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Tracheostomy: Let's Have a Look at the Procedure

Tracheostomy formation, a video by Mr Guri Sandhu.

In this video, Mr Guri Sandhu, Consultant ENT Surgeon at Charing Cross and The Royal Brompton Hospitals, demonstrates the surgical procedure for the formation of a tracheostomy.

When watching the video pay particular attention to the communication and interaction between surgical and anaesthetic team.

Inserting a tracheostomy is a high-risk airway procedure. Good teamwork and communication, experienced staff, and meticulous planning are necessary. Most insertions are elective or semi-elective, so the patient should be fasted, and their clotting, respiratory function and physiology should be optimised beforehand.
Insertion can be either percutaneous or surgical and occurs typically between the second and third tracheal ring.
Percutaneous insertions make up the majority of tracheostomies and are mostly performed on intensive care on patients who are anticipated to require prolonged ventilation. You can read about percutaneous tracheostomy formation in this article.
High risk patients, or those with difficult anatomy, may be referred for a surgical tracheostomy. The patient is anaesthetised and paralysed and the trachea intubated from the upper airway with a tracheal tube. The patient’s position is optimised with neck extension.
Occasionally it is necessary to perform a tracheostomy under local anaesthesia on a patient who is awake and spontaneously breathing if after a thorough airway assessment, this appears to be the safest management strategy, as you have learnt in Week 2.
The surgeon dissects down to the trachea and the anaesthetist manipulates the tracheal tube to facilitate passage of the tracheostomy tube. The tracheal tube is removed once correct positioning of the tracheostomy tube is confirmed by chest movement and capnography. The tracheostomy tube is then safely secured.

A tracheostomy may be considered to be especially high-risk if any of the following conditions are present:

Anatomical Physiological
Obesity Deranged clotting
Short or fixed neck Inadequate fasting or full stomach
Previous surgery or radiotherapy to the site High oxygen or ventilatory pressure requirement
Large thyroid goitre Cardiovascular instability requiring a high level of support
Prominent blood vessels at the site  
Unsecured or difficult upper airway  

After watching this video, please take a few minutes to reflect on the following: Have you ever performed or assisted at an insertion of a tracheostomy? Was is percutaneous or surgical? What are the main differences? What are the Human Factors and Ergonomics implications during the procedure? Please share your thoughts in the discussion below.

In the next video, we will see Dr Helen Drewery and the Trachy Team at The Royal London Hospital, talking about multidisciplinary tracheostomy care.

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Airway Matters

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