Tracheostomy - Procedure, Steps & Postoperative care

🫁 Tracheostomy – Surgical Steps & Post-operative Care

This post covers:

• Pre-operative preparation
• Surgical steps of tracheostomy
• Confirmation of Tracheostomy tube placement
• Immediate securing of tube
• Post operative care of Tracheostomy tube
• Tracheostomy tube suctioning protocol
• Tracheostomy tube care
• Tracheostomy tube change & stoma care

📝 Pre-operative Preparation

✅ Informed Consent

• Explain procedure
• Possible complications
• Recovery expectations
• Long-term care requirements

✅ Equipment Check

• Correct size tracheostomy tube
• Check cuff integrity (inflate → look for air leak)
• Lubricate tube tip with lignocaine jelly
• Keep ties ready
• Ensure suction apparatus is functioning

🛌 Tracheostomy Position of Patient

• Patient placed supine
• Neck extended
• Sandbag/pillow under shoulders
• Head supported on head ring

💉 Anaesthesia

• Local or General anaesthesia

What local anesthesia is used in Tracheostomy?

Why should you avoid Adrenaline in Tracheostomy?

✂️ Tracheostomy Incision

📍 Tracheostomy Incision Site

• Midway between cricoid cartilage and suprasternal notch
• OR 2 finger breadth above suprasternal notch

📍 Tracheostomy Incision Types

• Horizontal Incision (Elective)
• Vertical Incision (Emergency)

What are the advantages and disadvantages of Horizontal incision for Tracheostomy?

What are the advantages and disadvantages of Vertical incision for Tracheostomy?

🔍 Tracheostomy Procedure Steps

Following are the steps of Tracheostomy :

1️⃣ Tracheostomy Skin incision

2️⃣ Deepening the Incision

What are the layers encountered while deepening the skin incision in Tracheostomy?

Which vein can get injured while deepening the skin incision in Tracheostomy?

3️⃣ Strap Muscle Separation

• Separate in midline:

  • Sternohyoid

  • Sternothyroid

4️⃣ Thyroid Isthmus Management

Two options:

• Retract superiorly/inferiorly
• Clamp → divide → ligate

5️⃣ Identification of Trachea

What are the different features that will help in correct identification of trachea during tracheostomy?

What test is done to confirm the trachea position?

6️⃣ Tracheal Incision

Before Tracheal incision, we should check for the following :-

• Achieve complete haemostasis
• Recheck suction apparatus
• Instill few drops of 4% lignocaine into trachea

Why do we instill a few drops of 4% lignocaine into the trachea before the tracheal incision?

What is the most common site of Tracheal Incision?

What are the different types of Tracheal Incisions?

What is Bjork Flap?

What are the disadvantages of Bjork Flap?

👉 Children → Prefer Vertical tracheal incision

⚠️ Avoid round opening → Risk of tracheal stenosis

🔄 Variations in Trachea

• Soft trachea → Children → Need stay sutures
• Hard calcified trachea → Elderly → May need bone cutter
• Carcinoma larynx → High tracheostomy

🚨 Special Points in Emergency Tracheostomy

• Perform rapidly → Anoxia >5 min fatal
• Avoid intratracheal anaesthetic
• Avoid paratracheal infiltration → RLN paralysis risk

7️⃣ Tube Insertion

• Insert tracheal dilator
• Insert tube with obturator
• Remove obturator immediately

What is the most common Tracheostomy tube size used in males and females?

How would you confirm the placement of the Tracheostomy tube into the trachea?

What are the causes of Respiratory Failure After Tracheostomy Tube Placement?

8️⃣ Securing the Tube

• Inflate cuff with 3-5 ml air
• Cuff lodges between 4th-7th tracheal rings
• Release neck extension
• Tie tapes → One finger space
• Keyhole dressing around stoma

🏥 Post operative Care of Tracheostomy

1️⃣ Communication

• Patient cannot speak
• Provide paper + pen
• Provide bell

2️⃣ Humidification (Very Important)

Loss of nasal humidification → crust formation

Methods:

• Wet gauze over tube
• Heat Moisture Exchanger (HME)
• Nebulization
• Boiling kettle (last option)

3️⃣ Tracheostomy tube suction

Frequency

• Every 30 min in first 24 hrs
• Then every 1–2 hrs

What is the formula for selectig the catheter size for tracheostomy tube suctioning?

How to suction tracheostomy tube

• Deflate cuff
• Attach catheter to a source of negative pressure: 100–150 mmHg
• Lubricate catheter tip
• Insert catheter while blocking the suction during inspiration
• Suction while withdrawing in rotating motion

What is the pressure used usually to suction the tracheostomy tube?

⚠️ Duration:

• 5–10 seconds only
• Maximum 2–3 attempts

What should you do if the secretions in the tracheostomy tube is too thick?

4️⃣ Tracheostomy Tube Care & Tracheostomy Tube Change

• Do NOT change outer tube for 5–7 days

• Inner tube cleaning:

  • 3–4 times/day initially
  • Clean with Hydrogen peroxide
  • Wash → Dry → Reinsert

• After 7 days → Can change to uncuffed tube

5️⃣ Tracheostomy Stoma Care

• Daily dressing change
• Prevent crust & granulation
• Look for infection
• Apply antibiotic ointment if needed

6️⃣ Tracheostomy tube cuff care

• Deflate every 1 hour for 5 minutes
• Prevent tracheal stenosis

7️⃣ Nutrition

• Encourage oral feeding
• If not possible → Parenteral nutrition

8️⃣ Oral Hygiene

• Maintain regular oral care

⭐ Exam Pearls

• Most common tracheostomy → Mid tracheostomy
• Tube change only after 5–7 days
• Suction catheter size formula → Very important viva
• Cuff must be periodically deflated → Prevent stenosis

➡️ Next Topic: Complications of Tracheostomy