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Tracheostomy 1167

extending to the 5th tracheal cartilage. • Appose the skin edges cranial and caudal to • No closure of the tracheostomy site is recom-
the tracheostomy site.
This tracheostomy technique should be • Fold the mucosa over the free cartilage edges, mended, and the stoma should be allowed
used only when conversion to a permanent
to heal by second intention.
VetBooks.ir tracheostomy is not warranted due to the and suture the mucosa to the skin edge using • For flap tracheostomy, any excess granulation
tissue should be debrided, and the flap should
simple interrupted sutures at each corner of
potential damage to the tracheal mucosa.
the tracheostomy.
• After the tracheostomy is complete, two stay
using 4-0 polydioxanone.
sutures should be placed at each edge of the • The remainder of the mucocutaneous appo- be sutured back into its anatomic location
incision and appropriately labeled (cranial/ sition may be performed by using simple Permanent tracheostomy care:
caudal or medial/lateral). The stay sutures interrupted sutures or in a simple continuous • Frequent cleaning of the stoma is necessary
will be used to stabilize the trachea during pattern using 4-0 polydioxanone. to keep the area free of mucus, debris, and
tube insertion and during tube exchanges. • Peritracheostomy skin folds may warrant foreign material.
• Secure the tracheostomy tube using umbilical resection if the risk of tracheostomy occlu- • Long-term maintenance includes routine
tape tied around the patient’s neck. sion is foreseen. Caution should be exercised clipping of the hair surrounding the stoma.
• The cranial and caudal skin edges may be when removing skin folds not to remove • Patients should not be allowed to swim or be
sutured together if necessary. too much tissue and create tension across kept in environments with high particulate
• The stoma around the tube is gently covered the tracheostomy site. debris. Procedures and Techniques
with antibiotic ointment. Cuffed tubes:
Permanent tracheostomy: Postprocedure • Inflation of cuffs is necessary to seal the
• Make a ventral, cervical midline skin incision Temporary tracheostomy tube care: airway during positive-pressure ventilation.
extending 6-8 cm in length from the most • Proper tracheostomy site care is critical to Auscultation of the airway during positive-
caudal aspect of the larynx. Continue the ensure proper healing, prevent airway infec- pressure ventilation should be performed to
incision by blunt dissection through the tion, and reduce the risk of acute obstruction. ensure no leaks are present.
subcutaneous tissues to expose the underlying • Aseptic technique should be practiced by all • Cuff deflation is not recommended unless
paired sternohyoid muscles. personnel who are involved with tracheos- positive-pressure ventilation cannot be
• The ventral aspect of the trachea can be tomy care (unless emergency). achieved.
exposed by bluntly separating the sternohyoid • Tracheostomy tubes should be removed and
muscles along their midline aponeurosis and cleaned or replaced every 12-24 hours (or Alternatives and Their
retracting the muscle bellies and skin laterally. as needed). Tubes should be soaked in 2% Relative Merits
Retraction can be aided by the placement chlorhexidine solution and thoroughly rinsed • Oxygen supplementation (p. 1146): should
of Gelpi retractors. before replacement. be initiated in all patients with respiratory
• After the ventral aspect of the trachea is • Before any non-emergent tube care proce- distress, even though it may not be adequate
exposed, proper positioning of the trache- dure, patients should be preoxygenated for as sole therapy. Oxygen supplementation
ostomy should be determined by locating 2-5 minutes to help reduce hypoxemia. before the initiation of more invasive mea-
the 3rd through 6th tracheal rings. • A sterile suction catheter no greater than sures can help reduce the oxygen deficit and
• Create a small tunnel dorsal to the trachea one-half the diameter of the tracheostomy provide some level of initial stabilization.
by blunt dissection. tube with a blunt end and side suction holes • Oral/endotracheal intubation: due to the
• The paired sternohyoid muscles can be should be used for tube maintenance. The ease and noninvasive nature, this method
apposed dorsally to the trachea by placing catheter should be inserted to the level of the of management should be attempted first
mattress sutures using polydioxanone through obstruction before the initiation of suction. in patients with upper airway obstruction.
the tunnel. The dorsal apposition of the ster- Intermittent suction should be used while
nohyoid muscles induces a ventral deviation rotating the catheter as is it is removed to Pearls
of the trachea and aids in tension relief when eliminate any debris causing obstruction. • Overweight patients or those with redundant
apposing the tracheal mucosa to the skin. Try to limit the time the catheter is in the skin folds along the ventral neck are at
• The ventral aspects of the 3rd through 6th trachea to 10-15 seconds per cleaning. increased risk for tube complications and
tracheal rings are removed by incising the • The frequency of catheter suctioning is deter- physical obstruction of the tracheostomy
tracheal cartilages to the level of the mucosa mined by the degree of mucus production. stoma. Extra attention should be paid when
and gently dissecting the free edges of the Initial maintenance may be necessary q 15 tube placement or exchange is performed.
cartilage rings using the back of a scalpel minutes but is usually q 4-6h. • Always have a replacement tube and a full
blade and thumb forceps. • Nebulization and coupage q 4h can aid in set of replacement supplies readily available
• The width of the cartilage removed should removal of mucus and debris. for any patient with a tracheostomy due to
be no wider than one-half of the tracheal Temporary tracheostomy tube removal: the fact that obstruction may be very acute,
circumference. Care should be taken during • Tracheostomy tube removal should be and rapid response times are critical.
the removal of the tracheal rings to try to prioritized as soon as adequate upper airway • Dogs tend to do better than cats with
preserve the integrity of the tracheal mucosa. flow has been re-established. permanent tracheostomy.
• Perimucosal tissue may be apposed to • To ensure that adequate airflow through
the dermis surrounding the tracheostomy the upper airway has returned, the patient SUGGESTED READING
site using 2-0, 3-0, or 4-0 polydioxanone should be challenged for 10-15 minutes Mazzafero EM: Temporary tracheostomy. Top
sutures. The apposition of these tissues with the tracheal tube removed. During this Companion Anim Med 28(3):74-78, 2013.
before the mucocutaneous apposition of the trial period, the patient should be carefully
tracheostomy is critical in order to provide observed for signs associated with respiratory AUTHOR: K. David Hutcheson, DVM
EDITORS: Leah A. Cohn, DVM, PhD, DACVIM; Mark S.
a tension-free closure. distress and/or obstruction. If the respiratory Thompson, DVM, DABVP
• Make an I- or H-shaped incision into the rate and effort are satisfactory during this
tracheal mucosa. trial, the tube is removed.

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