Tracheostomy Tracheostomy • Surgical procedure = tracheotomy • State after artificial opening of trachea to body surface = tracheostomy • Purpose: to ensure passage to airways to enable ventilation Tracheostomy • Ancient method (Egypt, Greece) • 18th century Pierre-Joseph Desault used the term “tracheotomy” Tracheostomy - indication • Mechanical obstruction in lower airways • Secretion retention in lower airways • In patients suffering from respiratory insufficiency • Prolonged endotracheal intubation Tracheostomy - indication • Obstructed airways • - upper airways foreign body, lingual swelling epiglottitis ac., Quincke’s edema neurogenic disorders, traumatic stenosis injuries of larynx and basis of oral cavity tumors Usual pathologies Tracheostomy - indications • Obstructed airways : lower airways - chronic pulmonary diseases (COPD) - emphysema - cystic fibrosis (advanced state) - asthma (severe conditions) Tracheostomy - indication • Respiratory failure central - cerebral hemorrhage/trauma - intoxication - tumors perifpheral - chest injury - neurolog. diseases (neuromuscular dystrophy) - hypoventilation caused by other factors Tracheostomy • Temporary • Permanent severe tracheomalaciae, stenoses myopathy conditions after total laryngectomy children cerebral palsy, epilepsy, other congenital disorders Tracheostomy Elective tracheostomy • lowering of resistance in airways • easier hygiene of airways • prevention of complications of long-term intubation (e.g. subglottic stenosis) Tracheostomy Urgent tracheostomy acute conditions prohibiting endotracheal intubation LA, contraindication: lying positions, sedatives (!) Benefits • More effective breathing • Increased effectiveness of medicament application to lower airways • Improved conditions for hygiene of airways, diagnostic and therapeutic procedures (mucus suction bronchoscopy, BAL) • Promptly performed TS prevents formation of late morphological and functional changes of larynx Disadvantages • Elimination of nasopharyngeal part of upper airways • Phonation loss • Effective coughing loss • Lower CO2 concentration in blood • Olfaction loss TS - peroperative complications • Hemodynamic instability (bradycardia, hypertension, hypoxia) • Apnoe (vagová synkopa) • Embolism • Aspiration (of blood, gastric content) • Hemorrhage TS - peroperative complications • Iatrogenic injury of trachea • Iatrogenic injury of oesophagus • Paresis of n. recurrens TS - postoperative complications • Early - infection of wound, bleeding - subcutaneous emphysema, pneumothorax, - mediastinal emphysema • Late - granuloma formation - tracheocutaneous fistula, keloid scar - stenosis, malacia, laryngeal atrophy - tracheoesophageal fistula - swallowing difficulties - dysphagia, odynophagia Tracheostomy Skin incision • Vertical • Horizontal (more often) Tracheostomy Incision of tracheal wall • Bjork flap (U-shaped) • Elliptical opening • Vertical incision of 3 tracheal rings • H-shaped incision • Star plasty Tracheostomy Tracheostomy in children • Horizontal incision (vertical is less often) • Blunt preparation • Endotracheal intubation • Middle or lower TS (opening of trachea in relation to thyroid gland) • U-shaped opening of tracheal wall Puncture-dilatation TS • Indication: ONLY adults (trachea in childhood is too soft) • Contraindication: • tracheal deviations • enlarged thyroid gland • previously undergone tracheostomy • tracheomalacia • obesity Puncture-dilatation TS • percutaneous dilatational tracheostomy by Ciagla – PDT • Forceps dilatation (by Griggs) - FDT • Translaryngeal (by Fantoni) - TLT • Fibroscope-assisted punction TS Thank you for your attention