Minitracheostomy

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Minitracheostomy is a technique used to assist in removal of airway secretions while maintaining glottic function, by placing an inlying small bore catheter in the trachea through the cricothyroid membrane.1 With the neck in extension, anatomic landmarks are precisely identified: the thyroid notch, the cricoid cartilage, and the cricothyroid membrane. Five cc of 2% lidocaine hydrochloride with epinephrine is infiltrated over a site of incision in the midline of the cricothyroid membrane. The cannula is placed over a guide through a vertical incision that is 3 to 5 mm in length (Figure 22-2). A kit for the procedure contains a reclosable flanged cannula, obturator, bevelled knife blade, 15 mm adaptor, no. 10 French suction catheter, and tracheostomy tape (Figure 22-3). We have not used the Seldinger method.

Successful placement of the catheter is confirmed by listening for air exchange through the proximal end of the cannula, by aspiration of tracheobronchial secretions, by stimulation of cough with the catheter, and routinely by flexible bronchoscopy to observe the position of the catheter directly and rule out intra-tracheal bleeding. Aspiration of secretions is performed with the suction catheter. Complications following careful placement are few, but include hematoma, subcutaneous emphysema, and hoarseness. Hemorrhage is rare but potentially serious. It is best managed by immediate intubation and an inflated cuff to guarantee an airway and to tamponade further bleeding. With routine bronchoscopy, bleeding will not go unnoticed.

Percutaneous tracheostomy is discussed in Chapter 10, "Tracheostomy: Uses, Varieties, Complications."

Special Scalpel Minitracheostomy
figure 22-3 Minitracheostomy kit (Portex, Keene, NH). From the top: cannula, with connector at right; introducer; suction catheter. Tracheostomy tape and disposable scalpel are also included.

figure 22-4 Closure of persistent tracheostomy. A, The chronic stoma is circumscribed, leaving sufficient surrounding skin to effect closure. The tapered oval incision around the circular incision will become a transverse incision. Incision includes platysma. Superior and inferior flaps are raised over the sternohyoid muscle surfaces. Both lateral cutaneous triangles of the incision are excised. B, Cross section indicating cutaneous incision around stoma, carefully dissected to preserve the central blood supply of the circular flap, which arises through marginal stomal scar. C, The peristomal flap is elevated. The medial margins of sternohyoid muscle are dissected and elevated sufficiently to allow later midline apposition without tension.

figure 22-4 Closure of persistent tracheostomy. A, The chronic stoma is circumscribed, leaving sufficient surrounding skin to effect closure. The tapered oval incision around the circular incision will become a transverse incision. Incision includes platysma. Superior and inferior flaps are raised over the sternohyoid muscle surfaces. Both lateral cutaneous triangles of the incision are excised. B, Cross section indicating cutaneous incision around stoma, carefully dissected to preserve the central blood supply of the circular flap, which arises through marginal stomal scar. C, The peristomal flap is elevated. The medial margins of sternohyoid muscle are dissected and elevated sufficiently to allow later midline apposition without tension.

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