Tracheostomy

Berlian Chevi A.
20184010030
Tracheostomy

Tracheostomy is an operative procedure that creates a

surgical airway in the cervical trachea.

*Percutaneous dilational tracheostomy (PDT) aslso referred

to as bedside tracheostomy, is the placement of a
tracheostomy tube without direct surgical visualisaion of
trachea.
Indication

upper airway obstruction caused by

1. upper respiratory tract infection:
• acute epiglottis
• acute laryngrankeobronchitis
• head and neck trauma
• benign tumor or malignant tumor on pharynx, larynx or
esophagus area
• congenital anomaly on upper airway
• bilateral abductor paralysis
• foreign body in the larynx
2. removing secretions from the tracheobronchial
3. support thebreath or mechanical ventilation
(bronchopneumoni, bronchiectasis, coma)
4. cannot be performed intubation in general anesthesia
procedures (pulmonary emphysema, paralysis of breath
muscles)
Contraindication

• mass in the mediastinum or thorax

• blood clotting disorders
Preparation

• Informed consent
• Consultation : Anaesthestic, internist, Pediatric,
Cardiologist
• Laboratorium
• Ro thorax (non emergency)
• ECG (non emergency)
• Premedication : inj prophylactic antibiotics;
corticosteroids and tranexamat acid if needed.
• fasting 6 hours before surgery (non emergency)
Equipments
• gauze
• antiseptic
• lidocaine
• sulfa atropine
• suction meter
• bisturi knife
• disposable knife
• sewing thread
• tracheal cannula
tracheostomy set

• drapping
• scalpel
• bent artery clamps
• scissor
• tweezers
• langenbeck hook
• needle holder
Procedure

1. Identification
2. Sign in
3. Time out
4. Tracheostomy can be done with local or general
anesthesia
5. The position of the patient is supine on the
hyperextension head (back is propped up by a pillow)
6. disinfection and drapping
7. infiltration of epinephrine lidocaine in the operating area
for anesthesia and vasoconstriction
8. incisions vertically or horizontally in the middle between
the cricoid cartilage and the sternum

midline incisions are separated (deepened) layer by layer bluntly with arterial clamps.
Be careful of the anterior jugular vein of the thyroid artery, the thyroid (the thyroid
ismus can be clipped and then cauterized or set up or down)
9. identification of the trachea with experimental puncture (if the tracheal lumen is
indicated by air or bubble into a fluid filled syringe
10. identification of the
trachea with experimental
puncture (if the tracheal
lumen is indicated by air or
bubble into a fluid filled
syringe
11. the trachea is incised at
the second and third stages
from the direction inferior to
the superior (inferior bjorg
flap) or other types of
incisions such as the vertical
superior vertical bjorg flap
and starplasti
12. the tracheal cannula is gently inserted and a thread test is performed, if the tracheal cannula enters the
tracheal lumen, it will move to be blown out by cannula air
13. The trachea cannula is fixed by filling the balloon cannula, sutures on the skin of the
neck and neck band

14. Operation wounds that are too wide can be sewn loosely, finally closed with gauze and
cannula in place

15. operation completed

16. SIgn out
Outcome evaluation

• There is no stridor and

retraction
• good cannula position
• no active bleeding
• there are no complications
of subcutaneous
emphysema
Treatment plan

• the patient is treated for 2 days

• During treatment, cannula and cannula
treatment was carried out and observation of
the presence or absence of complications,
among others, by taking a chest radiograph if
subcutaneous emphysema was found.

• If there are no complications the cannula

balloon is deflated after 1 week (outpatient)

• Patients were educated on how to care for

the cannula and cannula as well as the first
action if the total dead end of the cannula or
wrong position
Post medication

medical postoperative
antibiotics (amoxicillin
3x500mg or cephalosporin)
and mucolytic (ambroxol
carbocysteine, adjusted
dosage) for 5 days.
Percutaneous Dilational Tracheostomy

• Ciaglia
• With this technique, there is no sharp
dissection involved beyond the skin
incision. The patient is positioned and
prepped in the same way as for the
standard operative tracheostomy.
General anesthesia is administered
and all steps are done under
bronchoscopic vision.
Procedure
• Skin incision is made and the pretracheal tissue is cleared with blunt dissection.
• Endotracheal tube is withdrawn enough to place the cuff at the level of the glottis.
• Endoscopist places the tip of the bronchoscope such that the light from its tip shines through
the surgical wound.
• Operator enters the tracheal lumen below the second tracheal ring with an introducer needle.
• The tract between the skin and the tracheal lumen is then serially dilated over a guidewire and
stylet.
• A tracheostomy tube is placed under direct bronchoscopic vision over a dilator.
• Placement of the tube is confirmed again by visualizing the tracheobroncial tree through the
tube.
• Tube is secured to the skin with sutures and the tracheostomy tape.

• Shachner (Rapitrac)
system
• After making a small skin incision, the surgeon
passes a dilator tracheotome over the
guidewire into the trachea to dilate the tract fully
in one step. The tracheotome has a beveled
metal core with a hole through its center that
accommodates a guidewire. Once inside the
trachea, the tracheotome is dilated. A
conventional tracheostomy cannula, fitted with
a special obturator, is passed through the
tracheal opening. The dilator and obturator are
then removed.
• Translaryngeal
tracheostomy (Fantoni’s
technique)
• Unlike the other techniques, the initial puncture
of the trachea is carried out with the needle
directed cranially and the tracheal cannula
inserted with a pull-through technique along the
orotracheal route in a retrograde fashion. The
cannula is then rotated downward using a
plastic obturator. The main advantage of
Fantoni’s tracheostomy is the minimal amount
of skin incision required, with practically no
bleeding observed. It should be noted that the
procedure can only be carried out under
endoscopic guidance, and rotating the tracheal
cannula downward may pose a problem –
demanding that the surgeon have more
experience.
Advantage of PDT
• Advantages of PDT
• Although there is a learning curve to the technique of PDT, it is relatively easy to
learn. The learning curve may be overcome by performing a number of supervised
procedures. Other advantages include:

• Time required for performing bedside PDT is considerably shorter than that for an
open tracheostomy
• Elimination of scheduling difficulty associated with operating room and
anesthesiology teams for critical care patients
• PDT expedites the performance of the procedure because critically ill patients who
would require intensive monitoring to and from the operating room need not be
transported
• Cost of performing PDT is roughly half that of performing open surgical tracheostomy
due to the savings in operating room charges and anesthesia fees
Source

Panduan Praktik Klinik

Tindakan PP PERHATI-KL
Volume 2
2016

Medscape

hopkinsmedicine.org