CHAPTER 120: TRACHEOTOMY

INDICATIONS

Tracheotomy is performed for two groups of patients. The first group comprises those with an obstruction of the airway at or above the level of the larynx. Such obstruction may result acutely from laryngeal tumors, edema, fracture, foreign bodies, burns about the oropharynx, or severe throat and neck infections.

The second group consists of patients with chronic or long-term respiratory problems. Inability to cough out tracheobronchial secretions in paralyzed or weakened patients may be an indication for tracheotomy, which allows frequent and easy endotracheal suctioning. This group of patients includes those with prolonged unconsciousness after drug intoxication, head injury, or brain surgery and those with bulbar or thoracic paralysis, as in poliomyelitis. To this group are added patients with general debility, especially in the presence of pulmonary infection or abdominal distention, where a temporary course of respiratory support with an endotracheal tube and mechanical ventilator for 10 to 14 days must be converted into a longer course of pulmonary assistance. In these patients inability to maintain an adequate gas exchange or oxygen or carbon dioxide may dictate conversion of the endotracheal tube to a tracheotomy tube. Frequently, checks of arterial blood gases will reveal hypoxemia or hypercarbia, while simple measurements of vital capacity and negative inspiratory force will detect insufficient respiratory muscular effort. These tests are important in the decision to continue tracheal intubation with ventilator assistance. Other candidates for tracheotomy may include patients undergoing major operative or radical resections of the mouth, jaw, or larynx, where this procedure often is done as a precautionary measure. Antibiotics may be indicated.

PREOPERATIVE PREPARATION

Because the patient is usually in respiratory difficulty, preoperative preparation is generally not possible.

ANESTHESIA

In cooperative patients, in both elective and emergency situations, local infiltration anesthesia is preferred. In patients who are comatose or are choking, no anesthesia may be necessary or possible. Because it helps to ensure a good airway during tracheotomy, endotracheal intubation is especially useful in patients whose laryngeal airway is very poor and who may obstruct at any moment. It is also an aid in palpating the small, soft trachea of infants.

POSITION

A sandbag or folded sheet under the shoulders helps extend the neck (figure 1), as does lowering the head rest of the operating table. The chin is positioned carefully in the midline.

OPERATIVE PREPARATION

In emergency tracheotomy, sterile preparation is either greatly abbreviated or omitted entirely. In routine tracheotomy, a sterile field is prepared in the usual manner.

A. EMERGENCY TRACHEOTOMY

INCISION AND EXPOSURE

Emergency tracheotomy is done when there is no time to prepare for a routine tracheotomy. There may be no sterile surgical instruments available and no assistants.