Tracheotomy

Tracheotomy refers to urgent, in other cases and planned surgical interventions, produced in the event of respiratory obstruction of the larynx or trachea, resulting in suffocation. The production of urgent tracheotomy pursues the main goal - saving the patient's life, and then - for intubation anesthesia, the introduction of drugs into the trachea and bronchi, aspirations from the lining space and the underlying parts of pathological contents, etc.

Tracheotomy is divided into upper and lower, depending on whether the trachea is dissected above or below the neck of the thyroid. The location of the opening of the trachea should always be below the site of its constriction, otherwise the operation does not reach the 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, whose physiological displacement of the larynx is already complete in the course of its development; In addition, in young children, the isthmus covers the upper tracheal rings and is tightly attached by the fascia to the lower edge of the cricoid cartilage, so it is not possible to pull it downwards to produce the upper tracheotomy; so children prefer to do lower tracheotomy, and in adults - upper, technically more convenient. However, with pronounced inflammatory phenomena in the larynx, especially in the laryngeal angina, abscesses and phlegmon of the larynx, perichondritis, it is advisable to carry the lower tracheotomy, thus distancing itself from the focus of inflammation.

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

To make a tracheotomy is most convenient "on the tube", i.e. With an intubated trachea. Typically, such a tracheotomy is made when the intubation tube is in the trachea for longer than 5-7 days, and the patient continues to need either ventilation, or can be switched to independent breathing, which, however, can not be performed naturally. Transfer of the patient to "tracheotomy" breathing prevents bedsores in the larynx and allows various interventions to be made if necessary.

The autopsy of the trachea to provide the patient with paralaringnal breathing is of two kinds - tracheotomy and tracheostomy. Tracheotomy is limited only to the opening of the trachea (transverse or longitudinal) for temporary use of the tracheotomy cannula or the intubation tube. Tracheostomy is used when there is a need for prolonged or continuous use of a hole in the trachea, for example, in the future plastic surgery on the larynx or after its extirpation for cancer. In the latter case, a hole with a diameter of up to 10-12 mm is cut into the wall of the trachea and its edges are sewn to the skin. Thus form a tracheostomy for long-term use. When the need for a tracheostomy passes, it is closed by a plastic flap of the skin on the feeding leg.

For the tracheotomy, the main instruments are a pointed (tracheotomy) scalpel, a two- or three-lobed Trusso expander, 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 tools (single-toothed hook, hooks, retractors, Kocher and Pean clamps, etc.).

With the planned (regular) tracheotomy, the following preparatory measures are envisaged (according to VK Suprunov, 1963). On the eve of the patient prescribe sedatives, at night - sleeping pills. 20 minutes before surgery, a standard premedication with the administration of atropine and diphenhydramine is carried out. Usually the patient is placed on his back with his head thrown back and a roller is placed under his back at the level of the shoulder blades. If the patient has difficulty breathing due to obstruction of the larynx, then this situation dramatically increases this difficulty, in such cases, this position is given to the patient immediately before the incision. After treatment of the skin with alcohol along the middle line, the back side of the end of the scalpel is applied with a vertical scratch, thus denoting the line of the future incision.

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

Top tracheotomy technique

The surgeon rises from the right side of the patient, the assistant - on the other hand, the operating nurse - at the table for surgical instruments - to the right of the assistant. Surgeon I and III with fingers fixes the larynx, and II finger puts in the gap between the thyroid and cricoid cartilage. This ensures reliable fixation of the larynx and its retention in the median plane. A skin incision is made along the planned middle line; it begins under the ledge of the thyroid cartilage and continues downwards by 4-6 cm in adults and 3-4 cm in children. Dissect the skin with subcutaneous tissue and aponeurosis; bleeding from arteries and veins is stopped by clamping with hemostatic clamps and bandaged.

Correct sequence: 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 transferred to the vertical position, while the cannula shield is installed horizontally.

Carrying the upper tracheotomy, it is necessary to avoid injuring the cricoid cartilage, so it can lead to its chondroperichondritis and subsequent occurrence of persistent stenoses. Bleeding vessels, if the patient's condition allows, it is better to bandage before opening the trachea, otherwise they should be left under the clamps. Failure to comply with this rule leads to the ingress of blood into the trachea, which causes cough, an increase in intrathoracic and arterial pressure and increased bleeding.

Lower tracheotomy

Lower tracheotomy is an operation more complicated than the upper one, since the trachea at this level deviates deeply back and is braided by a dense network of venous vessels. In 10-12% of cases in this area is an abnormal vessel a. Thyroidea ima is the lowest and deepest artery, the wound of which causes severe hard-to-stop bleeding.

Cut the skin from the lower edge of the cricoid cartilage down the middle line to the jugular fossa. After dissection of the skin, subcutaneous tissue and aponeurosis stupidly penetrate into the depth between the sternocleid muscles, split loose connective tissue lying on the trachea and expose the trachea.

The incision of the soft tissues of the anterior surface of the neck is carried out so as not to injure the isthmus of the thyroid gland and the inconstant pyramidal process emerging from it. At the top tracheotomy it is necessary to know that the upper edge of the isthmus lies at the level of 1 cartilage of the trachea, rarely - II or III. In children it is located somewhat higher, touching the cricoid cartilage and covering it. The isthmus covers 2-3 upper tracheal rings, so when it is tracheotomy it is vyseparovyvayut and pulling the blunt hook down. When carrying out this ethane operation, it should be borne in mind that the isthmus is covered in the front with the sternum muscles, above which is the pre-tracheal plate, then the superficial plate of the cervical fascia and finally the skin. On the middle line of the neck, respectively, the gap between the medial edges of the pseudo-lingual muscles of the isthmus is covered only by fissures in this place with fascial leaves and skin. To separate the isthmus and move it downward to expose the upper tracheal rings, the right and left sternum muscles are spread out in a blunt way, first releasing them from the fascial bed, then dissecting the fibers that connect the isthmus with the fascial leaves and the skin. Naked in this way, II and III tracheal rings dissect from below upwards, puncturing the scalpel with the blade outward so as not to injure the posterior wall of the trachea, which is devoid of cartilage (longitudinal tracheotomy). With a longitudinal section of soft tissues, a tracheal opening (longitudinal-transverse tracheotomy according to VI Voyachek), produced between the 2nd and 3rd rings, is possible, while the scalpel is inserted into the gap between them, consisting of dense fibrous tissue, laterally, with the blade up, on the The depth, allowing immediately to penetrate into the cavity of the trachea. A sign of this is the air outlet through the incision, accompanied by splashes of mucus and blood, as well as a cough. This stage is extremely responsible, as with some inflammatory and infectious diseases of the trachea, its mucous membrane is especially easily exfoliated from the perichondrium, which may create a false impression of penetration into the lumen of the trachea, leading to a gross error - insertion of the tracheotomy tube not into the lumen of the trachea, but between its wall and exfoliated mucosa. For tracheostomy in the anterior wall of the trachea, the assistant pulls the trachea forward and holds it strictly along the middle line, and the surgeon opens it with a longitudinal or transverse incision.

Features, difficulties and complications of tracheotomy

With severe stenosis of the larynx, placing the platen under the shoulders of the patient and tilting the head back stenosis increases dramatically, up to asphyxia. In these cases, the tracheotomy is made in the sitting position: the patient's head is thrown back somewhat and in this position the assistant holds it, and the operating doctor sits on a low stool in front of the patient. All other actions are carried out as described above.

Sometimes, if the assistant, capturing the trachea with soft tissues, shifts it to the side, there is a difficulty in finding the trachea. The situation in these cases can become menacing, especially with urgent tracheotomy. If trachea ire can be found within 1 minute, and the patient is in a state of complete or almost complete obstruction of the airways, then immediately one of the following surgical interventions is performed:

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

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

In some cases, if anatomical changes in the larynx are allowed, the trachea is intubated from the ventilator before the tracheotomy and, after some improvement in the patient's condition, a tracheotomy "on the tube" and then a tracheotomy in "comfortable" conditions.

Complications during tracheotomy usually occur either because of its late conduction (the so-called tracheotomy on the "corpse", i.e., during the oncoming or onset of clinical death, or in acute cardiovascular insufficiency). In the first case, it is necessary to open the trachea as soon as possible, to proceed to the ventilation and resuscitation measures, in the second case, simultaneously with the urgent opening of the trachea and giving oxygen, a complex therapy is performed to maintain cardiac activity. Other complications and errors include injuring the posterior wall of the trachea, a large vessel, detaching the mucosa and inserting a tube between it and the trachea rings, which dramatically 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 eliminated during surgery.

After tracheotomy, the most common complications are subcutaneous emphysema and aspiration pneumonia. Subcutaneous emphysema occurs after dense suturing of the edges of the wound around the cannula, and the latter is loosely attached to the hole made in the trachea and the air partially passes between the cannula and the edge of the opening into the cellulose. Emphysema during inattentive examination of the patient (examination after a tracheotomy is carried out every 10-15 minutes within the next hour) can spread to large body surfaces (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, as it causes the compression of large vessels, lungs, and heart.

Subcutaneous emphysema usually appears immediately after the dressing is applied and is recognized by the skin swelling on the front wall of the neck and the characteristic crepitation when feeling this swelling. In this case, it is necessary to remove the bandage, partially loosen the seams, and put a new bandage in a weakened form.

A serious complication of tracheotomy is pneumothorax, which occurs as a result of rupture of the parietal or visceral pleura, alveoli, or bronchi. This complication can occur with poor tracheotomy, in which there is a valve mechanism - a light breath and a labored exhalation. Pneumothorax - an accumulation of air in the pleural cavity due to a violation of the tightness of the lung, trachea or bronchus. If during the inhalation air is sucked into the pleural cavity, and when it exhales, there is an obstacle to its exit (the mechanism of the check valve) due to the closure of the defect, a valve (strained, valve) pneumothorax arises. Pneumothorax, resulting from tracheotomy, can be attributed to both spontaneous and traumatic pneumothorax. The main symptoms of spontaneous pneumothorax are sudden chest pain, a feeling of lack of air due to the compression of the lung by the accumulation of air in the chest cavity or its falloff. Sometimes there is cyanosis, tachycardia, in rare cases, a drop in blood pressure is possible. On examination, the lag of half of the thorax during respiration is noted. In young children, sometimes the bulging of the affected half of the breast is noted. On the side of the lesion there is no detectable palpation voice tremor, a box percussion sound is determined, respiratory noise is weakened or not audible. The final diagnosis is established by X-ray examination (reveals the accumulation of gas in the pleural cavity and, accordingly, the decline of the lungs). For anesthesia, morphine, omnopon; carry out oxygen therapy. In the progressively deteriorating state of the patient (the increase in dyspnea, cyanosis, a sharp drop in blood pressure, etc.) due to the valve pneumothorax, it is necessary to urgently make pleural puncture in the second intercostal space along the midclavicular line through which aspirate the air located in the pleural cavity. Such patients are evacuated to the thoracic surgery department, where they are provided with specialized care.

The emergence of aspiration pneumonia is prevented by the implementation of thorough haemostasis before opening the trachea and the appointment of antibiotics. Of the rare complications, mention should be made of bleeding with a rapid (within a few minutes) fatal outcome from a brachiocephalic trunk damaged during surgery or later as a result of a decubitus from a tracheotomy cannula or artery wall of the vessel as a result of infection.

Care for tracheotomized patients in the absence of a different pathological condition requiring special care is simple. Periodic purification of the inner tube, instillation of proteolytic enzymes into it to dilute the drying mucous discharge, if necessary, antibiotics in a mixture with hydrocortisone to reduce postoperative edema of the mucosa. In some cases, with abundant discharge from the trachea, they are sucked off with a thin rubber catheter. The need to change the outer tube appears rarely, mainly in the first days after the operation. When the external tube is changed, the patient is laid in the same way as during the operation, and before the tube is inserted, the wound is hooked, and the tracheotomy opening is expanded by the Tissaur expander. In this case, it should be borne in mind that the tracheotomy without the cannula located in it has the ability to close quickly within a few minutes, so removing the outer tube and replacing it with a new one should occur almost immediately, especially in the lower tracheotomy, when the tracheotomy the hole is in a deep wound.

After the operation, a special bandage is applied, two long gauze bandages are passed into the ears of the tracheotomy cannula, which form 4 ends tied around the neck with a knot with a "bow" on the side. Under the shield from below put the so-called panties - several folded together gauze napkins with a notch in the middle to half, in which the tube lies. Under the upper ends of this napkin lay a second napkin folded in several layers. Then, a bandage from the gauze bandage is placed above the opening of the tracheotomy tube. After this, directly under the scutcheon is supplied with a cutout for the tube "apron" from the medical oilcloth, so that the discharge from it does not impregnate the bandage. "Apron" with ties attached to its upper ends tied to the neck in the same way as the tracheotomy cannula.

It is important to care for the skin around the tracheostomy, which even under adequate measures is often subjected to maceration and inflammation. The dressing should always be dry, and the skin should be densely lubricated with zinc ointment in combination with corticosteroids and antibiotics before the dressing is applied or when it is replaced (if there are pustular complications).

Important in the treatment of a tracheotomy patient is the conduct of decanulation - extraction of the tracheotomy cannula. Decanulation is performed with a stable restoration of the laryngeal and tracheal patency, which is determined by the ability of the patient to breathe for a long time and freely with the closed external opening of the tube or when it is removed, as well as in the presence of a sonorous voice and the corresponding laryngoscopic picture.

As noted by VFUndrits (1950), AI Kolomiychenko (1958), etc., in acute diseases of the larynx and trachea, dekanulation can often be carried out after several hours or days, provided the obstacle that caused stenosis of the larynx foreign body or inflammatory edema) by appropriate therapeutic measures. Only the defeat of the deep tissues of the larynx and trachea (prolonged intubation and stay of the foreign body, trauma and violation of the supporting skeleton of the larynx, perichondritis, etc.) prevent early decanulation. As AI Kolomiychenko (1958) notes, sometimes, more often in children, dekanulation is difficult on the basis of some functional disorders (spasmophilia, etc.): the child begins to choke after decanulation, to protest against the airway that has become less convenient for him. This adjustment reflex can be suppressed by periodic temporal restrictions of breathing through the tube, after which the child perceives the removal of the latter with relief. In chronic processes, which cause stable changes in the larynx (tumors, scleral infiltrates, papillomatosis, scar process, paralysis, etc.), decanulation in the early period is impossible, and in later periods it is always more or less difficult.

[1], [2], [3], [4], [5], [6]