In today's video with the help of the cadavers here in the lab, we're going to be discussing
the procedure known as the Tracheostomy and see exactly what's going on as that airway
is being restored.
It's going to be a refreshing one.
Let's do this!
[Intro]
Let's first start with the anatomy in the area that way we can best understand exactly
what's happening during the procedure.
The larynx or what most would refer to as the "Voice Box" is the beginning of the respiratory
tract or at least the point with which it fully separates from the digestive tract.
Now, it's made up of several cartilages, muscle tissue, epithelial tissue, and connective
tissues, but the largest of the cartilages is what's known as the Thyroid Cartilage and
it's typically even larger in males due to testosterone fueling its growth.
Just below it is the cricoid cartilage which is shorter in the front than it is in the
back.
Now, both the cricoid and thyroid cartilages are made of what's known as Hyaline Cartilage.
Now, hyaline cartilage functions to reduce friction as well as hold its shape.
However, there is another visible cartilage in the larynx called the Epiglottis and this
is going to be made of elastic cartilage tissue.
Now, the epiglottis functions to block the airway when swallowing from food and drink
because that would obviously be bad.
In fact, we did an entire video about when it doesn't work properly.
So, you should definitely go check that out.
If we look past the epiglottis and directly into the larynx itself, you'll see a small
gap with soft tissue to the sides.
These are the vocal folds which are involved in controlling pitch during speaking and singing.
So, like ho ho ho ho ho ho hoooo....
I know, that was beautiful but there's no need to applaud so please take a seat [Chuckle].
The thyroid actually translates to "Shield" and that's exactly what it's doing.
It's a thick piece of cartilage that is there and designed to shield the vocal folds from
any potential damage.
Between the thyroid and cricoid cartilages is a connective tissue called the cricothyroid
membrane or also sometimes called the cricothyroid ligament.
Now, it acts to limit the movement between the thyroid and cricoid cartilages and knowing
its location is essential to performing a proper tracheostomy.
The trachea or what's most often called windpipe is formed by C-shaped rings called Tracheal
Rings although the rings don't go all the way around but just as in the larynx, these
rings are made of hyaline cartilage which allows it to retain its shape while also always
staying open so that you can constantly breathe in and out.
Between the rings, we find connective tissue segments called Annular Ligaments which are
there to keep those cartilage and this rings in place while also allowing for movement
to occur.
On the posteria side of the trachea, you're going to find muscle tissue which is going
to assist in coughing.
So, it's like [Coughing] - but it's like also going to help to provide just overall integrity
to the trachea itself.
The trachea will then split into what's known as the primary bronchia and then from there,
it's just going to continue splitting and splitting as it goes deeper into the lung
tissue.
We then have the thyroid gland which is just below the larynx but it doesn't belong to
the respiratory system.
Instead, it's a part of the endocrine system and is responsible for things such as metabolism
and bone density.
Still though, it's an important landmark to identify simply because you don't want to
damage it the procedure.
Okay, so now that we have an understanding of what we're looking at, let's go ahead and
discuss exactly what's happening during a tradechiostomy.
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Alright, let's get back to it.
Most people are aware of something called a tracheotomy.
However, definition, equipment, procedures change over time and these days, most refer
to a tracheotomy as the incision being made in the neck and then a tracheostomy is when
you add tubing to that hole in the neck.
However, depending on who you're talking to, they may use the the terms interchangeably
which personally, I don't really have a big problem with.
There can be several different reasons why someone would require a tracheostomy but it's
probably easiest if you just think of it as being either emergent or elective.
Emergent tracheostomies are seen as the last resort and are typically caused by a full
obstruction of the airway itself and that could be caused by say food although that's
a whole lot less common than people think it is or facial trauma as in maybe you experience
some horrible accident.
This is where you'll usually see something called a cricothyroidotomy which is where
they make an incision in the cricothyroid membrane and then insert tracheostomy tubing
in order to restore the airway.
Although, there is another pathway that we're about to discuss that you also could take
under emerging conditions.
Elective tracheostomies are performed under general anesthesia and are usually a result
of respiratory failure from things such as neurological problems - so may be had brain
or spinal cord trauma or maybe lung issues like pneumonia, but it also could be many
other things that just require prolonged mechanical ventilation.
To make things simple, let's assume that someone is undergoing an elective tracheostomy.
The surgical team is going to need to identify a few marks to ensure that they're cutting
into the correct location.
So, first, they're going to identify what's called the Thyroid Notch which is at the top
center of the thyroid cartilage.
From there, they're going to locate the Jugular Notch which is the groove at the top of the
sternum.
Then, they're going to go just a couple of centimeters below the thyroid notch and locate
the cricothyroid membrane as well as the cricoid cartilage.
This is where they'll make an incision - cutting either horizontally or vertically and making
their way through the skin layers until they see an extremely thin muscle called the Platysma.
Now, they'll then cut through the platysma exposing two strap-like muscles of the throat
called the Sternohyoid and Sternothyroid.
These muscles as well as many others are going to be involved in speaking and swallowing.
They'll then pull the muscles laterally to expose the cricoid cartilage and thyroid gland.
Although, the thyroid gland isn't always visible, meaning, they just sometimes don't to do anything
with it but other times, they need to ensure that they're not going to damage it during
the procedure.
So, they will tie or clamp off what's known as the Thyroid Isthmus which is going to connect
the left and right aspects of the thyroid gland.
From there, they'll place a hook underneath the cricoid cartilage and lift it towards
the head pulling both the larynx and the trachea into view.
From there, they'll identify the second and third tracheal rings and an incision will
be made.
Now, here's where different techniques can be used.
Maybe they just cut into the annular ligament between the tracheal rings or maybe they cut
into the tracheal rings themselves and actually remove the segment outright or they could
just cut it enough that they can bend it over and create this cartilage and this flap that
could be placed back and stitch together at a later point - but, regardless of the technique
used, from here, this is where they insert the tracheostomy tubing essentially completing
the procedure.
Several complications can arise from performing tracheostomy although the most common is going
to be bleeding.
Bodies are unique and additional blood vessels can grow that you don't anticipate and normal
blood vessels can take a different pathway than you anticipate making it all the more
likely that a surgeon could potentially cut them during the procedure.
However, surgeons are very much aware of this and this is typically not an issue.
The bigger problem with bleeding is that most patients that require a tracheostomy are critically
ill.
Meaning that they may a coagulation problem and that can be a pretty serious problem considering
even if the surgery is going very well, the patient can continually bleed which is why
many patients will require a platelet transfusion prior to the surgery to ensure proper clotting
but other complications could be an infection or maybe Pneumothorax which is where air gets
trapped between the lungs and the rib cage although those are extraordinarily rare.
When it comes to removing the tracheostomy tubing, they'll ensure the patient can breathe
on their by capping off the tubing and then observing the patient over time to see how
oxygen and carbon dioxide levels are handling it.
If all goes well, they will then remove the tubing stitch the patient up and they are
now on their way towards recovery.
It's unfortunate that I even need to say this but chances are pretty good that you've seen
a movie or a television show where someone performs an emergency tracheostomy with something
like a pen.
This is a really bad idea and it's far more likely to cause harm than it is to do real
good.
Again, just think to the variability within the human species.
Blood vessels may not be where you think they are.
I was once teaching a class of EMTs and they informs me that EMTs aren't allowed to perform
emergency tracheostomies anymore and that's because some EMTs when attempting to perform
the tracheostomy were missing the cricothyroid membrane or maybe they were hitting blood
vessels that they weren't intending to.
Or in some cases, they even went too far in to the trachea and we're damaging the posterior
wall of the trachea.
Again, causing an extreme damage and in some cases, even killing the patients they were
attempting to save.
So, unless it's the apocalypse or you've exhausted pretty much every option you have, please
avoid using a pen at all costs.
Thanks again to Aura for sponsoring today's video.
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As always, be sure to Like, Comment, Subscribe if you feel so inclined.
I'll see you in the next video.