Surgical airway
Tracheostomy
Indication
- Airways obstruction
- Protection from aspiration (decreased consciousness, GBS, tetanus)
- Prolonged intubation / long-term ventilation
- Facilitate airways suction
Types of Tubing
- Metal / plastic
- Cuffed (reduces risk of aspiration) / uncuffed (used in children - as risk of mucosal ulceration)
- Windowed - permits speech
Open Procedure
- ETT intubation + GA
- Sandbag beneath shoulders to maintain neck extension
- Transverse skin incision midway between cricoid cartilate and suprasternal notch
- Separate pretracheal muscles
- Divide thyroid isthmus between clamps + oversew
- Tracheostomy between 2nd and 4th rings: (1) Bjork flap opens inferiorly (2) vertical slit
- Insert tube, secure
Percutaneous procedure
More rapid, less traumatic, doesn't need surgeon/anaethestist
- LA + fibre-optic bronchscopy to aid insertion
- Small skin incision between cricoid / sternal notch
- 14G cannula
- Guide wire through
- Remove cannula
- Ram Rhino dilator over guidewire to make a big hole
- Pass tracheostomy over guidewire
- Secure in place, get a CXR
Complications:
- Nerve, vessel damage, pleural injury
- Stenosis if incision too high
- Tracheo-inominate fistula if too low
- Bleeding
- Displacement
- Blockage
- Infection
- Mucosal ulceration
