Tracheotomy 286403 218621111 2008-06-11T13:19:10Z Drum guy 1868842 fix refs (<ref> → </ref>) [[Image:Traqueostomia.png|thumb|166px|Completed '''tracheotomy''':<br> 1 - Vocal cords<br> 2 - Thyroid cartilage<br> 3 - Cricoid cartilage <br> 4 - Tracheal cartilages<br> 5 - Balloon cuff]] '''Tracheotomy''' and '''tracheostomy''' are [[surgical]] procedures on the neck to open a direct airway through an incision in the [[Vertebrate trachea|trachea]] (the windpipe). They are performed by [[paramedic]]s, [[veterinarian]]s, emergency [[physician]]s and [[surgeon]]s. Both surgical and percutaneous techniques are now widely used. While tracheostomy may have possibly been portrayed on [[ancient Egypt]]ian tablets,<ref>[http://www.tracheostomy.com/resources/pdf/evolution.pdf "Tracheostomy: Evolution of an Airway,"] Steven E. Sittig and James E. Pringnitz, ''AARC Times,'' February 2001.</ref> the first correct description of the tracheotomy operation for [[Suffocation|suffocating]] patients was described by [[Ibn Zuhr]] in the 12th century,<ref name=Shehata>Prof. Dr. Mostafa Shehata, "The Ear, Nose and Throat in Islamic Medicine", ''Journal of the International Society for the History of Islamic Medicine'', 2003 (1): 2-5 [4].</ref> and the currently used surgical tracheostomy technique was described in 1909 by [[Chevalier Jackson|Dr. Chevalier Jackson]] from [[Pittsburgh, Pennsylvania|Pittsburgh]], [[Pennsylvania]]. ==Terminology== ''Tracheotomy'', from the [[Greek language|Greek]] [[root (linguistics)|root]] ''tom-'' meaning "to cut," refers to the procedure of cutting into the trachea and is an emergency procedure.<ref>[http://www.bcm.edu/oto/grand/03_06_03.htm "Adult Tracheostomy,"] Romaine F. Johnson, M.D. March 6, 2003, Baylor College of Medicine.</ref> A ''tracheostomy'', from the root ''stom-'' meaning "mouth," refers to the making of a semipermanent or permanent opening, and to the opening itself.<ref>{{Dorlands|t_15|12815726}}</ref> Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the [[Stoma (medicine)|stoma]] at the time it is created.<ref name="titleeMedicine - Tracheostomy : Article by Jonathan P Lindman, MD">{{cite web |url=http://www.emedicine.com/ent/topic356.htm#section~introduction |title=eMedicine - Tracheostomy : Article by Jonathan P Lindman, MD |accessdate=2007-12-30 |format= |work=}}</ref> ==Uses of tracheotomy== The conditions in which a tracheotomy may be used are: * Acute setting - [[Maxillofacial surgery|maxillofacial]] injuries, large tumors of the head and neck, congenital tumors, e.g. [[branchial cyst]], acute [[inflammation]] of head and neck, and * Chronic / elective setting - when there is need for long term [[mechanical ventilation]] and tracheal toilet, e.g. [[coma]]tose patients, surgery to the head and neck. In emergency settings, in the context of failed [[endotracheal intubation]] or where intubation is contraindicated, [[cricothyroidotomy]] or mini-tracheostomy may be performed in preference to a tracheostomy. == Tracheotomy procedure == # Curvilinear skin incision along [[relaxed skin tension lines]] (RSTL) between sternal notch and cricoid cartilage. # Midline vertical incision dividing [[Strap_muscles|strap muscles]]. # Division of [[thyroid]] isthmus between ligatures. # Elevation of [[cricoid]] with cricoid hook. # Placement of tracheal incision. An inferior based flap or [[Björk flap]] (through second and third [[Tracheal_rings|tracheal rings]]) is commonly used. The flap is then sutured to the inferior skin margin. Alternatives include a vertical tracheal incision ([[pediatrics|pediatric]]) or excision of an ellipse of anterior tracheal wall. # Insert tracheostomy tube (with concomitant withdrawal of endotracheal tube), inflate cuff, secure with tape around neck or stay sutures. # Connect ventilator tubing. It is also possible to make a simple vertical incision between tracheal rings (typically 2nd and 3rd) for the incision. rear end flaps may produce more intratracheal granulation tissue at the site of the incisions, making it less favorable to some surgeons. == Percutaneous Tracheotomy procedure == # Curvilinear skin incision along relaxed skin tension lines between sternal notch and cricoid cartilage. # Midline blunt dissection down to the trachea (optional depending on technique). # Insertion of 14-gauge plastic [[Cannula|cannula]] and needle with fluid filled syringe attached into trachea. Aspiration of air confirms correct placement of the tip in the trachea. # Removal of needle leaving cannula in place. # Insertion of soft tipped guide wire into trachea through cannula. # Removal of cannula leaving guide wire in place. # Tracheal dilatation is now undertaken - different techniques do this in different ways. ## Ciaglia - the sequential insertion and removal of a series (usually 4-5) of increasing larger dilators over the wire into the trachea. ## Griggs - insertion of a specially designed pair of guide-wire forceps along the wire into the trachea and then are opened to complete the dilation in one step. ## Rhino - insertion of a single large tapered dilator over a plastic guidewire reinforcement. ## Frova Percutwist - insertion of a specially designed screw of increasing diameter which rotates to create the dilatation. # Insert tracheostomy tube (with concomitant withdrawal of endotracheal tube), inflate cuff, secure with tape around neck or stay sutures. # Connect ventilator tubing. ==Complications== # Immediate - [[pneumothorax]] or pneumomediastinum, tracheoesophageal [[fistula]], injury to great vessels or recurrent [[larynx|laryngeal]] nerves, bleeding, e.g. from divided thyroid isthmus. The various rhino techniques may be associated with an increase in fractured tracheal rings the significance of which is unclear. # Early - secretions and mucus plugging, dislodged tube, respiratory arrest and post obstructive [[pulmonary edema]] (when tracheostomy is performed in a patient with longstanding upper airway obstruction, and is dependent on [[hypoxic drive]] for respiration). # Late - bleeding from [[tracheoinnominate fistula]] (can be torrential), [[tracheal stenosis]] (from [[ischemia]] induced by a cuffed tracheostomy tube), tracheoesophageal fistula, tracheocutaneous fistula and cosmetic deformity must be considered upon [[decannulation]]. == Problems == # [[Immune]] problems - air [[Inhalation|inhaled]] through a [[stoma]] is not filtered or moistened like it is when inhaled through the [[nose]] or the [[mouth]]. # [[Drowning]] - as little as two teaspoons of water in the stoma can drown the person; therefore, they cannot swim and bathing must be done with extreme care. # [[Suffocation]] - if the stoma is covered, the person will suffocate, as in some cases they cannot breathe through their nose or their mouth. == See also == *[[Cricothyroidotomy]] *[[Intubation]] *[[Mechanical ventilation]] *[[History of Tracheotomy]] ==References== {{reflist}} == External links == * [http://www.tracheotomy.info Tracheotomy Info] (A Community For Tracheotomy-wearers and the people who love them) at tracheotomy.info * [http://www.tracheostomy.com Aaron's tracheostomy page] (Caring for a tracheostomy) at tracheostomy.com * [http://www.tracheostomy.com/resources/surgery/emergency.htm How to perform an emergency tracheotomy] (For information purposes only.) at tracheostomy.com (This page actually depicts cricothyroidotomy, not tracheostomy) *[http://www.rtcorner.net RT Corner (Educational Site for RT's and Nurses)] at rtcorner.net *[http://www.drtbalu.com/tracheostomy.html (Pictures with video clipping)] at drtbalu.com {{Respiratory system surgeries and other procedures}} [[Category:Surgical procedures]] [[Category:Emergency medicine]] [[Category:Oral and maxillofacial surgery]] [[Category:Otolaryngology]] [[af:Trageotomie]] [[ar:ثقب القصبة الهوائية]] [[cs:Tracheotomie]] [[da:Tracheostomi]] [[de:Tracheotomie]] [[es:Traqueotomía]] [[fr:Trachéotomie]] [[it:Tracheotomia]] [[nl:Tracheotomie]] [[ja:気管切開]] [[no:Trakeotomi]] [[pl:Tracheotomia]] [[pt:Traqueostomia]] [[ru:Трахеотомия]] [[fi:Trakeostomia]] [[sv:Trakeotomi]] [[zh:氣管切開術]]