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Tracheotomie je výkon indikovaný při poranění hrtanu, trachey, případně při obstrukci dýchacích cest. Protože změnčuje mrtvý prostor v dýchacích cestách, je často život zachraňujícím výkonem při respirační insuficienci. Provádí se buď v LA příp. celkové anestézii a to buď jako horní nebo dolní tracheotomie. Nejčastěji se volí dolní tracheotomie. Mediální přístup ve výši istmu štítné žlázy se nedoporučuje, protože si nutně vyžaduje jeho přetětí.

V urgentních případech se provádí horní tracheotomie. Dolní tracheotomie je u dospělých obtížnější pro hlubší uložení průdušnice. První tracheální prstenec nemá být protínán, aby se zabránilo následné stenóze z tlaku tracheotomické kanyly na chrupavku prstencovou.

Pacienta ukládáme na záda s mírně zdviženou horní polovinou těla a zakloněnou hlavou.Pozor! Při tracheomalacii může trachea vlivem záklonu hlavy kolabovat.

 Horní tracheotomie:

1. přístup získáme svislou nebo příčnou 3-4cm dlouhou kožní incizí. Lepší kosmetický výsledek má příčná incize.

2. Protneme kůži, m. platysma a povrchovou krční fascii. Všechny cévy pečlivě podvážeme. Horní lalok m. platysma odtáhneme od svalů ležících vespod. V mediální čáře, kde se mm. sternohyoidei nedotýkají, uvolníme tracheu.

3. Lamina praetrachealis fasciae cervicalis odtáhneme spolu s mm. sternothyroidei do stran a obnažíme isthmus štítné žlázy. Při horní tracheotomii se isthmus stáhne po tupém uvolnění dolů. Je-li přítomen lobus pyramidalis, odtáhne se ke straně. Po zafixování druhého tracheálního prstence dvěma ostrými háčky následuje jeho vertikální protětí, event. i incize 3. tracheálního prstence. Někteří chirurgové provádějí oválnou excizi z přední stěny trachey nebo incizi ve tvaru písm. l, aby zabránili pozdější stenóze z vchlipování incidovaných okrajů do lumen. Dříve než založíme kanylu, vysprejujeme tracheu asi 0,5 – 0,8ml 2% LA, abychom omezili kašlací reflex.

 Dolní tracheotomie:

1. Ze stejného přístupu jako při horní tracheotomii odtáhneme isthmus štítné žlázy nahoru a protneme 3. nebo spíše 4. tracheální prstenec, případně vyřízneme do přední stěny trachey oválné okénko.

  Založení kanyly:

1. Tahem za háčky rozšíříme otvor v průdušnici a zavedeme kanylu. Je-li přítomen hlen, odsajeme ho. Po odstranění háčků se svaly a pretracheální fascie k sobě spontánně přiblíží., takže jejich sutura není nutná.

2. Kožní ránu uzavřeme 1-2 stehy. Těsný uzávěr rány se pro často přítomnou infekci nedoporučuje. Ránu volně obložíme mulem a mezi destičku kanyly a obvaz vložíme kousek Billrothova batistu (nebo sterilního igelitu). Kanylu fixujeme tkanicemi, jejichž konce na šíji zavážeme. Otvor v kanyle přikryjeme vlhkým mulovým obkladem tak, aby nebránil dýchání.

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