Editing Tracheostomy (section)

== '''Choice of procedure''' (methods from Shields) ==

=== '''Percutaneous''' ===

** Favoured in most situations except emergencies
** Same complication rate as an open tracheostomy, and can be done bedside in ICU
** Do it under bronchoscopy guidance
** Prep as for open
** Visualise retraction of ETT to just below cords
** 22-guage needle into the intercartilaginous space between second and third rings
** J-wire fed through needle
** Horizontal 1cm incision centred on wire
** 14Fr dilation over wire
** Appropriate size dilator in the kit then inserted and the tracheostomy placed into airway
** Wire and dilator removed
** Flange sutured to skin

=== '''Open''' ===

** Check tracheostomy sizing and check cuff
** Supine with neck extended with shoulder roll, and slight reverse Trendelenburg
** Prep skin from nipple to mandible
** Pre-oxygenate and sedate
** LA
** Mark thyroid and cricoid cartilages with dots, and a 2cm transverse incision above the second or third tracheal ring, about 2cm below cricoid
** Divide subcutaneous tissues and platysma
** Retract strap muscles laterally to expose thyroid isthmus from first to fourth tracheal ring - blunt dissection in midline
** Move thyroid isthmus out of the way (usually second cartilaginous ring)
*** Dissect it off trachea with right angle
*** Ligate with 0 vicryl ties on either side
*** Divide in middle
** '''Check oxygen off and diathermy away'''
** Warn anaesthetist and incise trachea horizontally with 11 blade between the second and third rings - may need to use scissors too.
** Oropharyngeal tube out. Place new tracheostomy tube and inflate cuff, sometimes over a bougie. Check ventilation and that it is above carina. 
** Flange sutured to skin in all four quadrants (2/0 Prolene)
** Close any excess skin to provide a snug fit around the tube

=== '''Cricothyroidotomy''' (upper airway obstruction and unable to establish an oral airway OR for mini-tracheostomy to aid in removal of airway secretions) ===

** Prep as for open tracheostomy
** Palpate cricothyroid membrane (feel Adam's apple as thyroid cartilage, then move down to just below that, above cricoid cartilage)
** Make a horizontal incision directly over the cricothyroid membrane (can also do vertical, between sternal notch and hyoid)
** Lateralise strap muscles and trachea exposed
** Stabilise trachea/thyroid cartilage with non-dominant hand
** Horizontal cut in trachea using 10 (or 11) blade in the cricothyroid membrane
** Finger dilate
** Size 6 ETT