Contents 1 Pinyin 2 English reference 3 Surgery name 4 Alias ??for tracheotomy 5 Category 6 ICD code 7 Overview 8 Applied anatomy 9 Indications for tracheotomy 10 Contraindications for tracheotomy 11 Preoperative preparation 12 Anesthesia 13 Surgical steps 13.1 Conventional tracheotomy 13.2 Emergency tracheotomy 14 Intraoperative precautions 15 Tracheotomy complications 16 Postoperative management 1 Pinyin
qì guǎn qiē kāi shù 2 English Reference
tracheotomy 3 operation name
Tracheotomy 4 Alias ??of tracheotomy
Tracheotomy; tracheotomia; tracheotomy 5 classification
Thoracic Surgery/Invasive Diagnosis and Treatment Technology
6 ICD Code
31.3 01 7 Overview
Tracheotomy is a method of rescuing critically ill patients Emergency surgery is also a skill that thoracic surgeons must master. The method is to incise the skin and trachea in the neck and insert the cannula into the trachea. The patient can breathe directly through the cannula and suck out sputum through the cannula. Tracheotomy is divided into conventional tracheotomy and emergency tracheotomy. Two kinds. In normal people, 1/3 to 1/2 of the respiratory tract resistance comes from the upper respiratory tract. The air volume in the dead space of the respiratory tract (anatomical dead space) is about 150 ml, of which about 100 ml is in the upper respiratory tract. Therefore, after tracheotomy, the resistance in the trachea is greatly reduced. The effective ventilation volume is greatly increased, thereby improving the patient's breathing condition. In addition, after tracheotomy, sputum can be aspirated and intratracheal administration can be carried out in time to prevent suffocation of comatose patients, and oxygen inhalation can be pressurized in time to correct respiratory failure. Therefore, tracheotomy is of extremely important clinical significance for the rescue of patients with poisoning, coma, respiratory failure, laryngeal and upper respiratory tract infarction. 8 Applied Anatomy
The trachea is located in the middle of the neck, and its upper section is shallow, far away from the skin. About 1.5~2cm; the lower section gradually becomes deeper, and is about 4~4.5cm away from the skin at the upper edge of the sternum. The front of the trachea is covered by skin, subcutaneous tissue, superficial fascia, and platysma muscle. Between the superficial fascia and the platysma muscle, there are many small veins (anterior jugular venous plexus) that drain into the anterior jugular vein. The deep platysma muscle is the superficial layer of deep fascia, which surrounds the anterior cervical muscles on both sides and connects to a white fascia line in the midline. Behind the superficial layer of deep fascia is the middle layer of deep fascia, the pretracheal fascia and the trachea. The pretracheal fascia attaches to the anterior wall of the trachea. The thyroid is located on both sides of the trachea, and the thyroid isthmus is located in front of the third and fourth tracheal rings and is surrounded by the pretracheal fascia. During surgery, the thyroid isthmus should be pushed upward or cut off before the trachea is incised. On both sides of the trachea are the inferior thyroid artery and vein and the azygos plexus of the thyroid on the inner side, and on the outer side are the main blood vessels of the neck. Therefore, when performing a tracheotomy, the incision must be within the safety triangle of the neck (the two upper corners of the triangle) At the junction of the cricoid cartilage and the sternocleidomastoid muscle, the inferior angle is located at the midpoint of the sternal notch). 9 Indications
1. Acute and chronic laryngeal obstruction, such as acute laryngitis, diphtheria, laryngeal edema, throat tumors, scar stenosis, etc.
(1) Central respiratory depression: including central respiratory failure caused by various infections, encephalitis, poisoning, high fever, etc., intracranial hypertension, brain herniation, craniocerebral and spinal cord trauma, drug suppression wait.
(2) Peripheral respiratory paralysis: including respiratory muscle paralysis caused by spinal cord, peripheral nerve and muscle diseases. Such as ascending myelitis, high paraplegia, amyotrophic lateral sclerosis, Guillain-Barre syndrome (GBS), myasthenic crisis, thoracic trauma, etc.
2. Dyspnea caused by disorder of consciousness combined with retention of lower respiratory tract secretions, craniocerebral trauma, intracranial or peripheral nerve disease, tetanus, respiratory burns, cough and vomiting caused by major chest or abdominal surgery When phlegm function decreases or larynx is paralyzed.
3. Pulmonary insufficiency: severe pulmonary heart disease, poliomyelitis, etc. causing respiratory muscle paralysis.
4. Upper respiratory tract obstruction after laryngeal trauma or major maxillofacial and pharyngeal surgery.
5. Foreign bodies in the respiratory tract that cannot be removed through the mouth.
6. Myoplegic therapy for muscle spastic diseases. When frequent twitches and muscle spasms result in restricted ventilation due to different reasons, muscle relaxants and ventilators can be used for treatment
7. Preparation The preoperative pulmonary function test values ??of patients undergoing thoracic surgery are extremely poor, but the surgery must be performed. After the thoracotomy operation, a tracheotomy is performed immediately, and a ventilator can be used to assist breathing after returning to the ward. Often, after 3 to 5 days, Respiratory failure that may occur after surgery can be safely overcome. This method can be called "preventive tracheotomy" and also plays a role in expanding the indications for surgery. 10 Contraindications
1. Tension pneumothorax (you can go on the machine after intubation and closed drainage).
2. Hypovolemic shock, heart failure, especially right heart failure.
3. Pulmonary bullae, pneumothorax and mediastinal emphysema before drainage.
4. Patients with massive hemoptysis.
5. Myocardial infarction (cardiogenic pulmonary edema). 11 Preoperative preparation
1. Obtain the consent of the family and explain the necessity of the operation and possible accidents.
2. Prepare surgical lighting, suction device, direct laryngoscope and endotracheal intubation.
3. Select a tracheal cannula suitable for the thickness of the patient’s trachea, including an outer cannula, an inner cannula and a cannula core [Figure 11, 2].
11. Ordinary tracheal cannula
12. Tracheal cannula with balloon
Figure 1. Various tracheal cannula 12. Anesthesia
General application 1% procaine for local anesthesia. When tracheal puncture is performed after the trachea is exposed, 0.2-0.3ml of 1% to 2% dicaine can be instilled to anesthetize the tracheal mucosa. In emergencies or when the patient is in a coma, anesthesia is not required. 13 Surgical steps 13.1 Conventional tracheotomy
(1) Incision: There are two kinds of incisions, horizontal and vertical. The longitudinal incision is easy to operate, and the advantage of transverse incision is that there is light postoperative scar. Transverse incision: Centered on the midline, 3cm above the sternal notch, make a symmetrical transverse incision along the skin stripes of the front of the neck, 4 to 5cm long (Figure 5.1.111); Longitudinal incision: in the middle of the front of the neck, from the cricoid cartilage to the sternal notch. Above, 4 to 5cm long. After incising the skin, subcutaneous tissue, and superficial platysma fascia, use a retractor to pull to both sides. You will see the white line where the anterior cervical muscles on both sides join in the middle of the front of the neck. This is slightly concave. See emergency tracheotomy. Figure 5.1.111.
(2) Use straight vascular forceps or straight scissors to separate vertically up and down along the white line, and use retractors to pull the separated muscles to both sides. The force of the retractors on both sides should be even and not biased to one side. During separation, the surgeon should always use the left index finger to feel the position of the trachea to avoid directional deviation. After the muscles are separated, the pretracheal fascia is reached, and the anterior jugular veins can be ligated or cut (Figure 5.1.112). After the anterior tracheal wall is exposed, the pretracheal fascia does not need to be separated, which can avoid the occurrence of pneumomediastinum and reduce the chance of accidentally inserting the tracheal tube into the pretracheal space (Figure 5.1.113).
(3) After the anterior wall is fully exposed, pull the tracheal tube inserted through the mouth or nose outward to slightly above the plane of the tracheal incision, while still keeping it in the trachea, and use a sharp knife to inject it into the trachea. Insert between 2 to 4 tracheal rings, make a tracheal incision of about 1cm (Figure 5.1.114), then use tissue forceps to clamp the tracheal wall, and use a sharp knife or scissors to cut a circle or oval with a diameter of 0.8 to 1cm on the front wall of the trachea. shape hole, aspirate the secretions, use a tracheal spreader or curved hemostat to extend into the trachea and expand it, and insert a tracheal cannula of appropriate caliber into the trachea through the opening (Figure 5.1.115). Note that sometimes it is difficult to insert the tracheal tube because the opening is too small or the patient coughs hard, causing the tube to slip out of the opening and enter the pretracheal space.
(4) After the tracheal tube is placed, inflate the air bag, insert a suction tube to suck out the secretions and blood accumulated in the respiratory tract, and check whether the ventilation is good. If there is an oral or nasal intubation, the intubation can be removed. The skin on both sides of the tracheal cannula is sutured with one stitch. Wrap a cloth band around the neck to fix the tracheal cannula, and use a cut sterile gauze to place it between the tracheal cannula and the incision (Figure 5.1.116) to complete the operation.
13.2 Emergency tracheotomy
(1) During emergency tracheotomy, it is best to use a vertical midline incision on the skin, starting 2 to 3 cm below the laryngeal incision and 4 to 5 cm long (Figure 5.1 .117).
(2) Carefully maintain the midline and cut the scalpel directly into the trachea under the cricoid cartilage. Three tracheal rings and the membrane between them can be cut along the midline. Avoid incising the cricoid cartilage (Fig. 5.1.118).
(3) Insert the knife handle into the tracheal incision and rotate it slightly to separate the soft tissue so that air can freely enter and exit the trachea (Figure 5.1.119).
(4) Insert the tracheal tube. The subsequent operation is the same as conventional tracheotomy. This surgery is now mostly replaced by oral endotracheal intubation, and routine tracheotomy is performed after the dyspnea is quickly relieved. Only use it when conditions are critical and the situation is critical. 14 Intraoperative Precautions
1. Due to the seriousness of the condition, no delay is allowed, and there is no tracheotomy instrument, you can use a daily physiological knife to incise the skin in front of the trachea, Use your fingers to explore the subcutaneous tissue and cervical white line to feel the tracheal ring, and use your fingers as a guide to cut the tracheal ring. Then, insert the handle of the knife into the trachea, turn it at an angle to open the tracheal incision, and then insert an ordinary rubber catheter. Its outer end is cut into two flaps, and holes are cut at the ends of the flaps to fasten the straps and separate them on both sides to replace the tracheal cannula. After padding the area around the wound with oil gauze and small gauze, secure the band around the neck [Figure 3].
2. During the operation, the patient’s head should be kept in a neutral and posterior position. Keep the incision in the midline of the neck. It cannot be dissected sideways. The position of the trachea should be explored at any time during the operation to guide the direction and depth of separation.
3. The retractor is pulled when it is separated to the deep part. Each time a layer is cut, the retractors on both sides will move at the same time to draw one layer deeper. The pulling force on both sides should be even to avoid uneven pulling force. , pull the trachea to one side. When separating to the front wall of the trachea, the retractor should be pulled outward and forward, and do not press backward to avoid compressing the trachea. When the tracheal cartilage ring has been cut and the tracheal cannula has not yet been inserted, special attention should be paid not to unhook it, so as not to increase the difficulty of intubation.
4. The pretracheal fascia should not be separated and can be incised at the same time as the anterior tracheal wall. Do not separate the side walls of the trachea, otherwise the pleural roof or mediastinum may be easily injured, and the tracheal incision may be deflected to one side, making extubation difficult.
5. The tracheotomy position should be between the 3rd and 4th cartilage rings. If it is too high, it will easily damage the first cartilage ring and cause laryngopharyngeal stenosis; if it is too low, it will easily cause the cuff to become inflamed. The tube prolapses or presses against the protuberance, causing mucosal damage and bleeding, mediastinal emphysema, and even injury to the large blood vessels in the chest. The pleural roof on the right side of children is higher, so be careful to prevent damage.
6. Hemostasis must be perfect during the operation, and the skin must not be sutured too tightly to prevent hematoma or emphysema. 15 Complications of tracheotomy
1. Bleeding at the tracheal incision. A small amount of bleeding can be stopped by local compression. If the amount of bleeding is large, hemostatic drugs should be used. In severe cases, you need to go to the operating room for treatment.
2. Subcutaneous emphysema is caused by excessive separation of paratracheal tissue or blocked tubes. No treatment is required and it is generally absorbed on its own.
3. Pneumomediastinum and pneumothorax are caused by excessive separation of the pretracheal fascia. Severe cases may cause difficulty breathing, and closed drainage should be performed.
4. Pulmonary infection.
5. Tracheoesophageal fistula is extremely rare, mostly due to the patient's lack of cooperation, causing the operator to lose accuracy during the operation or long-term compression by the tracheal cannula. Treatment can be through nasal feeding.
6. Airway stenosis: The proliferation of granulation tissue in the tracheal incision damages the thyroid cartilage and causes inversion of the tracheal incision, resulting in airway stenosis. Symptoms include dyspnea and stridor after extubation, which can be diagnosed by combining bronchoscopy and X-ray tomography. Mild cases do not require treatment, while severe cases require surgery. 16 Postoperative treatment
1. Keep the room clean, with fresh air, a temperature of about 22°C, and a relative humidity of about 50%. Change two layers of wet saline gauze to cover the casing opening every day to prevent dust and foreign matter from being inhaled and to prevent the formation of dry scabs.
2. Instill antibiotics, alpha chymotrypsin and steam inhalation into the trachea for 15 minutes as needed, 3 to 4 times a day. *** It is not advisable to move excessively. When turning over, the head, neck, and trunk should be kept rotating on the same axis to avoid pain or difficulty breathing caused by the movement or prolapse of the cannula.
For children or unconscious patients who are likely to remove the cannula on their own, their arms should be immobilized.
3. Pay close attention to whether there is dyspnea, increased breathing frequency and resistance, bleeding in the cannula, etc., and find the cause in time and deal with it.
4. The tube should be extubated as soon as possible after the respiratory and gas exchange volume are resolved. Note before extubation:
⑴ First block 1/2 of the tube opening with cork or tape. If there is no difficulty in breathing, you can further block 2/3 until it is completely blocked for 1 to 2 days without difficulty in breathing. Can be extubated. The cork or tape must be threaded onto the tracheal cannula strap to prevent it from being sucked into the trachea.
⑵ If a tracheal cannula with an air bag is used, the air bag should be discharged first, and then the cannula should be blocked.
⑶ Prepare a set of tracheostomy instruments before extubation in case of difficulty breathing after extubation and re-intubation.