facilitate the work of the operator, at the same time leads to venous stasis in the head and neck, which in turn adversely affects the blood supply to the brain and the work of the respiratory center
  • cessation of heart rate and circulation - may result from drug overdose, hypoxemia and respiratory acidosis or reflex excitation from the carotid sinus
  • bleeding
  • Tracheostomy tube incorrectly inserted or dropped
  • damage to the posterior wall of the trachea leading to the formation of a tracheoesophageal fistula
  • obstruction of the tracheostomy tube

Complications upatient with tracheostomy

  • bleeding
  • subcutaneous emphysema
  • tube loss
  • stenosis of the larynx and trachea are late complications and usually result from poorly performed emergency tracheotomy
  • pulmonary complications, which have, fortunately, been almost non-existent since the introduction of antibiotics
  • wound infection

Category:

Respiratory system