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Tracheostomy: Let’s Have a Look at the Procedure

Tracheostomy formation, a video by Mr Guri Sandhu.
This video demonstrates a surgical tracheostomy in an adult patient. More and more tracheostomies in hospitals are performed using the per cutaneous surgical technique. The type of patient that comes to Theatres to have a formal surgical tracheostomy is usually a patient who has a difficult anatomy, obesity, or problems with coagulopathy. In the case of a patient such as this, an appropriately sized tracheostomy tube with a size larger and smaller should be available with a catheter mount. It is important to check that the cuff on the tracheostomy tube is functional. The anaesthetist needs to ensure that they have access to the endotracheal tube when it is time to insert the tracheostomy into the airway.
At the start of the procedure, the surgeon and the anaesthetist need to discuss the case and ensure that all appropriate equipment is available. At the start of the procedure, it is helpful to mark the important landmarks on the skin and one needs to identify the thyroid cartilage, the cricoid cartilage, and the suprasternal notch. The incision for the tracheostomy is usually placed in a suitable skin crease halfway between the suprasternal notch, and the lower border of the cricoid cartilage. For an emergency tracheostomy, one can elect to place a vertical incision over the lower airway, cutting in the midline until a fenestration is created into the trachea and the tube is in place.
For an elective tracheostomy, the incision is usually 2 to 4 centimetres across, and one cut through the skin, the subcutaneous fat, and the investing layer of cervical fascia to expose the strap muscles Once the strap muscles are separated, the lower larynx, trachea, and the thyroid isthmus should become visible. If you encounter the anterior jugular veins, they should be clipped and tied.
If there is excessive subcutaneous fat, this can also be dissected away so that the skin sits closer to the airway. Some surgeons will choose to suture the free edge of the skin to the fenestration in the trachea prior to insertion of the tracheostomy tube.
Most ENT surgeons will choose to identify the thyroid isthmus, to apply artery clips across it, divide it, and oversew its edges. This ensures adequate exposure of the trachea and reduces the chance of being unable to replace a tracheostomy tube, should it become displaced within the first week. Although it is reasonable to diathermy and divide the thyroid isthmus in a paediatric patient, in the adult patient, this can lead to excessive bleeding.
Once the trachea is exposed, it is important to clearly define the upper three tracheal rings. A cricoid hook may be used to retract the cricoid and the larynx upwards, and this will allow adequate access to the trachea. We demonstrate the cricoid, the first tracheal ring, the second tracheal ring, and the third tracheal ring.
In an adult patient, the fenestration to the trachea is centred over the third tracheal ring. This fenestration can consist of a window, although in a younger patient, a vertical slit is usually preferred. Some surgeons will elect to perform an inferiorly-based cartilaginous flap known as the Bjork flap.
Fenestration is marked out on the outer surf the trachea using a monopolar diathermy. In an older patients such as this, the trachea may be calcified and creating a fenestration can be difficult, and heavy scissors may be necessary.
It is always easier to create a horizontal incision between the tracheal cartilage. This will allow the use of an Allis forceps to retract the superior aspect of the window before it is cut. The anaesthetist must be informed and allowed to access the endotracheal tube prior to creating the tracheal fenestration. The endotracheal tube balloon may be punctured, and the anaesthetist may need to make an allowance for this. Once the Allis forceps are in place and retracting the lower cartilage, heavy scissors can be used to cut out the fenestration. Try to avoid opening a window too wide, as this may later on lead to healing by contracture and produce a stenosis at the site of the tracheostomy.
The anaesthetist has pulled the endotracheal tube away from the penetration. The tracheostomy tube with its introducer can be inserted into the airway and the cuff inflated. A tracheal dilator may assist in this process. The catheter mount is attached and the anaesthetist will connect to the ventilator circuit. One needs to observe for adequate ventilation and also ensure that there is a carbon dioxide trace on the capnograph.
The incision in the skin is loosely approximated around the tracheostomy tube with a suture. A tighter closure risks surgical emphysema. I prefer to suture the flange of the tracheostomy tube to the skin as close as possible to the midline. This ensures that there is less chance of pulling the tracheostomy tube into the soft tissues of the neck.
A tracheostomy dressing is applied, and my preference is for a thinner dressing, rather than a sponge-based dressing. The problem with a sponge-based dressing is that if the neck is flexed, it tends to pull the tracheostomy tube away from the airway, and there is once again the potential for the tip of the tracheostomy tube to end up in the soft tissues of the neck.
It is also my preference to secure the tracheostomy tube with ribbons, rather than the velcro ties that are supplied with most tracheostomy tubes. The ribbons are quite snug and should allow one finger to be inserted under them as they are tied.
I would not advise the use of a bow to secure these ties, but prefer multiple knots. The problem with using a bow is that it may become untied. It is certainly safe to change the tracheostomy tube at one week and not before, as this period of time has allowed for an adequate tract to have formed. There is no reason and tracheostomy tube, providing it is clean and functional, should not be left in longer. Indeed, most tracheostomy tubes are licenced to be in place for at least a month.

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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