Tracheostomy

3. Indications of tracheostomy

The advent of intensive care units and presence of ventilators during 1950s changed the status of tracheostomy from a life saving emergency procedure to that of a prolonged life supporting procedure.



"The main indication of tracheostomy is that when the surgeon thinks about it" (Mosher).


1. In upper air way obstruction (obstruction above the level of larynx). Trachesotomy is indicated in all cases of upper airway obstruction irrespective of the cause as an emergency life saving procedure. It is also indicated in impending upper airway obstruction as in the case of angioneurotic oedema of larynx.


2. For assisted ventilation: In comatose patients who donot have the required respiratory drive airway can be secured by performing a tracheostomy and the patient can be connected to a ventilator for assisted ventilation.


3. For bronchial toileting: Chronically ill patients who donot have sufficient energy to cough out the bronchial secretions may have to undergo tracheostomy with the primary aim of sucking out the bronchial secretions through the tracheostome.


4. In cases of prolonged intubation: tracheostomy will have to be performed to prevent subglottic stenosis.




General indications for tracheostomy include:


1. Congenital anomaly compromising airway like hypoplastic larynx, vascular web etc


2. Foreign bodies in upper airway that cannot be dislodged with Heimlich or other supportive maneuvers


3. Supra glottic / glottic pathology ( infections, neoplasm, bilateral vocal cord paralysis)


4. Neck trauma causing severe injuries to thyroid / cricoid cartilages, hyoid bone or great vessels


5. Subcutaneous emphysema that could endanger the airway


6. Facial bone fractures that could endanger airway


7. Upper airway angioneurotic oedema or oedema of upper airway due to burns, infection etc


8. Prophylaxis before extensive head and neck surgical procedures


9. Severe sleep apnoea not amenable to continuous positive pressure air way pressure


10. Tracheostomy needs to be performed if the patient needs to be on prolonged ventilation


11. To clear air way secretions in patient with poor cough reflex


12. Council for critical care of the American College of chest physicians recommend tracheostomy in patients who require mechanical ventilation for more than 7 days (prolonged intubation).