Tracheotomy

The trachea is located in the middle of the neck, and the upper section is shallow, about 1.5 to 2 cm from the skin; the lower section gradually becomes deeper, and is about 4 to 4.5 cm 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. Between the superficial fascia and the platysma, there are many small veins (anterior venous plexus) that flow into the anterior jugular vein. The deep platysma is a deep layer of deep fascia that surrounds the anterior cervical muscles and forms a white fascia line in the midline. Behind the deep layer of deep fascia is the deep fascia middle anterior fascia and trachea. The anterior tracheal fascia is attached to the front wall of the trachea. The thyroid gland is located on both sides of the trachea. The thyroid isthmus is located in front of the 3rd and 4th tracheal rings, and is surrounded by the anterior fascia of the trachea. During operation, the thyroid isthmus should be pushed up or cut and then the trachea should be cut. There are thyroid dysplasia, veins and thyroid venous plexus on both sides of the trachea, and there are major blood vessels in the neck. Therefore, when the tracheotomy is performed, the incision must be in the safety triangle of the neck (the upper two corners of the triangle) At the junction of the ring cartilage and the sternocleidomastoid muscle, the lower corner is at the midpoint of the sternal notch).

Treatment of diseases: laryngeal paralysis, pulmonary heart disease, laryngeal obstruction

Indication

1. Acute and chronic laryngeal obstruction: such as acute laryngitis, diphtheria, laryngeal edema, throat tumor, scar stenosis, etc.

2. Difficulty breathing caused by respiratory secretion retention: craniocerebral trauma, intracranial or peripheral neurological disorders, tetanus, respiratory burns, cough caused by major chest and abdominal surgery, decreased dysfunction or laryngeal paralysis.

3. Pulmonary insufficiency: severe pulmonary heart disease, poliomyelitis and other respiratory muscle paralysis.

4. Upper airway obstruction after laryngeal trauma and maxillofacial throat surgery.

5. Foreign bodies in the respiratory tract cannot be taken out by mouth.

Contraindications

1. Tension pneumothorax (can be put on the machine after closed cannula drainage).

2. Low blood volume shock, heart failure, especially right heart failure.

3. Pulmonary bullae, pneumothorax and mediastinal emphysema before drainage.

4. Large hemoptysis patients.

5. Myocardial infarction (cardiac pulmonary edema).

Preoperative preparation

1. With the consent of the family member, explain the necessity of surgery and possible accidents.

2. Prepare surgical lights, aspirator, direct laryngoscope and endotracheal intubation.

3. Select a tracheal tube that fits the patient's tracheal thickness, including the outer cannula, inner cannula, and cannula core.

Surgical procedure

1. Position: supine position, flat and under the neck pillow, and maintain the back of the neck, the head is in the middle, the patient can use a semi-sitting position when the condition is not allowed.

2. Incision: The midline incision of the neck, the lower edge of the thyroid cartilage, down to the sternum above the notch.

3. Cut the subcutaneous tissue: Cut the superficial cervical fascia and platysma into the anterior cervical muscle. Use a small hook to pull the incision symmetrically to the sides, and ligation and cutting of the large superficial veins in the subcutaneous tissue. In patients with difficulty breathing, these small veins become thick and thick and must be ligated to avoid intraoperative bleeding and affect surgery. After the anterior cervical muscle is exposed, the white line is cut longitudinally.

4. Open the thyroid isthmus: use your fingers to probe the trachea and separate it downwards. The pale red and soft thyroid isthmus can be seen upwards. After separating the isthmus and the trachea with a curved hemostat, use the small hook to pull the isthmus upward. If the isthmus is larger, it can be cut with two curved hemostat clamps and the tracheal ring can be seen. The pre-tracheal fascia, sternal fossa and paratracheal tissue do not need to be separated too much to avoid mediastinal emphysema or pneumothorax. If there is a small blood vessel in front of the trachea to obstruct the tracheotomy, use a hemostatic forceps to clamp the small gauze ball gently to push one side away from the trachea; if there is bleeding, it should be ligated to stop bleeding.

5. Cut the tracheal ring: use a sharp knife to cut the 3rd to 4th (or 4~5) cartilage ring of the trachea in the median line before the trachea. When cutting, the blade should be facing upwards, picking up from the bottom upwards, the tip of the knife should not be pierced. Too deep, preferably 2 to 3 mm. When coughing, the anterior wall of the esophagus and the posterior wall of the trachea can be squeezed into the tracheal cavity. Therefore, the coughing should be quickly cut during the inhalation process.

6. Insert the tracheal cannula: After cutting the cartilage ring on the anterior wall of the trachea, use a curved hemostat or a tracheal intubation dilator to open the tracheal incision, and then insert the core tracheal cannula. If the patient has a strong cough, immediately remove the tube and use the aspirator to absorb the endocrine secretions and bloody fluid, and then put into the inner cannula. After confirming that the cannula has been inserted into the trachea, the hooks on both sides can be removed; if there is no gas in and out, the tracheal cannula should be pulled out. Reposition.

7. Handling the incision: the incision does not require suturing. If the incision is too long, suture 1 or 2 needles at the upper and lower ends, but not too tight, so as to avoid subcutaneous or mediastinal emphysema. The area around the incision is covered with oily gauze. A small gauze (3 to 4 layers) is cut between the incision and the cannula. Finally, the fixing band is wrapped around the neck and knotted on the side of the neck. The knot should be tightly stretched. When too loose, the sleeve is easy to slip off, causing suffocation; if it is too tight, local swelling may affect the venous return of the head. For example, when applying a cannula with an air bag, inject about 3 ml of air from the gas injection tube, and then fold the gas injection tube and tie it with a wire to ensure that there is no air leakage during artificial respiration.

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