An artificial opening into the trachea through the neck in order to by pass an obstruction of the airway and/or to provide access to the lower airway facilitating ventilatory support.
Indications
Emergency Tracheostomy: Foreign bodies (in the upper airway), maxillofacial trauma (patient cannot breath and endotracheal intubation impossible), inflammatory conditions such as; epiglottis, Ludwig's angina, retropharyngeal and other oropharyngeal abscesses with respirator,' obstruction, tumours of head and neck with acute obstruction to airway (due to oedema, bleeding, infection, etc). Elective tracheostomy (ventilation likely to continue for more than two weeks); surgery for tumours of head and neck, major reconstructive facial surgery, prolonged ventilatory support surgery e.g. in: Flail chest, acute respirator,' distress syndrome, pneumonia. Guillain-Barre syndrome.
Management
• In case of complete acute upper respiratory tract obstruction give oxygen through a big bore needle or a canula inserted through cricothyroid membrane (Cricothyrotomy). Quickly extend the neck over a rolled up towel or pillow. Feel for the cricoid prominence (Adam's apple) and the depression just distal to its membrane. Insert a big bore needle or canula to the trachea (with or without local anaesthetic depending on circumstances).
Tracheostomy Technique
• Ideally done in theatre, properly cleaned and draped. Position patient supine with neck extended over a pillow and head stabilised in tracheostomy position.
Anaesthesia General Anaesthesia through a tracheal tube if possible. Local anaesthesia. No anaesthetic in extreme circumstances.
Incision Transverse incision, 2 cm below the lower angle of cricoid cartilage. Incision made through the skin, subcutaneous fat and deep cervical fascia. Blunt dissection then expose the anterior jugular vein, infrahyoid muscles and occasionally thyroid isthmus (which should be ligated and divided). A cruciate incision or a circular window is then made through the third and fourth tracheal rings. A tracheostomy, endotracheal or other tube is then inserted. The skin incision is closed loosely around the tube. Fix the tube securely with well tied tapes.
NB Use as short a time as possible through this simple procedure. Humidification of the gases/air and frequent suction through the tube must be done. When a clear passageway has been established and ventilation restored then refer the patient. For continued care of the tracheostomy, decannulation, etc. Refer to a relevant textbook for detail.
