Describe tracheostomy with its indications, complications and care.

Indications and Technique

• Tracheostomy is the creation of an opening in the anterior wall of the trachea to establish an airway.
• It is the oldest operation in surgery and remains one of the most valuable, and its indications go well beyond obstruction.
• The indications divide into four groups, and reciting them as groups is clearer than listing diseases:

Complications and Care

• Complications are classified by timing:
• Immediate (at operation) — haemorrhage; injury to the recurrent laryngeal nerve; injury to the oesophagus (from cutting too deeply); pneumothorax, particularly in children, in whom the pleural dome is high; air embolism; and cardiac arrest from sudden release of hypercapnia
• Intermediate (hours to days) — tube blockage by crusts.
• Late (weeks to months) — tracheal stenosis, at the stoma or at the cuff site; tracheomalacia; tracheo-oesophageal fistula, from an over-inflated cuff or a nasogastric tube; tracheo-innominate artery fistula; granulations; a persistent tracheocutaneous fistula; scar; and difficulty in decannulation
• Tracheo-innominate fistula is rare but catastrophic — it presents with a sentinel bleed, and brisk bleeding from a tracheostomy is an emergency managed by hyperinflating the cuff to tamponade, applying digital pressure anteriorly through the stoma, and immediate transfer to theatre
• The cuff pressure must be kept below capillary perfusion pressure (20 to 25 cmH2O) and checked regularly.
• Routine care, which determines outcome far more than the operation:
• Humidification is essential, because the nose has been bypassed and inspired air is no longer warmed or moistened; without it, secretions crust and block the tube
• Regular suction, with a sterile technique, of appropriate depth and duration, with pre-oxygenation
• The inner tube is removed and cleaned regularly.
• Stoma care, tapes checked and changed, and skin protection
• Emergency equipment AT the bedside AT all times — a spare tube of the same size, one a size smaller, a tracheal dilator, suction, and the stay sutures in a child
• The blocked or displaced tube is the emergency to rehearse — remove the inner tube first, since that resolves most blockages immediately; then suction; then deflate the cuff; and then remove and replace the tube, using the dilator or stay sutures if the track is not yet mature
• A tract takes 5 to 7 days to mature — before that, replacing a displaced tube is hazardous and may create a false passage, so an early displacement is managed by oral intubation where the larynx is patent
• Remember that a laryngectomy stoma is different — such a patient cannot be intubated or ventilated through the mouth or nose at all.
• Speech may be restored with a fenestrated tube and a speaking valve, with the cuff deflated — which is important for morale and for swallowing
• Decannulation is undertaken when the original indication has resolved, the patient can protect the airway and clear secretions, and tolerates cuff deflation and tube occlusion — achieved by progressive downsizing and capping trials, with endoscopic assessment of the airway before decannulation
• Humidification is essential, not optional, since the nose has been bypassed and secretions crust without it
• Remove the inner tube first in an emergency, which resolves most blockages within seconds
• Prefer a tube with an inner cannula, since regular cleaning of it is the best protection against blockage
• The tract takes five to seven days to mature, and before that a displaced tube may be replaced into a false passage
• Manage early displacement by oral intubation where the larynx is patent, rather than forcing a tube through an immature tract
• Keep the cuff below twenty-five centimetres of water, and check it regularly.
• Use stay sutures in a child, which allow the trachea to be pulled forward if the tube is displaced early
• Never excise cartilage in a child; a vertical slit is made.
• Avoid a high tracheostomy, which risks cricoid perichondritis and subglottic stenosis