Tracheotomy

Tracheotomy is an urgent, and in other cases planned, surgical intervention performed when respiratory obstruction of the larynx or trachea occurs, leading to suffocation. The main goal of urgent tracheotomy is to save the patient's life, and then for intubation anesthesia, administration of drugs into the trachea and bronchi, suction of pathological contents from the subglottic space and underlying sections, etc.

Tracheotomy is divided into upper and lower, depending on whether the trachea is dissected above or below the isthmus of the thyroid gland. The site of opening the trachea should always be below the site of its narrowing, otherwise the operation does not achieve its goal. Age is also taken into account: in children, the distance between the isthmus of the thyroid gland and the sternum is relatively greater than in adults, in whom the physiological downward displacement of the larynx during its development has already been completed; in addition, in young children, the isthmus covers the upper rings of the trachea and is tightly attached by fascia to the lower edge of the cricoid cartilage, which is why it is impossible to pull it down to perform an upper tracheotomy; therefore, in children, it is preferable to perform a lower tracheotomy, and in adults - an upper tracheotomy, which is technically more convenient. However, in case of severe inflammatory phenomena in the larynx, especially in case of laryngeal tonsillitis, abscesses and phlegmons of the larynx, perichondritis, it is advisable to perform a lower tracheotomy, thus distancing oneself from the source of inflammation.

In emergency cases, tracheotomy is performed with minimal preparatory measures, sometimes even without them, without anesthesia and even at the patient's bedside or in field conditions with improvised means. Thus, once O. Khilov had to open the trachea on the landing with a table fork; the result was successful.

It is most convenient to perform a tracheotomy "on a tube", i.e. with an intubated trachea. Usually, such a tracheotomy is performed when the intubation tube is in the trachea for more than 5-7 days, and the patient continues to need either artificial ventilation or can be transferred to independent breathing, which, however, cannot be done naturally. Transferring the patient to "tracheotomy" breathing prevents bedsores in the larynx and allows for various interventions to be performed in it, if necessary.

There are two types of opening of the trachea to provide paralaryngeal breathing to the patient: tracheotomy and tracheostomy. Tracheotomy is limited to opening the trachea (transversely or longitudinally) for temporary use of a tracheotomy cannula or an intubation tube. Tracheostomy is used when there is a need for long-term or permanent use of the opening made in the trachea, for example, in the case of upcoming plastic surgery on the larynx or after its extirpation due to cancer. In the latter case, an opening with a diameter of up to 10-12 mm is cut out in the wall of the trachea and its edges are sutured to the skin. In this way, a tracheostomy is formed for long-term use. When the need for a tracheostomy passes, it is closed plastically with a skin flap on a feeding leg.

The main instruments used to perform a tracheotomy are a pointed (tracheotomy) scalpel, a two- or three-bladed Trousseau dilator, a set of tracheotomy tubes of different sizes (No. 1-7 mm, No. 2-8 mm, No. 3-9 mm, No. 4-10 mm, No. 5-10.75 mm, No. 6-11.75 mm), as well as a number of auxiliary instruments (single-pronged hook, hooks, retractors, Kocher and Pean clamps, etc.).

During a planned (usual) tracheotomy, the following preparatory measures are envisaged (according to V.K. Suprunov, 1963). The day before, the patient is prescribed sedatives, and at night - a sleeping pill. 20 minutes before the surgical intervention, standard premedication is administered with the introduction of atropine and diphenhydramine. Usually, the patient is placed on his back with his head thrown back and a bolster is placed under his back at the level of the shoulder blades. If the patient has difficulty breathing as a result of obstruction of the larynx, then this position sharply increases this difficulty, in such cases, the patient is given this position immediately before the incision. After treating the skin with alcohol, a vertical scratch is made along the midline with the back of the scalpel, thus marking the line of the future incision.

Anesthesia is produced by injecting an anesthetic solution under the skin and into deeper tissues, focusing on the position of the larynx and trachea (20-30 ml of 0.5-1% novocaine solution with the addition of 1 drop of 1:1000 adrenaline solution per 1 ml of novocaine). The injection sites and directions of injection of the anesthetic solution are shown in Fig. 353, a.

Upper tracheotomy technique

The surgeon stands on the right side of the patient, the assistant on the other side, the operating nurse at the table for surgical instruments to the right of the assistant. The surgeon fixes the larynx with the first and third fingers, and places the second finger in the space between the thyroid and cricoid cartilages. This ensures reliable fixation of the larynx and its retention in the median plane. An incision is made in the skin along the previously marked midline; it begins under the protrusion of the thyroid cartilage and continues downwards by 4-6 cm in adults and 3-4 cm in children. The skin with subcutaneous tissue and aponeurosis are dissected; bleeding from arteries and veins is stopped by clamping with hemostatic clamps and bandaged.

The correct sequence is: first, the end of the cannula is inserted into the lumen of the trachea from the side; only after the end of the cannula has entered the trachea, the tracheotomy tube is moved to a vertical position, while the cannula shield is installed horizontally.

When performing an upper tracheotomy, it is necessary to avoid injury to the cricoid cartilage, as this can lead to its chondroperichondritis with subsequent development of persistent stenosis. Bleeding vessels, if the patient's condition allows, are best ligated before opening the trachea, otherwise they should be left under clamps. Failure to comply with this rule leads to blood entering the trachea, which causes coughing, increased intrathoracic and arterial pressure and increased bleeding.

Lower tracheotomy

Lower tracheotomy is a more complicated operation than the upper one, since the trachea at this level deviates deeply back and is entwined with a dense network of venous vessels. In 10-12% of cases, an abnormal vessel a. thyroidea ima passes through this area - the lowest and deepest artery, the injury to which causes severe bleeding that is difficult to stop.

The skin is incised from the lower edge of the cricoid cartilage down the midline to the jugular fossa. After the skin, subcutaneous tissue and aponeurosis are incised, the blunt incision is made between the sternohyoid muscles, the loose connective tissue lying on the trachea is split and the trachea is exposed.

The incision of the soft tissues of the anterior surface of the neck is carried out in such a way as not to injure the isthmus of the thyroid gland and the unstable pyramidal process emanating from it. In case of upper tracheotomy, it should be known that the upper edge of the isthmus lies at the level of the 1st tracheal cartilage, less often - II or III. In children, it is located somewhat higher, touching the cricoid cartilage and covering it. The isthmus covers 2-3 upper rings of the trachea, therefore, in case of upper tracheotomy, it is separated and pulled downwards with a blunt hook. In carrying out this stage of the operation, it should be taken into account that the isthmus is covered in front by the sternohyoid muscles, above which is the pretracheal plate, then the superficial plate of the cervical fascia and, finally, the skin. Along the midline of the neck, corresponding to the interval between the medial edges of the sternohyoid muscles, the isthmus is covered only by adhesions in this place with the fascial sheets and skin. To separate the isthmus and move it downwards to expose the upper rings of the trachea, the right and left sternohyoid muscles are spread apart bluntly, having first freed them from the fascial bed, then the fibers connecting the isthmus to the fascial sheets and skin are dissected. The II and III rings of the trachea, exposed in this way, are dissected from the bottom up, piercing the scalpel with the blade outward so as not to injure the posterior wall of the trachea, devoid of cartilage (longitudinal tracheotomy). With a longitudinal incision of soft tissues, a transverse opening of the trachea is possible (longitudinal-transverse tracheotomy according to V. I. Voyachek), performed between the II and III rings, while the scalpel is pierced into the gap between them, consisting of dense fibrous tissue, from the side, with the blade upward, to a depth that allows immediate penetration into the tracheal cavity. A sign of this is the release of air through the incision, accompanied by splashes of mucus and blood, as well as coughing. This stage is extremely important, since in some inflammatory and infectious diseases of the trachea, its mucous membrane is especially easily peeled off from the perichondrium, which can create a false impression of penetration into the lumen of the trachea, entailing a gross error - insertion of the tracheotomy tube not into the lumen of the trachea, but between its wall and the peeled mucous membrane. For tracheostomy in the anterior wall of the trachea, the assistant pulls the trachea forward with a hook and holds it strictly along the midline, and the surgeon opens it with a longitudinal or transverse incision.

Features, difficulties and complications of tracheotomy

In case of severe laryngeal stenosis, placing a cushion under the patient's shoulders and throwing the head back sharply increases the stenosis, up to asphyxia. In these cases, tracheotomy is performed in a sitting position: the patient's head is thrown back a little and held in this position by an assistant, and the operating doctor sits on a low chair in front of the patient. All other actions are performed as described above.

Sometimes, if the assistant, having grasped the trachea together with soft tissues, moves it to the side, difficulty arises in finding the trachea. The situation in these cases can become threatening, especially in case of urgent tracheotomy. If the trachea ire can be found within 1 minute, and the patient is in a state of complete or almost complete obstruction of the respiratory tract, then one of the following surgical interventions is immediately performed:

1. dissection of the cricoid cartilage arch together with the lig. cricothyroideum;
2. dissection of the thyroid cartilage (thyrotomy);
3. dissection of the entire larynx (laryngotomy), and then, when breathing is restored and the necessary resuscitation measures have been carried out, a typical tracheotomy is performed, and the dissected parts of the larynx are sutured layer by layer.

If a tracheotomy fails to bypass a sharply enlarged thyroid gland, its isthmus is crossed between two previously applied hemostatic clamps. Such surgical intervention on the trachea is called a middle, or intermediate, tracheotomy.

In some cases, if anatomical changes in the larynx allow, tracheal intubation with artificial ventilation is performed before tracheotomy and after some improvement in the patient’s condition, tracheotomy is performed “on the tube”, and then tracheotomy is performed in “comfortable” conditions.

Complications during tracheotomy usually arise either because it is performed late (the so-called tracheotomy on a "corpse", i.e. during approaching or already occurred clinical death, or in case of acute cardiovascular failure). In the first case, it is necessary to open the trachea as soon as possible, start artificial ventilation and resuscitation measures, in the second case, simultaneously with the urgent opening of the trachea and oxygen administration, complex therapy is carried out to maintain cardiac activity. Other complications and errors include injury to the posterior wall of the trachea, a large vessel, detachment of the mucous membrane and insertion of a tube between it and the tracheal rings, which greatly increases asphyxia. In the first case, no action is taken, since the inserted cannula covers the damage, which spontaneously closes through the healing process. In other cases, errors are corrected during surgery.

After tracheotomy, the most common complications are subcutaneous emphysema and aspiration pneumonia. Subcutaneous emphysema occurs after tight suturing of the wound edges around the cannula, and the latter does not fit tightly to the hole made in the trachea, and air partially passes between the cannula and the edge of the hole into the tissue. Emphysema, with inattentive examination of the patient (examination after tracheotomy is carried out every 10-15 minutes for the next hour), can spread to large areas of the body (chest, abdomen, back), which, in general, is not fraught with any serious consequences for the patient. At the same time, the spread of emphysema to the mediastinum is a serious complication, since it causes compression of large vessels, lungs, and heart.

Subcutaneous emphysema usually appears immediately after applying the bandage and is recognized by swelling of the skin on the anterior wall of the neck and characteristic crepitation when palpating this swelling. In this case, it is necessary to remove the bandage, partially loosen the stitches, and apply a new bandage in a loosened form.

A serious complication of tracheotomy is pneumothorax, which occurs as a result of a rupture of the parietal or visceral pleura, alveoli or bronchi. This complication can occur with a poorly performed tracheotomy, in which a valve mechanism occurs - an easy inhalation and a difficult exhalation. Pneumothorax is an accumulation of air in the pleural cavity due to a violation of the tightness of the lung, trachea or bronchus. If during inhalation air is sucked into the pleural cavity, and during exhalation there is an obstacle to its exit (a check valve mechanism) due to the closure of the defect, a valve (tension, valve) pneumothorax occurs. Pneumothorax resulting from tracheotomy can be classified as both spontaneous and traumatic pneumothorax. The main symptoms of spontaneous pneumothorax are sudden chest pain, a feeling of lack of air due to compression of the lung by air accumulating in the chest cavity or its collapse. Sometimes cyanosis and tachycardia occur, in rare cases a drop in blood pressure is possible. During examination, a lag in half of the chest during breathing is noted. In young children, bulging of the affected half of the chest is sometimes noted. On the affected side, there is no palpable vocal fremitus, a box percussion sound is determined, respiratory sounds are weakened or not audible. The final diagnosis is established by X-ray examination (accumulation of gas in the pleural cavity and, accordingly, collapse of the lungs are detected). For pain relief, morphine, omnopon are administered; oxygen therapy is carried out. In case of progressively worsening condition of the patient (increasing dyspnea, cyanosis, sharp drop in blood pressure, etc.) caused by valvular pneumothorax, it is necessary to urgently perform pleural puncture in the second intercostal space along the midclavicular line, through which the air in the pleural cavity is aspirated. Such patients are evacuated to the thoracic surgery department, where they receive specialized care.

The occurrence of aspiration pneumonia is prevented by careful hemostasis before opening the trachea and by prescribing antibiotics. Rare complications include bleeding with a rapid (within minutes) fatal outcome from the brachiocephalic trunk, damaged during surgery or later as a result of a pressure ulcer from the tracheotomy cannula or erosion of the vessel wall due to infection.

Care for a tracheotomized patient in the absence of another pathological condition requiring special assistance is simple. Periodic cleaning of the inner tube is performed, proteolytic enzymes are instilled into it to liquefy the drying mucous discharge, and, if necessary, antibiotics mixed with hydrocortisone are administered to reduce postoperative edema of the mucous membrane. In some cases, with abundant discharge from the trachea, they are aspirated with a thin rubber catheter. The need to change the outer tube occurs rarely, mainly in the first days after surgery. When changing the outer tube, the patient is positioned in the same way as during surgery, and before inserting the tube, the wound is spread with hooks, and the tracheotomy opening is spread with a Trousseau dilator. It should be borne in mind that the tracheotomy opening without a cannula in it has the ability to close quickly, within a few minutes, so the removal of the outer tube and its replacement with a new one should occur almost immediately, this is especially important in the case of a lower tracheotomy, when the tracheotomy opening is in a deep wound.

At the end of the operation, a special bandage is applied, two long gauze ties are threaded through the ears of the tracheotomy cannula shield, which form 4 ends, tied around the neck with a knot with a "bow" on the side. So-called pants are placed under the shield from below - several gauze napkins folded together with a cut in the middle up to half, into which the tube is placed. A second napkin folded in several layers is placed under the upper ends of this napkin. Then a bandage made of gauze bandage is applied above the opening of the tracheotomy tube. After this, an "apron" made of medical oilcloth with a cut for the tube is placed directly under the shield so that secretions from it do not soak the bandage. The "apron" is tied to the neck with the help of ties attached to its upper ends in the same way as the tracheotomy cannula.

It is important to take care of the skin around the tracheostomy, which, even with adequate measures, is often subject to maceration and inflammation. The dressing should always be dry, and the skin should be thickly lubricated with zinc ointment mixed with corticosteroids and antibiotics (if pustular complications occur) before applying the dressing or when changing it.

Decannulation - removal of the tracheotomy cannula - is important in the treatment of a tracheotomized patient. Decannulation is performed when the patency of the larynx and trachea is persistently restored, which is determined by the patient's ability to breathe freely for a long time with the external opening of the tube closed or when it is removed, as well as in the presence of a sonorous voice and corresponding laryngoscopic data.

As noted by V.F. Undrits (1950), A.I. Kolomiychenko (1958) and others, in acute diseases of the larynx and trachea, decannulation can often be performed after several hours or days, provided that the obstruction that caused laryngeal stenosis (foreign body or inflammatory edema) is stably eliminated by appropriate therapeutic measures. Only damage to the deep tissues of the larynx and trachea (prolonged intubation and presence of a foreign body, trauma and disruption of the supporting skeleton of the larynx, perichondritis, etc.) prevent early decannulation. As noted by A.I. Kolomiychenko (1958), sometimes, more often in children, decannulation is difficult due to certain functional disorders (spasmophilia, etc.): immediately after decannulation, the child begins to choke, protesting against the air passage that has become less convenient for him. This installation reflex can be suppressed by periodic temporary restrictions of breathing through the tube, after which the child perceives the removal of the latter with relief. In chronic processes that cause persistent changes in the larynx (tumors, sclerotic infiltrates, papillomatosis, cicatricial process, paralysis, etc.), decannulation in the early stages is impossible, and in the later stages it is always more or less difficult.

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