Percutaneous Technique of tracheostomy
Failure to wean from the ventilator – this is probably the most common reason for tracheostomy. Placing a tracheostomy allows the endotracheal tube to be removed but still allows for trials off the ventilator. If the patient “fails” spontaneous breathing trials it is a simple thing with a tracheostomy to resume mechanical ventilation.
Improved control of secretions – sometimes patients have lung function that is adequate for removal of the endotracheal tube but have copious mucous secretions in their airways that prevents easy gas exchange. This is called mucous plugging. It is easier for the nursing staff and respiratory therapists to suction patients with a tracheostomy than through an endotracheal tube.
Mechanical obstruction of the trachea – this occurs most commonly with large head and neck tumors, such as anaplastic thyroid cancer. For thyroid cancers, the tracheostomy is below the area of external compression and obstruction of the trachea and prevents the patient from suffocating to death. This is most probably why the late Chief Justice William Rehnquist received his tracheostomy
Either a horizontal midline or vertical incision maybe used. A horizontal incision risks injuring the anterior jugular vein but has the advantage of improved cosmesis as the incision may be placed in a skin crease.
Details of the Tracheostomy Procedure
1. The patient is placed supine on the ICU bed or operating room table.
2. A bolster (usually a rolled up blanket) is placed horizontally under the clavicles (shoulder blades).
3. Several cc’s of lidocaine with 1% epinephrine is injected intradermally for analgesia and to retard bleeding from the skin edges.
3. A #15 scalpel is used to make a skin incision.
4. Cautery may be used to dissect through the subcutaneous tissue and through the Scarpa’s fascia. Some surgeons do not use cautery at all secondary to the risk of igniting the concentrated oxygen usually being delivered to the patient through the endotracheal tube.
5. The skin and subcutaneous tissue are retracted open using a Weitlander retractor or by placing stay stitches (typically 2-0 Vicryl)
6. Blunt dissection using the forefinger is performed to separate the strap muscles and to dissect down to the pretracheal fascia.
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