Surgical techniquesPercutaneous procedreOpen procedure

Open procedure

Midline incision from the lowr border of the thyroid to the manubrium sterni

Cut the skin, superficial fascia, platysmaand the deep fascia connecting thepretracheal muscles of the two sides

Pretracheal muscles?

Separate the pretracheal muscles of bothsides by a retractor

The thyroid isthmus is divided by 2 kochers, transfixed by catgut to prevent bleeding and leak of thyroxin and then retracted.

Expose the trachea and inject 1/2 c.c surface anaesthetic (pantrocaine 1%) in the trachea to diminish the cough reflex Fix the trachea and elevate it by a cricoid hook.

7- Open the trachea by an incision or by removal of a circular part of the 3rd and 4th rings.

Surgical techniquespercutaneous procedure

Surgical techniques percutaneous procedure

Surgical techniques percutaneous procedure

Surgical techniques percutaneous procedure

• Should be done in carefully selected patients• Under fiber optic control• To be ready to switch to open

procedure

Types of Tubes

Cuffed tubes Un-cuffed Fenestrated

SilverInner cannulaAdjustable Flange

Cuffed TubesAllows ventilation and prevents aspiration

High cuff pressure can be damaging

Check pilot cuff

Don’t BLOCK THIS TUBE

Cuffed Tubes• Tubes with inflatable cuffs

• Why the cuffs are needed? • Any guesses about fixation?• when the patient is unable to breathe on their own and requires artificial

respiration. Unless there is an air-tight seal around the tube, the air being blown into the lungs by the respirator escapes around the sides of the tubes.or

• when an air-tight seal is necessary to prevent blood and other secretions from running down the sides of the tracheostomy tube into the lungs. During and following surgery to the head and neck, such complications are a real danger and it is for this reason that a cuffed polythene tube is used for the first couple of days post-operatively.

Un-cuffed TubesMaintains airway once aspiration risk has passed

Increase airflow to the larynx

Long term tracheostomy pts

Patients who do not require a seal

Paediatrics

Any idea about how th

e tracheosto

my patients speak?

Fenestrated TubeIncreases airflow to larynx/ vocalisation

Cuffed or un-cuffed

Enables phonation (speaking)

The fenestrated tube can be used as such if the patient is tolerating the cuff down

To suction always use the non fenestrated inner tube for suctioning

Fenestrated are the only tubes (when inner fenestrated tube insitu and cuff is down) that can be intentionally occluded

Inner CannulaAllows maintenance of tube patency

Aids tube hygiene

Close observation

Allows fenestrated tubes to be used earlier

Inner CannulaUse of an inner cannula:

The inner cannula provides a vital safeguard against life-threatening complications of tube obstruction in a cuffed tube and must be present at all times.

Tracheostomy tubes without an inner cannula should be avoided wherever possible particularly in the ward environment;

Adjustable FlangeProvide a longer tube – offer secure placement of tube in a deep-set trachea

Essential for patients with difficult anatomy and on whom the insertion will be complicated; insertion of this tube is usually via the surgical technique (considered to be an unsuitable tube for the percutaneous insertion technique)

These tubes are inserted in patients with very difficult anatomy and therefore subsequent tube changes should be considered carefully.

Silver Negus

• Metal Tracheostomy Tubes• These are made of silver because the metal is inert and does not irritate the

tissues. The most commonly used silver tube is the ‘Silver-Negus’. The sizes of the tubes for adults vary from 28-36 FG. The letters FG stand for ‘French gauge’. The number represents the circumference of the inner tube measured in millimetres. As a rough guide, the FG size is 4 times the portex size.

• The tubes have a normal inner tube and a speaking tube with a small valve on.• Speaking tubes should not be used to sleep in because of the danger of the valve

blocking and occluding the airway. Silver tubes cost approximately £200 each. Each set is individual and pieces are not interchangeable. If a piece is lost it can cost £100 at least to replace. The tubes also need repairing and maintaining occasionally. Manufacturers of plastic tubes claim silver tubes are not as comfortable as plastic but they have no evidence to support this.

Speech with tracheotomy