Editing Tracheostomy (section)

=== '''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