The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [370]
A permanent tracheostomy is the creation of a tracheostomy following a total laryngectomy (Prior and Russell 2004) (Figure 10.11c). The larynx is removed and the trachea is sutured in position to form a permanent stoma, known as a laryngectomy stoma (Clotworthy 2006a). The patient will breathe through this stoma for the remainder of their life. As a result, there is no connection between the nasal passages and the trachea (Edgtton-Winn and Wright 2005).
Percutaneous tracheostomy
The percutanous method most commonly used is known as percutaneous dilatational tracheostomy (PDT) (De Leyn et al. 2007), enabling the pretracheal tissues to be incised under local anaesthesia. A sheath is inserted into the trachea between the cricoid and the first tracheal ring or between the first and second rings. The trachea is progressively dilated with a series of conical dilators, which are slipped over a guidewire, ready for a tracheostomy tube to be inserted. Now frequently performed in the critical care setting as an early intervention post initiation of mechanical ventilation, the procedure takes less time and requires fewer resources, such as theatres and surgeons, resulting in fewer costs, than a surgical tracheostomy (Patel and Matta 2004). Another potential benefit of percutaneous tracheostomy is more rapid stomal closure and smaller scar formation once the tracheostomy tube has been removed (Patel and Matta 2004).
Surgical
Elective surgical tracheostomy is ideally performed in the operating theatre under general anaesthetic, although it can be performed under local anaesthetic (De Leyn et al. 2007). A horizontal incision is made halfway between the sternal notch and the cricoid cartilage (Price 2004a). The strap muscles are divided and the thyroid isthmus is retracted/divided, enabling the trachea to be exposed and the tracheal cartilages to be counted. The tracheostomy should be sited over the second and third or third and fourth tracheal cartilages (Price 2004a).
Mini-tracheostomy
Unlike the previous two techniques, which enable oxygen therapy and mechanical ventilation, this method is used only when frequent aspiration of airway secretions is required. The procedure is also referred to as a cricothyroidotomy (De Leyn et al. 2007). The cricothyroid ligament is incised, enabling a small endotracheal tube or a mini-tracheostomy tube to be inserted (Price 2004b). The mini-tracheostomy tube has a small internal diameter, of often only 4 mm. This technique can also be used in an emergency to alleviate upper airway obstruction.
Evidence-based approaches
Rationale
Indications
There are four main indications for tracheostomy.
To enable the aspiration of tracheobronchial secretions (e.g. excessive secretions/ poor cough).
To maintain the airway (e.g. upper airway obstruction) (ICS 2008).
To protect the airway (e.g. bulbar palsy) (ICS 2008).
For long-term mechanical ventilation and to aid weaning off mechanical ventilation.
Contraindications
The only absolute contraindications for tracheostomy are severe localized sepsis/skin infection, uncontrollable coagulopathy (ICS 2008) or prior major neck surgery which completely obscures the anatomy (De Leyn et al. 2007).
Legal and professional issues
Competencies
The most common problems associated with tracheostomy, in both general wards and critical care, are related to obstruction or displacement (ICS 2008). All hospitals or community settings should have a procedure for managing such situations and all staff involved in the care of the patient must be both aware of the procedure and appropriately trained in either managing the situation or supporting additional staff. At all times if there is any doubt about the appropriate care that needs to be given or the management of a situation, call for more senior