Welcome back to the Deep Dive. Today the vibe in the studio is
a little different. Usually we are relaxed, we are
curious, we are just exploring ideas.
But today, today my palms are sweating just a little bit.
I can feel it. Because today we are simulating
the walk down that long quiet corridor to the exam hall.
We are stepping into the shoes of a final year MD
Anesthesiology student facing the Gujarat University
Examiners. The pressure cooker, I remember
that walk well. And honestly, for anyone
listening who isn't actually taking that specific exam, don't
tune out. No, definitely not.
Because what we are doing today is essentially a master class in
advanced airway management, we are stripping away the fluff and
focusing purely on examiner centric knowledge regarding
tracheostomy. Exactly, I've got my stack of
books here. I'm looking at Millers
Anesthesia, Ocean Intensive care manual, Morgan and Michael, but
I don't have time to read 200 pages right now.
Nobody does. I need the extraction.
I need the examiner centric gold.
Our mission is tracheostomy indications, techniques,
complications and management. And that is a topic that smells
like fear in an exam. It's the ultimate crossover
topic. It's surgical, it's airway, it's
ICU, and it's Emergency Management.
All in one. All in one.
If you're sitting in a Viva and they hand you a tracheostomy
tube, you can either look like a consultant or you can fail the
station in 30 seconds. That is terrifying.
Yeah. So let's structure this exactly
how the exam demands. We need to cover the long
question, that massive 20 mark essay structure.
Yeah, read the short note on PDT.
Yeah. And we need to survive the table
Viva traps. Let's start with part A,
introduction and exam framing. If I open that exam paper and
see tracheostomy is the long question.
How do I start without rambling? You start with the definition
crisp and precise. Do not just say it's a hole in
the neck. Right, that's two basic
undergraduate level. Exactly.
You define it strictly as a surgical procedure creating an
opening, an artificial opening in the anterior aspect of the
neck to access the lower airway through the trachea.
OK, specific. And here is where you grab your
first nuance point from Miller's Anesthesia, the difference
between tracheotomy and tracheostomy.
Oh I saw this in the notes. It's the suffix right?
The Tomi versus Stomi. Exactly, it's etymology and
examiners love it because it shows you respect the language
of medicine. Tomi AT comes from the Greek
tome meaning to cut. OK, so the cut itself.
The act of slicing the skin and trachea, that's the tracheotomy.
So the ACT is the TOMI correct? But stomi STMA means mouth or
opening. So the tracheostomy is the
actual semi permanent opening where the tube lives, the stoma.
The maintained opening? Yes, the.
Skin is sewn to the trachea or held open by the tube.
Clinicians use the words interchangeably.
You know, in day-to-day practice.
Sure, everyone does. But if you write that
distinction down in your exam, tracheotomy is the cut,
tracheostomy is the opening. It shows you've read the big
books. It's an easy mark.
Nice easy points right off the bat, yeah.
Now, context. Why do we do this?
Why not just leave the endotracheal 2IN forever?
It's about the long game. Historically and still today,
it's the definitive substitute for endotracheal intubation.
We'll call it ETT. Yeah, ETT, either to bypass an
upper airway obstruction or you know, much more commonly for
long term ventilation. OK.
So the clinical importance, what are the bullet points for my
intro? OK, four key things and you
should list them just like this. One, it reduces Dead Space.
We'll get into why later. OK, two, it reduces the work of
breathing, hugely important for waning, right?
Three, it improves patient comfort.
They can potentially eat, they can vocalize a bit.
It's much more humane than an ETT.
I'm 4/4 it facilitates pulmonary toilet.
Pulmonary toilet. I always love that turn.
It sounds so undignified, but it's crucial.
It is. It just means you can stick a
suction catheter down there and clean out the lungs easily if a
patient has a weak cough. That ability to suction is the
difference between pneumonia and recovery.
Makes sense. And the other big one, which is
sort of linked to comfort, is sedation holidays.
Oh, with an ETT, the patient usually needs some sedation to
tolerate that big plastic tube in their throat.
It's really uncomfortable. Yeah, you see them gagging on it
all the time. Exactly.
With a track it's much more comfortable so you can often
wake them up completely. You can stop the propofol and
start weaning them from the ventilator much sooner.
It accelerates the whole process.
OK, so that's our intro and framing.
I feel good about that. Now let's move to Part B,
Anatomy and Physiology. The outline marks this as
absolutely essential and exam core.
You cannot bluff the anatomy. You just can't.
If you are discussing the surgical technique in an exam,
you need to visualize the layers.
OK, so let's do that. Picture the neck.
Where do I start? Start with the surface
landmarks. What can you feel?
You have the laryngeal prominence, the Adam's apple got
it. Below that you feel a gap and
then a hard ring that is the cricoid cartilage.
Level C6. Correct C6 level, and the
cricoid is unique because it is the only complete cartilaginous
ring in the entire airway. The only one that goes all the
way around. It's a full circle, like a
signet ring. Everything below it.
The trichial rings are C shaped. Right, the tracheal rings are
open at the back. Exactly.
They are D shaped with the flat part at the back and that flat
part, the membranous posterior wall lies right against the
esophagus. Which is a huge deal.
It's a massive danger zone. If you push too, with a needle
or a dilator during the procedure, you can punch right
through the back of the trachea and into the esophagus.
Creating a TT tracheoesophageal fistula.
Exactly a disaster. Now let's talk numbers.
Exams love numbers. The trachea extends from the
cricoid to the Karina and an adult that length is about 10 to
13 centimeters. OK, the magic number to quote is
that the distance from the cricoid to the Karina is
approximately 11 centimeters. 11 centimeters?
That doesn't seem like a lot of room for error.
It isn't. And that brings us to the danger
zone regarding blood vessels. This is what keeps surgeons and
anesthetists awake at night. OK, let's do a mental
dissection. You are cutting down the
midline. What layers are you passing
through? OK, so skin subcutaneous fat.
Right then the platysma muscle, then you get to the investing
layer of deep cervical fascia. Then you find the strap muscles,
the sternohyoid and sternothyroid, and you separate
them in the midline. You retract them laterally.
Exactly, and then you hit the pre tracheal fascia and sitting
right there usually mocking you is the thyroid is.
Smith and this usually sits over the second, third and fourth
rings. Usually, but anatomy is rude.
It varies. Sometimes it's high, sometimes
it's low, but you have to deal with it.
You can retract it up. You can retract it down.
But Morgan and McHale is very specific here for the exam.
You mentioned division and ligation.
Cut your tie. Yes, because if you just retract
it, it can slip back over the stoma later and cause
obstruction or bleeding. So division and ligation is the
definitive answer. Got it.
But looking deeper, below the isthmus, we enter the real
danger zone, the enominate artery, the brachiocephalic.
There's that exactly. In relation to the trachea, it
crosses the trachea low down in the neck, usually behind the
sternum, but and here's the catching children or in people
with a very narrow necks, it can ride high.
So it's more vulnerable. Much more if you place a
tracheostomy too low, say below the 4th ring, or if the tip of
your curved tube angles forward and erodes over time.
It can eat right into that that artery.
It can erode through the tracheal wall and into that.
Artery A tracheoenominate fistula.
Which is essentially an arterial blowout into the airway.
We will talk about managing that in the emergency section.
But anatomically, you must know it's there, OK?
And don't forget the nerves. What's running on either side?
The recurrent laryngeal nerves. In the tracheoesophageal groove,
stray too far laterally with your dissection and you paralyze
A vocal cord. Unilateral is bad.
Bilateral is a catastrophe. Right.
So midline, midline, midline. That's the mantra.
Stay in the middle. Let's pivot to Physiology.
We mentioned Dead Space earlier. Can you unpack that for me in
exam terms? Sure, let's get a little nerdy
with the physics. Anatomical Dead Space is the
volume of air in your conducting Airways, nose, throat, trachea
that doesn't reach the alveoli for gas exchange.
It's still in the Pikes. Exactly.
When you breathe through your nose and mouth, that path is
long. When you breathe through a
tracheostomy, you are bypassing the entire upper airway.
You are cutting that path in half, sometimes more.
So the ratio of Dead Space to tidal volume, the VDVT ratio,
goes down. Exactly.
For a standard tidal volume, more of that air is actually
participating in gas exchange. This means the patient doesn't
have to breathe as deeply or as frequently to maintain their
blood gases. Which means less energy
expenditure. It all contributes to lowering
the overall work of breathing, but the bigger factor is
resistance. Poiseuille's Law.
That's the one. Resistance is inversely
proportional to the radius to the power of four and directly
proportional to length. So a long thin tube has high
resistance. Right.
An endotracheal tube is long, maybe 30 centimeters.
A tracheostomy tube is short, maybe 8 centimeters.
So simply by short the tube, you drop resistance significantly.
Drastically, which again decreases the work of breathing
or WOB. This is huge for a patient who
is weak and trying to wean off the ventilator.
OK. But is there a catch?
However, and this is a distinction level point for the
exam, remember the radius factor.
A very small tracheostomy tube, say a size 6 point O, can
actually have higher resistance than a normal airway because the
radius is so small. Oh, interesting.
So the benefit really kicks in with appropriate sizing.
Size 8.0 is usually the sweet spot for adult males, 7.0 or 7.5
for females. Is there a downside to bypassing
the nose, physiologically speaking?
Definitely. The nose isn't just a tube.
It's an air conditioner. It warms and humidifies the air
we breathe. It's the mucosiliary escalator,
right? When you bypass it, you lose
that humidification. The secretions in the lungs get
dry, thick and sticky. We call that inspiration.
It's like concrete. That's a huge problem.
And what about the laryngeal breaking mechanism?
I've seen that term. This is a subtle but important
physiological point. Normally when you exhale, your
vocal cords narrow slightly. This creates a tiny back
pressure, a physiological peep. Positive and expiratory
pressure. Right, a natural peep that helps
to keep your alveoli open at the end of expiration.
Under the track, you lose that. You lose that completely, the
air just dumps out of the hole in the neck.
So unless you add some external PEEP or C PAP from the
ventilator, these patients are prone to basal atelectasis.
Their lung bases collapse because they lost that natural
back pressure. Fascinating.
OK, let's move to Part C indications and types.
This is labeled Exam gold. If I'm writing the long answer,
how do I organize the indication so I sound professional?
Don't just list them randomly, categorize them.
It shows organized thinking. OK, what are the categories?
Category 1 Upper airway obstruction.
This is the classic life saving indication.
So things like infections. Yes, sync infections like
Ludwig's angina where the floor of the mouth swells up, or
epiglottitis. Trauma like severe maxillofacial
fractures where you can't intubate orally.
Tumors of the larynx or thyroid that are compressing the airway,
or bilateral vocal cord paralysis where the cords are
stuck closed. Basically anything blocking the
door from above. Got it.
Category 2. Prolonged mechanical
ventilation. This is the most common reason
in the ICU today. The Trackman trial is the famous
study here. Generally, if a patient is going
to be on a ventilator for more than 7 to 14 days, we start
thinking about a track. And why is that?
It prevents laryngeal stenosis from the ETT pressing on the
vocal cords for weeks. And like we said, it makes
weaning much, much easier. Is there a hard rule on the
days? Seven days, 10 days?
I feel like this is always debated.
It is. The Trackman trial showed that
doing a tracheostomy very early, like within four days, didn't
necessarily improve 30 day mortality compared to doing it
later after 10 days. So the consensus is usually to
make a decision around day 7 to 10 based on clinical judgment.
So it's not a race. It's not a race.
If you know the patient isn't waking up anytime soon, say a
severe head injury, you might do it earlier.
If you think they might just turn a corner tomorrow, you
wait. OK, Category 3.
Pulmonary toilet This is for patients who cannot clear their
own secretions. So neurological causes mainly.
Yes, bulbar palsy, a big stroke, Guillain Barre syndrome.
They are literally drowning in their own mucus and the track
gives us a direct route to suction them out effectively
and. What about airway protection?
Is that its own category? I'd put it as #4 prevention of
aspiration in patients with no gag reflex, maybe after a head
injury. But, and this is a crucial exam
nuance, OK, a cuff tracheostomy tube does not guarantee 100%
protection against aspiration. Right, I remember reading that.
Why is that? Liquid can still trickle down
the microscopic channels in the cuff folds.
Microaspiration happens. It's much better than a
completely unprotected airway, but it's not a perfect seal.
You have to mention that to show you understand the limitations.
Are there any absolute contraindications?
Very few absolute ones because it's often a life saving
procedure, but there are strong relative contraindications that
you must mention. One if the patient requires very
high oxygen and FIO 2 / 80% or high PEEP over 10 centimeters of
water. Why is that a contraindication?
It seems like they need a secure airway more than anyone.
Because during the procedure, specifically the percutaneous 1,
you have to disconnect the circuit and stop ventilation to
swap the tubes or dilate the tract.
So they have no reserve. They have 0 reserve.
They will desaturate instantly and potentially have a cardiac
arrest on the table. You have to stabilize them
first. OK, that makes sense.
What else? Two uncorrected Coagulopathy,
especially for a percutaneous tracheostomy, a PDT, you are
poking a hole blindly. If they have an INR of three or
platelets of 20,000, you're going to cause a massive
hematoma that compresses the airway.
So you have to correct the numbers before you start.
You have to or opt for an open surgical procedure where you can
actually see and control the bleeding vessels.
Let's distinguish the types of tracheostomy.
The outline mentions high versus low.
What does that mean? This is an anatomy question.
It's about where you make the hole in the trachea.
A high tracheostomy enters above the thyroid isthmus at the first
or second ring. This is bad practice.
Why? It's too close to the cricoi
cartilage and can cause subglottic stenosis, a scarring
and narrowing of the airway that is very, very hard to fix.
OK, so avoid high, What about low?
A low tracheostomy is below the isthmus.
This is also dangerous. Why?
The inominant artery. The inominant artery we talked
about high risk of erosion and catastrophic bleeding.
So we want to be in the middle. The mid tracheostomy is the
sweet spot behind the isthmus entering at the second, third or
fourth rings. That's the ideal location.
And the other big distinction is surgical versus percutaneous,
the PDT. Correct surgical is done in the
OR open incision direct visualization.
It's better for patients with difficult anatomy, short fat
necks or big goiters. And PDT.
PDT is done at the bedside in the ICU using using the cylinder
technique, guide wires, and dilators.
It's faster, it's cheaper, but it really requires the patient
to have normal neck anatomy. We'll get into the details of
those now. Perfect.
Which brings us to Part D technique.
Let's start with the classic surgical tracheostomy.
This is exam core. Walk me through the steps,
focusing specifically on what I, as the anesthetist, need to be
doing and thinking about. OK, step one is positioning.
You want the trachea to be as superficial and accessible as
possible. So patient is supine and you put
a sandbag or a shoulder roll under their shoulders to extend
the neck. To bring the trachea forward.
Exactly. And a little head up.
Tilt maybe 15 to 20° to drain the veins in the neck and reduce
bleeding. The surgeon makes the incision.
Usually a transverse or collar incision for cosmetic reasons.
About midway between the cricoid and the Super sternal notch.
OK. They dissect down in the
midline, separate the Strat muscles, ligate the thyro,
dismiss. Then they identify the trachea
itself. They might confirm it by
aspirating air with a needle and syringe.
And then the cut into the trachea.
Right, they can make a simple window a cruciate cut, but a key
term to drop in your exam answer is the Bjork flap.
Bjork flap. So I see this in the textbooks.
What is it exactly and why is it important?
It's where the surgeon cuts an inferiorly based flap of the
tracheal wall. So AU shaped cut opening
downwards. Exactly, and they take that
little flap and suture it to the skin of the neck.
It creates a little ramp. I ramp.
Yes. If the tube falls out
accidentally in the first few days before the tract is mature,
that flap keeps the hole open and basically guides the tube
back into the trachea. It's a huge safety feature,
especially for decannulation emergencies.
That's brilliant. OK, now the critical moment.
The airway exchange. I want to slow down here because
this feels like the part where careers can end.
I'm at the head of the bed. The surgeon is ready to put the
track tube in, but my oral ETT is in the way.
What is the dance? This is all about closed loop
communication. It has to be perfect.
The surgeon will say something like trachea is open, I'm ready
to insert. OK, what do I do?
You, the anesthetist, check your monitor.
Is the patient fully paralyzed? Are they 100% oxygenated?
You have to be ready for a period of apnea.
You say ready. OK, the surgeon says withdraw
the ETT. Now.
What's the very first thing you do before you pull?
Deflate the cuff. Even before that, suction the
mouth and pharynx. Of course, so gunk doesn't fall
down into the lungs. Exactly.
So you suction thoroughly, then you deflate the cuff of your
oral ETT completely, and you pull back slowly.
How far do I pull back? You are watching the surgeon.
The surgeon is looking into the hole they just made in the neck.
They want to see the tip of your EPT slide up past their
incision. As soon as they see the cuff
clear the window they'll yell STOP.
And I hold it there. I freeze.
You freeze. The tip of your tube is now
sitting just above the vocal cords or high in the subglottic
space. It is not out of the patient.
Why not just take it out completely?
Get it out of the way. Because what if the surgeon
can't get the trash tube in? What if the hole collapses?
What if there's a massive bleed right at that moment?
Then you've lost the airway. You have completely lost the
airway by leaving the tube tube just above the cords.
If disaster strikes you, just push it back down a few
centimeters, inflate the cuff and you are ventilating again.
It is your lifeboat. OK.
That's a critical safety step. Absolutely critical.
Only when the surgeon says tracks in cuff is up and you've
connected your circuit to the new track tube and see a
beautiful CO2 waveform on your monitor, only then do you remove
the oral ETT completely. Got it.
Confirm placement first. Always end title CO2 is your
confirmation. Now let's talk percutaneous
dilatational tracheostomy PDT. This is listed as very high
yield for short notes. Yes, because PDT is the standard
in most Icus now for elective cases.
It uses the Seldinger technique just like putting in a central
line. OK, walk me through it.
Step one bronchoscopic guidance. This is the gold standard.
You pass a flexible bronchoscope down the existing ETT.
You're watching from the inside. Exactly.
You're watching the anterior wall of the trachea on a screen.
Step 2. The operator punctures the
trachea between the second and third rings with a needle.
You watch the needle indent the wall and then pop into the lumen
right on the screen. That's much safer than doing it
blind. Infinitely safer.
Step three, they pass a guide wire through the needle into the
trachea. Step four they remove the needle
and dilate the tract over the wire.
The Ciaglia Blue Rhino is the most common single tapered
dilator. It looks like a curved rhino
horn. And you just push that in to
stretch the hole. You gently advance it to stretch
the hole to the right size. Step five you slide the
tracheostomy tube over the dilator and into the trachea.
Then you pull the dilator and guide wire out.
Inflate the cuff and confirm with your CO2 trace.
Why is the bronchoscope so important?
What's the main thing it prevents?
Posterior wall puncture. Remember we said the esophagus
is right behind the thin membranous part of the trachea.
If you push that needle too hard without seeing where it's going,
you can easily stab the esophagus.
The scope lets you see the needle enter the lumen of the
trachea safely and stops you from going too far.
OK. And the main advantages of PDT
over surgical? It's a bedside procedure.
You don't have to transport a critically I'll unstable patient
to the operating room. That's a huge plus, right?
Avoids the transport risk. Also a smaller skin incision
which means less infection and better cosmetic result.
It's generally faster and more cost effective.
But the disadvantage is that it's still a semi blind
procedure, right? Correct.
Even with a scope, we don't have the same direct vision of the
surrounding vessels. So it's not for patients with
difficult anatomy, previous neck surgery or as we said,
Coagulopathy. Moving on to part E anesthetic
management pre op prep. We've covered some of this.
You're going to check coagulation PTINR platelets.
You need to optimize FIO 2 to one point O to pre oxygenate
them as much as possible. Build that reserve.
Build that reserve for the apnea period and you must have the
difficult airway cart in the room and ready Plan B, Plan BC
and D. You need smaller ET TS a
laryngeal mass airway cricothyroidotomy kit.
You have to be prepared for total airway loss.
What about anesthesia type GA versus local?
How do you decide? For 99% of cases, especially
elective ones, general anesthesia is standard.
You have a secure airway with the ETT.
You have controlled ventilation. The patient is still
uncomfortable. OK, when would you ever use
local? Consider the patient with a
massive friable upper airway tumor or LED wigs angina where
the neck is rock hard and swollen shut.
The ones you're terrified to induce.
Exactly. If you put them to sleep and
paralyze them, the airway muscles relax.
The tumor might flop over and block everything completely.
You might find yourself in a cannot intubate, cannot
ventilate situation. The ultimate nightmare.
It is in that specific high risk scenario you may opt for an A
weak tracheostomy under local anesthesia.
That sounds incredible, really stressful for everyone involved.
It is the most stressful procedure you will ever be a
part of. You use local infiltration
lidocaine with adrenaline along the incision line.
You might do a superficial cervical plexus block, but you
keep the patient breathing spontaneously the entire time.
You're talking to them. You're talking to them,
reassuring them you give them just enough sedation to tolerate
it, but not so much that they stop breathing.
You do not paralyze them until the surgeon has confirmed the
trachea is open and the tube is in and secure.
Maintain spontaneous ventilation at all costs at all costs.
And there's a note here about fire safety in the
intraoperative considerations. Seems like a classic exam
question. It is a classic.
What is the fire risk during a tracheostomy?
OK, what is it? When the surgeon cuts into the
trachea, there is oxygen rich gas leaking out of the hole from
your ventilator circuit. If they then use diathermy or
cautery to cut the trachea or control bleeding right at the
edge of the opening. Spark plus oxygen.
Equals a fire. You get a blowtorch effect right
in the patient's airway. It is devastating.
So what's the rule? The rule is do not use diathermy
to enter the trachea. The surgeon must use a cold
knife, a scalpel or scissors only for that step.
And as the anesthetist, you should try to reduce the Fio 2
to as low as is safely possible right before they make the
tracheal incision. No cautery on the airway.
Got it. Part F Complications absolutely
essential. Let's break this down into early
and late. OK early complications These
happen immediately in the OR or within the 1st 24 to 48 hours #1
Hemorrhage. This is the most common one.
Usually it's venous bleeding from the anterior jugular veins
or the thyroid isthmus. Usually controllable.
OK #2 pneumothorax, especially in children or in COPD patients
with large boule where the apex of the lung pleura can rise up
high into the neck. If the dissection goes too deep
and too lateral, you can pop the pleura.
How would you know that's happened?
Suddenly High Peak airway pressures drop in saturation and
decreased breath sounds on one side.
You'd need a chest X-ray and a chest string subcutaneous
emphysema. This is dramatic to see.
The patient puffs up like the Michelin Man, their face, neck,
chest, all full of crackly air. When does that happen?
Usually it's because the skin has been sutured too tightly
around the tube. Air leaks out of the tracheal
stoma, but it can't get out of the skin incision, so it tracks
into the subcutaneous tissue. Is it dangerous?
It's alarming, but usually self limiting.
If you loosen or remove a couple of skin sutures to let the air
escape, the bigger worries that it might be a sign of a false
passage. A false passage.
Yes, the tube isn't in the trachea at all.
It's sitting in the pre tracheal tissue.
That's our 4th early complication.
Tube misplacement. A true disaster.
OK. And leak complications.
These are the ones to show up weeks or months later.
Number one is tracheal stenosis, a narrowing of the trachea.
This is usually due to the cuff. Too much pressure.
Exactly. If the cuff pressure is too
high, consistently greater than 25 or 30 centimeters of water,
it exceeds the capillary perfusion pressure of the
tracheal mucosa. It.
Cuts off the blood supply. It cuts off the blood supply,
the mucosa becomes ischemic, it dies, it scars down, and the
trachea narrows at that spot. This is why regular cuff
pressure monitoring is so important.
Right. What's next?
Tracheosophageal fistula or TF We mentioned the risk.
It's due to erosion of the posterior wall, either from the
cuff pressure or the tip of the tube rubbing against it to what
else? Granulation tissue.
Little fleshy cauliflower like growths can form at the stoma
site or at the tip of the tube. They can bleed easily or even
grow large enough to obstruct the tube.
Part G Tracheostomy emergencies. This is Viva gold, the examiner
asks. You are the anesthetist on call
for the hospital. You were called to the ward.
A patient's tracheostomy tube has fallen out.
It was put in yesterday. What do you do?
This is the accidental decannulation scenario.
It is a tract. The entire answer depends on one
question. What's that?
Is it a fresh tract or a mature tract?
And what's the cut off? How do you define that?
Usually seven days. It takes about a week for the
tract to epithelialize to heal into a stable tunnel from the
skin to the trachea. OK.
So in the scenario it was put in yesterday, it's a fresh tract.
It's a fresh tract. The tissue planes, skin, muscle,
trachea are all still soft and mobile.
The second the tube comes out, they will slide over each other
and the hole will disappear. So what's the rule?
The Golden rule Do not blindly poke a tube back into a fresh
stoma. Why not?
I mean if the hole is right there you can see it it.
Looks like it's there, but if you try to force A2 in, you will
almost certainly miss the small collapsed tracheal opening and
slide into the pretracheal space instead.
You create a false passage. You create a false passage.
Then you attach a bag and ventilate.
You pump air into the soft tissues of the neck, which then
compresses the real airway from the outside.
The patient will desaturate and die of hypoxia and you will have
caused it. OK, so for a fresh track, what
is the algorithm? What do I say in the exam?
One, call for help anesthetic senior ENT surgeon crash team.
Two, apply high flow oxygen to the patient's face and over the
stoma. They might be able to get some
gas and through the hole. Three, do not poke the neck.
And four. Four, perform oral intubation.
Treat it like a standard difficult airway.
Secure the airway from above. Once the patient is stable and
intubated, you can then take them back to the OR and have the
surgeons redo the tracheostomy in a controlled setting.
OK, that's a very clear, safe answer.
Now what if it's a mature tract, say 3 weeks old?
Then you have a well formed tunnel.
It's much safer. You can attempt to reinsert the
tube. You use the obturator that comes
with the tube to give it a smooth rounded tip.
You gently try to reinsert it, or even better, you can try a
smaller size tube first, or put a gum elastic bougie into the
stoma feel for the tracheal clicks and then railroad the
tube over it. But what if you meet resistance?
If you meet any resistance, you stop.
Oral intubation is always the ultimate safety net for a fresh
or a mature tract. If you can't secure the airway
from the neck, secure it from the mouth.
Another emergency, the blocked tube.
What are the steps? Very common.
Usually it's a thick mucus plug. Step one is the easiest and
often works. Remove the inner cannula.
Most tubes have an inner tube you can just pull out and clean
or replace. If the plug is in there, you've
solved the problem instantly. And if that doesn't work.
Step 2. Pass a suction catheter down the
tube. If it goes in easily, the tube
tube is patent. If it stops, it's blocked.
OK, Step 3. Deflate the cuff.
Sometimes the cuff can honeyate over the end of the tube and
cause an obstruction. Deflating it might relieve it.
And if you still can't pass a suction catheter after all that?
The two is definitively obstructed.
You must remove it and replace it with a new one, just like in
an accidental depanulation. Now the bleeding emergency.
The big one, we talked about the anomin artery earlier.
Let's talk about the Sentinel bleed.
This is absolutely vital for any exam.
A small amount of bright red pulsatile blood from the stoma,
maybe just a teaspoonful, is often a warning sign.
A warning for what? It's called a Sentinel bleed.
It means the tracheoenominate fistula has formed and is
leaking slightly before the main catastrophic blowout.
You must not ignore it. If a nurse calls you about a
small bleed, you have to go see it immediately and get the
surgeons involved. OK, now the worst case scenario
happens. The massive haemorrhage, blood
is hitting the ceiling. What is the immediate maneuver?
This is the ugly maneuver, right?
You have seconds to act. What's step one?
Step one, hyperinflate the cuff of the tracheostomy tube.
Shove 20-30 mils of air in there.
Sometimes a balloon itself will expand and push against the
artery wall and temporarily stop the flow.
And if that fails. If that fails and blood is still
pouring out, you have to perform digital compression.
Paint the picture for me. What am I physically doing I
need to be able to describe? This You remove the tracheostomy
tube. Yes, you take it out completely.
You insert your index finger directly into the stoma.
You slide it down along the interior surface of the trachea
until you are behind the manubrium, the top of the
breastbone. OK, I'm in the chest, you are in
the chest. Then you hook your finger
forward, pulling up. So I am pinching the artery
between my finger inside the neck and the back of the sternum
outside. Exactly.
You are manually clamping the innominate artery against the
posterior surface of the manubrium.
The bleeding should stop, or at least slow dramatically, and
then you are the clamp. You cannot let go.
You climb onto the Gurney, your finger deep in the patient's
chest, and you ride with them to the operating theater for an
emergency sternotomy. That is the only way they
survive. That is intense, but if you say
digital compression of the innominate artery against the
manubrium in the exam, you've basically passed the station.
Absolutely. It shows you know the anatomy
and you know the desperation of the situation and exactly what
to do. Let's take a breath and move to
Part H post operative and ICU care.
This feels a bit calmer. Once the tube is in and secure,
the care is routine but vital. Number one has to be
humidification. It's non negotiable.
You bypass the nose, so you must replace its function.
You use a heat moisture exchanger or HME, the little
plastic nose, or a heated humidified circuit from the
ventilator. And if you don't?
If you don't, the secretions turn to concrete.
As we said, they form thick plugs that can block the tube or
the smaller Airways. #2 Suctioning.
Yes, it must be a sterile technique.
You pre oxygenate the patient before you suction and you don't
suction for longer than 10 to 15 seconds at a time to avoid
hypoxia and trauma to the mucosa.
And cuff care. You need to monitor the cuff
pressure or regularly with a manometer.
The goal is to keep it between 20 and 25 centimeters of water,
just enough to create a seal for ventilation, but not so much
that it causes tracheal ischemia.
Weaning and decannulation. When do we finally take it out?
We often use special tubes for weaning.
A fenestrated tube is a common one.
What does that mean? It has a hole or a fenestration
in the outer curvature of the tube.
When you remove the inner cannula and deflate the cuff,
air can go up from the lungs through the fenestrations into
the vocal cords. This allows the patient to
speak. And the speaking valve.
I see the passing mirror valve used a lot.
That's a one way valve. It sits on the end of the track
tube. It has a diaphragm that opens to
let air in when the patient inhales, but it closes when they
exhale. So the exhaled air is forced to
go up around the outside of the tube and through the vocal cords
so they can talk in a much more natural voice.
OK, there's a huge safety point here, isn't?
There a critical exam safety point.
If you put a speaking valve on, you must deflate the cuff.
You have to write that in bold in your mind.
Why is that so? Absolutely, but.
Think about the physics. The valve let's air in, but it
blocks air from coming out through the tube.
If the cuff is still inflated, the air can't get up around the
tube either. So the air is trapped.
You have created a one way system that is just filling the
lungs. The patient can breathe in but
cannot breathe out at all. You will cause breath stacking,
a massive tension pneumothorax and cardiac arrest within
minutes. So the mantra is.
Cuff down in Valvarin. Always decanulation criteria.
When is the patient ready? The patient must be able to
protect their own airway. That means they have a good
swallow and a strong, effective cough, the original reason for
the track. Like an upper airway,
obstruction must be resolved and their secretions must be minimal
and thin. And how do you test that?
If they pass those checks, we often downsize to a very small
tube and then cap it for 24 hours.
If they can breathe perfectly fine with the cap on, tolerating
it without any distress, then we know they don't need the track
anymore. We pull the tube and cover the
stoma with an occlusive dressing.
It usually closes on its own in five to seven days.
Finally, Part 1 exam integration.
Let's hit the comparison tables in Viva Traps Tracheostomy
versus ETT Quick Fire Pros and cons.
OK tracheostomy pros Lower Dead Space, lower work of breathing,
better patient tolerance, allows eating and speech.
Very stable airway for a long term care.
ETT Pros. Quick and non invasive to place
in an emergency. Protects against aspiration a
little better initially. No surgical risks.
OK. Tracheostomy Cons.
All the surgical risks leading methorax nerve injury, stoma
scars, risk of late complications like tracheal
stenosis. And ET cons.
High airway resistance, very uncomfortable so it usually
requires sedation and significant risk of laryngeal
and vocal cord trauma if it's left in for too long.
Perfect. Right.
Next comparison surgical tracheostomy versus PDT.
OK PDT Pros. It's faster, it can be done at
the bedside, smaller hole, less bleeding, and it's cost
effective. And the downside?
It's a semi blind procedure. Higher risk of posterior wall
puncture or creating a false passage.
It's not good for patients with difficult anatomy.
And surgical prose. Better for those patients with
difficult anatomy. You have direct vision so
bleeding is better controlled and you can create a Bjork flat
for added security. The downside being.
It requires transport to the OR. It's a bigger procedure and
there's a higher risk of wound infection.
Great. And let's just recap the common
exam questions in Viva Traps one last time.
Trap #1 the examiner asks how do you do a tracheostomy?
And the trap is jumping straight to the.
Knife. Exactly.
The answer is not I pick up a scalpel.
The answer is first I would assess the indications.
I would ensure all contraindications are
considered. I would check the coagulation
and get informed consent. And then I would position the
patient, show them you are a safe, thoughtful Dr. before you
are a technician. Track #2 The patient desaturates
during the procedure. Don't just say give more oxygen,
be systematic. My first thought is an airway
problem. I would immediately check the
position of the ETT. Has it been pushed too deep into
the right main bronchus or has it been withdrawn too far out?
Deco PE. Exactly.
Dislodgement, obstruction, pneumothorax, equipment failure.
Check for pneumothorax, Check for circuit disconnection.
Be an anesthetist. And trap #3 management of
massive hemorrhage. Don't just say call the surgeon.
You are the first responder you say.
My immediate actions would be to hyperinflate the cuff and if
that fails I would perform digital compression of the
enominate artery while calling for urgent surgical help.
Use the keywords. And for the written exam
diagrams, what should I be able to draw?
Practice drawing two things. First, a simple cross section of
the neck showing the relations, trachea in the middle, esophagus
right behind it, thyroid isthmus in front, strap muscles and the
great vessels laterally. It shows you on the anatomy.
And the second one. A schematic of the cylinder
technique for PDT. 4 simple steps Needle wire, dilator tube
Simple line drawing score very high marks because they show you
understand the process. And for the conclusion of the
Big 20 mark essay, how to wrap it all up?
You summarize nicely something like.
In conclusion, tracheostomy is a definitive airway procedure with
significant physiological benefits for long term
ventilation, specifically the reduction in anatomical Dead
Space and work of breathing. However, it is not without
significant risks, both immediate and delayed,
particularly hemorrhage, airway loss and tracheal stenosis.
The role of the anesthetist is therefore crucial and
preoperative optimization, ensuring intraoperative airway
security during the critical exchange and the rapid
recognition and management of life threatening complications.
Fantastic. This has been a true deep dive.
I feel like I can actually visualize the layers of the
neck. Now, and that visualization is
the key. If you can see the anatomy in
your mind's eye, you can reason through any question they throw
at you. To the student listening,
remember the 11 centimeters from Crickoid.
To Karina, remember the Sentinel bleed and Please remember cuff
down valve on. You've got this.
Go ace that Viva. Good luck.
Thanks for listening to the deep dive.