TRACHEOSTOMY

 

A tracheostomy is a medical procedure that involves creating an opening in the neck in order to place a tube into a person's trachea (windpipe). This opening, or stoma, allows air to enter the lungs, bypassing any blockages or obstructions in the upper airways. The procedure can be performed for various reasons, including:

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1. Airway Blockage: To bypass an obstructed airway, which could be due to tumors, swelling, or foreign objects.

2. Breathing Problems: For people with chronic respiratory diseases, severe neck or mouth injuries, or other conditions that make normal breathing difficult.

3. Long-term Ventilation: In cases where long-term use of a ventilator is needed, such as with severe neurological or muscular disorders, a tracheostomy may be more comfortable and safer than prolonged intubation through the mouth.

4. Pulmonary Hygiene: To help with the removal of secretions in patients who are unable to cough effectively or have thick secretions.

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The procedure is typically done under general anesthesia in a hospital setting. Post-procedure care includes regular cleaning of the tracheostomy tube and the stoma, monitoring for possible complications such as infection or blockage of the tube, and eventually, the process of weaning off the tracheostomy tube if the underlying condition improves.

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A tracheostomy can be temporary or permanent, depending on the reason for its placement and the overall health and recovery potential of the patient. It significantly affects the patient's ability to speak and swallow, and thus rehabilitation and adaptation are crucial aspects of care for individuals with a tracheostomy.

                                                                                                 

 

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                                                        Anesthetic Implications for Tracheostomy

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Anesthesia type: General, local anesthesia

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Airway: ETT, Tracheostomy tube (TT)

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Preoperative:

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• Patients are normally intubated and on a ventilator

• Have equipment for a possible difficult airway

• Potentially critically ill patient with limited reserve or multi-organ failure

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Intraoperative:

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• "Shared airway"

• Maintain close communication with the surgeon

• Airway fire precautions (low FiO2 and limited cautery use)

• Duration: 30-60 minutes

• Position: Supine, head extended with shoulder roll

• Motionless surgical field  with neuromuscular paralysis

• The tissues of the trachea and neck are quite vascular

• The recurrent laryngeal nerves may be damaged if dissection deviates from the midline

• The innominate artery crosses anteriorly 

• The tube is withdrawn cephalad, the surgeon inserts the tracheostomy cannula, and the anesthesia circuit is connected

• Major resistance to ventilation shoulder alert practitioner of incorrect cannula placement 

• Capnography is essential to confirm that the tube is in the trachea

• After ventilation is verified, the endotracheal tube is removed entirely

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Postoperative:

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• PONV prophylaxis

• Smooth emergence

• The obturator for the tracheostomy tube must accompany the patient

• The obturator is needed if the tracheostomy becomes dislodged and needs to be replaced

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Complications:

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• Bleeding

• Loss of airway

• False lumen

• Airway fire

• Air embolism

• Airway stenosis

• Bronchospasm

• Pneumothorax

• Pneumomediastinum

• Subcutaneous emphysema

• Pulmonary edema 

• Tracheoinnominate artery fistula

• Infection

• Aspiration

• Tracheal necrosis

• Tracheo-arterial fistula

• Nerve damage

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Sources:

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Elisha, S. (2010). Case Studies in Nurse Anesthesia.

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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