In emergency situations it is performed under local anaesthesia
In elective condition it is performed under general anaesthesia.
Supine with neck hyper extended
Emergency tracheostomy is performed with the vertical incision extending from the lower border of cricoid cartilage up to 2 cm above the supra-sternal notch in mid line. The area is also known as space of Burns and is devoid of deep cervical fascia.
Elective tracheostomy is performed through a horizontal incision 2 cm above the sternal notch.
SOFT TISSUE DISSECTION:
When we approach the trachea in the mid line, it is found under the following structure:
The subcutaneous tissue
Branches of anterior jugular vein
Thyroid isthmus at the level of 2nd tracheal ring
Pre-tracheal pad of fat through which inferior thyroid vein may wander and sometime thyroid ima artery may be found in tissue plane.
Incision is given through platysma, cervical fascia
Branches of anterior jugular vein if any are ligated and divided.
Strap muscles are bluntly dissected and retracted.
Isthmus is either retracted upward or ligated and divided.
Pretracheal fascia is splitted and tracheal rings are clearly identified.
A syringe with normal saline is inserted and air is aspirated to confirm.
A vertical incision is made between the 2nd – 3rd tracheal ring.
Tracheostomy tube is inserted into the tracheal opening and the cuff is inflated.
The wound is closed loosely & the tube is secured by tying the knot around the neck with neck flexed or in neutral position. It should be tight enough to allow one finger to be inserted between the tapes & the skin. Flanges are sutured to the skin.
A wet gauze is placed over the tracheostome.
A proper instruction is to be given about a tracheostomy care & management of any complications if arises to all the staff taking care of the patient.