indications and contraindications of tracheostomy

INDICATIONS AND CONTRAINDICATIONS OF TRACHEOSTOMY

Definition: Tracheostomy is making an opening on the anterior wall of the trachea for establishing an airway.

Functions of Tracheostomy:

  1. Reduces the dead space by 40%.
  2. In patients with severe respiratory depression, it allows Intermittent Positive Pressure Ventilation (IPPR).
  3. For tracheobronchial toilet. 
  4. Prevents aspiration as portex tracheostomy tube has a cuff.
  5. Creates a bypass to relieve upper respiratory tract obstruction.
Indications of tracheostomy:
    A. Intrinsic:

    I. Laryngeal causes:

      a) Congenital.

      b) Laryngeal stenosis.

      c) Laryngeal web.

      d) Laryngeal hemangioma.

      e) Laryngeal carcinoma- Certain cases who undergo total laryngectomy, during operation tracheostomy done to ventilate patient via tracheostomy tube and also post-operative permanent tracheostomy done to regain airway and voice rehabilitation done by artificial voice prosthesis.

    II. Traumatic:

      a) Cut throat injury.

      b) Laryngeal oedema due to toxic fumes.

      c) Strangulation.

    III. Inflammatory:

      a) Acute epiglottitis.

      b) Acute laryngotracheobronchitis.

      c) Diphtheria.

      d) Tuberculosis.

B. Extrinsic:
Extralaryngeal:
  1. Congenital – Choanal atresia.
  2. Trauma – Burns, chest trauma.
  3. Inflammatory:

      a) Ludwig’s angina.

      b) Cellulitis.

  4. Neoplastic:

      a) Bronchogenic carcinoma.

      b) Malignancy of thyroid.

      c) Lymphoma.

      d) Hemangiomas.

C. Neural:

  1. Poliomyelitis.
  2. Guillain-Barre Syndrome.
  3. Tetanus.
  4. Spinal cord lesions.
  5. Myasthenia gravis.
  6. Abductor cord palsy.

D. Central:

  1. Head injury.
  2. Muscle relaxant poisoning.
  3. Cerebrovascular accidents.
  4. Coma.

E. Miscellaneous:

  1. Prior to tongue, larynx and mandible surgery. Rarely prior to bronchoscopy.
  2. Tracheobronchial toilet.
  3. Foreign body larynx.
  4. Laryngomalacia.
Contraindications: As tracheostomy is a life-saving procedure, there are no absolute contraindications to tracheostomy. However, some relative contraindications are:
  1. In patients with obstructive carcinoma of the larynx, once tracheostomy is done there are increased chances of stromal recurrence.
  2. Bleeding disorders: They can give troublesome bleeding from the tracheostomy site.
  3. If a foreign body is lodged below the level of the tracheostomy site, it would not help in relieving the stridor unless emergency bronchoscopy is done.
It must be understood that the above should not be considered in cases of an emergency. “The time to do a tracheostomy is the first time you think of it”.

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