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AUTHOR AND EDITOR INFORMATION
Section 1 of 12  
Author: Jonathan P Lindman, MD, Consulting Staff, Department of Otolaryngology, ENT Care Associates
Jonathan P Lindman is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, Phi Beta Kappa, and Triological Society
Coauthor(s):
Charles E Morgan, DMD, MD, Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Alabama at Birmingham;
Susan Dixon, MD, Staff Physician, Department of Surgery, Division of Otolaryngology/Head and Neck Surgery, University of Alabama at Birmingham School of Medicine
Editors: John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Karen Hall Calhoun, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Missouri; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
tracheostomy, surgical airway, cervical airway, stoma, tracheotomy, intubation, cricothyrotomy, airway obstruction, cannula, upper airway obstruction, cricoid cartilage, thyroid cartilage, cricothyroid membrane, vocal cords, trachea, tracheostomy tube, tracheotomy tube, percutaneous tracheostomy, open tracheostomy, percutaneous transtracheal jet ventilation, PTJV, prolonged intubation
Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea. The traditional semantic difference between tracheostomy and tracheotomy is blurred in this instance because the hole is variably permanent. If a cannula is in place, an unsutured opening heals into a patent stoma within a week. If decannulation is performed (ie, the tracheostomy cannula is removed), the hole usually closes in a similar amount of time. The cut edges of the tracheal opening can be sutured to the skin with a few absorbable sutures to facilitate cannulation and, if necessary, recannulation; alternatively, a permanent stoma can be created with circumferential sutures. The term tracheostomy is used, by convention, for all these procedures and is considered to be synonymous with tracheotomy.
History of the Procedure
The history of surgical access to the airway is largely one of condemnation. This technique of slashing the throat to save the life was known as semislaughter. However, once the technique was perfected as a last resort in largely hopeless cases of diphtheria, the opportunities it offered for medical heroism ensured its place in the surgical armamentarium, such that Fabricius could write in the 17th century, "This operation redounds to the honor of the physician and places him on a footing with the gods." Documented references to the procedure include the following:
- 2000 BC: The Rgveda described a healed tracheostomy incision.
- Old Testament: Elijah performed mouth-to-mouth resuscitation on a child with heat stroke. This was the first example of assisted respiration.
- 100 BC: Asclepiades described a tracheostomy incision for improving the airway.
- Approximately 400 BC: Hippocrates condemned tracheostomy, citing threat to carotid arteries.
- Approximately 50 AD: Aretaeus of Cappadocia warned against the performance of tracheostomy for infectious obstruction because of the risk of secondary wound infections.
- Approximately 100 AD: Antyllus described the first familiar tracheostomy as a horizontal incision between 2 tracheal rings to bypass upper airway obstruction. He also pointed out that tracheostomy would not ameliorate distal airway disease (eg, bronchitis).
- 131 AD: Galen elucidated laryngeal and tracheal anatomy. He was the first to localize voice production to the larynx and to define laryngeal innervation. Additionally, he described the supralaryngeal contribution to respiration (eg, warming, humidifying, filtering).
- 400 AD: The Talmud advocated longitudinal incision.
- Approximately 400 AD: Caelius Aurelianus derided tracheostomy as a "senseless, frivolous, and even criminal invention of Asclepiades."
- 600 AD: The Susruta Samhita contained routine acknowledgment of tracheostomy as accepted therapy in India.
- Approximately 600 AD: Dante pronounced tracheostomy "a suitable punishment for a sinner in the depths of the Inferno."
- 1546: Brasavola published an account of tracheostomy for tonsillar obstruction. He was the first person known to actually perform the operation.
- 1561-1636: Sanctorius was the first to use a trocar and cannula. He left the cannula in place for 3 days.
- 1550-1624: Habicot performed a series of 4 tracheostomies for obstructing foreign bodies.
- 1702-1743: George Martine developed the inner cannula.
- 1718: Lorenz Heister coined the term tracheotomy, which was previously known as laryngotomy or bronchotomy.
- 1805: Viq d'Azur described cricothyrotomy.
- 1833: Trousseau reported 200 patients with diphtheria treated with tracheostomy.
- 1921: Chevalier Jackson codified indications and techniques for modern tracheostomy and warned of complications of high tracheostomy (cricothyrotomy).
- 1932: Wilson advocated prophylactic tracheostomy in patients with poliomyelitis.
Problem
Tracheostomy is a utilitarian surgical procedure of access and, as such, should be discussed in light of the problem it addresses: access to the tracheobronchial tree. The trachea is a conduit between the upper airway and the lungs that delivers moist warm air and expels carbon dioxide and sputum. Failure or blockage at any point along that conduit can be most readily corrected with the provision of access for mechanical ventilators and suction equipment. In the case of upper airway obstruction, tracheostomy provides a path of low resistance for air exchange.
Etiology
A tracheostomy is most commonly performed in patients who have had difficulty weaning off a ventilator, followed by thosewho have suffered trauma or some catastrophic neurologic insult. Infectious and neoplastic processes are less common in diseases that require a surgical airway.
Clinical
Suspect airway obstruction if signs or symptoms include the following:
- Dyspnea
- Stridor
- Inspiratory - Usually a supraglottic obstruction being sucked into the glottis with inspiration
- Expiratory - Usually a subglottic obstruction being blown up into the glottis during expiration
- Biphasic - Both of the above or a lesion isolated to the glottis (eg, edema)
- Voice change
- Pain
- Cough
- Decreased or absent breath sounds
- Bleeding
- Drooling
- Restlessness
- Hemodynamic instability (late)
- Loss of consciousness (very late)
The advent of the antibiotic era coupled with great advances in anesthesia have made tracheotomy the most commonly performed elective procedure.
- To bypass obstruction
- Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
- Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers
- Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral vocal cord paralysis)
- Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid bone, or great vessels.
- Subcutaneous emphysema
- Appears in face, neck, or chest
- Readily dissecting air, especially through inflamed or traumatized tissue planes, leading to massive soft tissue edema
- Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the midface and mandible)
- Edema
- Trauma
- Burns
- Infection
- Anaphylaxis
- To provide a long-term route for mechanical ventilation in cases of respiratory failure
- To provide pulmonary toilet
- Inadequate cough due to chronic pain or weakness
- Aspiration and the inability to handle secretions (The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing contents. Thus, this intervention can prevent aspiration and provide for the removal of any aspirated substances. However, some would argue that the risk of aspiration is not actually lessened, as secretions can leak around the cuffed tube and reach the lower airway.)
- Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period)
- Severe sleep apnea not amendable to continuous positive airway pressure (CPAP) devices or other, less invasive surgery
The larynx is composed of 3 large cartilage units: the epiglottis, the thyroid, and the cricoid cartilage. The cricoid cartilage is described as a reverse signet ring just inferior to the thyroid cartilage. The arytenoid cartilages lie on the posterior border of this ring of cartilage. The cricothyroid membrane stretches between the thyroid and cricoid cartilages. The cricothyroid muscle arises from the anterior surface of the cricoid and travels superiorly, posteriorly, and laterally to attach laterally to the surface of the thyroid cartilage. This muscle rotates the thyroid anteriorly and lengthens the vocal cords. The vocalis muscles arise from the inner surface of the thyroid cartilage in the midline and pass superiorly and posteriorly to attach to the length of the vocal cords. They shorten the cords and vary the tension on the cords. These 2 pairs of muscles and the cords are vulnerable to injury during cricothyrotomy (see Cricothyrotomy in Surgical therapy). The innominate artery, or brachiocephalic trunk, crosses from left to right anterior to the trachea at the superior thoracic inlet and lies just beneath the sternum. The trachea is membranous posteriorly and is formed of semicircular cartilaginous rings anteriorly and laterally. The spaces between the rings are membranous. The recurrent laryngeal nerves and inferior thyroid veins that travel in the tracheoesophageal groove are paratracheal structures vulnerable to injury if dissection strays from the midline. The great vessels (ie, carotid arteries, internal jugular veins) could be damaged should dissection go far afield, which is a real risk in pediatric patients or in those who are obese. The thyroid gland lies anteriorly to the trachea with a lobe on both sides and the isthmus, which crosses the trachea at approximately the level of the second and third tracheal rings. This tissue is extremely vascular and must be divided with careful hemostasis.
No absolute contraindications exist to tracheostomy. A strong relative contraindication to discrete surgical access to the airway is the anticipation that the blockage is a laryngeal carcinoma. The definitive procedure (usually a laryngectomy) is planned, and prior manipulation of the tumor is avoided because it may lead to increased incidence of stomal recurrence.
End-of-life issues may also come to bear on the decision to perform a tracheostomy because it may represent further mechanization of the patient's care to family members. In fact, the performance of a tracheostomy does not affect the decision to extend or to withdraw care. Hygiene is improved, quality of life (speaking and eating, if relevant) is improved, and placement in long-term care is facilitated in some cases; however, dependence on mechanical ventilation may not be changed. The patient is still "being kept alive by machines."
Lab Studies
- So many tracheostomies are performed electively in patients with secure airways (eg, for prolonged intubation) that to obtain the hematocrit and coagulation factors preoperatively is reasonable so that adequate correction can be made.
- As with any emergent procedure, the decision to perform an emergent tracheostomy is not altered by any laboratory values.
Surgical therapy
- Endoluminal
- Intubation may replace or precede tracheostomy and is comparably easy, more rapidly performed, and tolerated well for short periods. (The exact time is controversial but is generally considered to be 1-3 wk.) The intraoperative control provided by an endotracheal tube facilitates tracheostomy. The only reason not to intubate is the inability to do so. Contraindications to intubation include C-spine instability, midface fractures, laryngeal disruption, and obstruction of the laryngotracheal lumen.
- Supplements to intubation include the nasal airway trumpet, which provides dramatic relief of airway obstruction caused by soft tissue redundancy, collapse, or enlargement in the nasopharynx. The oral airway prevents the tongue from collapsing against the back wall of the oropharynx. Ironically, alert patients do not tolerate the oral airway, and patients obtunded enough to tolerate the oral airway without gagging should probably be intubated. Intubation can be performed orally or nasally. That decision generally depends on local trauma and the logistics of planned operative intervention.
Cricothyrotomy
- Emergent: The advantage of performing emergent cricothyrotomy is that the cricothyroid membrane is superficial and readily accessible, with minimal dissection required. The disadvantage is that the cricothyroid membrane is small, and adjacent structures (eg, conus elasticus, cricothyroid muscles, central cricothyroid arteries) are jeopardized; moreover, the cannula may not fit. Damage to the cricoid cartilage from scalpel or from pressure necrosis leads to perichondritis and, possibly, stenosis. The overall complication rate of emergent cricothyrotomy is 32%, which is 5 times that of the procedure under controlled circumstances.
- Elective: Cricothyrotomy has enjoyed a renaissance in cardiothoracic surgery. Recent studies have rehabilitated its image and raised questions about its inherent risks (recently 6.1%, which is comparable to the risk of tracheostomy). The advantage claimed by its practitioners is the increased distance between the airway stoma (unsterile) and the supposedly more sterile sternal wound.
- Jet: With the Seldinger technique, a catheter can be threaded into the cricothyroid membrane, and its tiny diameter can be compensated for with a stream of pressurized oxygen, which must be administered cautiously and manually. This is useful in endotracheal procedures (eg, microdebridement) that preclude intubation. The risk of barotrauma and the labor-intensive method of oxygen instillation dictate that this is a short-term intervention.
Tracheostomy
- Emergent (slash): This should be considered only when the patient is in extremis, which is when a cricothyrotomy should be performed. No conscientious physician should perform any procedure known (even colloquially) as a slash.
- Urgent (awake): Patients in acute respiratory distress may need acute surgical intervention. This can be performed in a controlled environment (eg, operating room) with the patient under local anesthesia. The awake patient contributes to the operative environment both negatively and positively. The patient's anxiety and restless movements challenge the surgeon and the anesthesiologist; however, the patient's vigilance is required to maintain the airway. These patients should be sedated and paralyzed only with extreme caution; better to have an agitated patient with an open airway than a relaxed patient with a complete obstruction. The risk of pneumothorax is increased in a patient with increased work of breathing because the cupulae expand high into the neck with high negative inspiratory pressures.
- Elective: Most elective tracheostomies are performed in patients who are already intubated and who are undergoing a tracheostomy for prolonged intubation. Additionally, patients undergoing extensive head and neck procedures may receive a tracheostomy during the operative procedure to facilitate airway control during convalescence. A smaller population of patients with chronic pulmonary problems (eg, sleep apnea) elect to undergo tracheostomy.
Preoperative details
As with any surgical procedure, a frank and honest discussion should take place between the surgeon and patient (and/or family) regarding the risks, benefits, and alternatives of tracheotomy.
Intraoperative details
Cricothyrotomy
The patient's neck is extended and stabilized. Palpate for the cricoid cartilage approximately 2-3 cm below the thyroid notch. A 1-cm horizontal incision is made just above the superior border of the cricoid (this avoids the vessels that run under the inferior border, in the same manner as the intercostal neurovascular bundles) to expose the cricothyroid membrane, which is then punctured in the midline. The blade must be directed inferiorly to avoid trauma to the true vocal cords. Care is taken not to extend this puncture through the back wall of the larynx and into the esophagus. Insert a blunt instrument (eg, knife handle) into the incision and rotate it perpendicularly to widen the incision to accommodate a small cannula. Later conversion to a tracheostomy is addressed below.
Tracheostomy
The performance of an open tracheostomy is more varied. Again, position the unconscious or anesthetized patient supine with the neck extended and the shoulders elevated on a small roll. The awake patient does not tolerate this; therefore, the procedure is performed with the patient in a sitting or semirecumbent position. Overextension of the neck should be avoided because it further narrows the airway; additionally, overextension can lead to placement of the tracheostomy too low (toward the carina) and too close to the innominate artery (especially in the very mobile pediatric trachea).
Palpate the landmarks (eg, thyroid notch, sternal notch, cricoid cartilage), and mark them with an ink pen. Plan a 3-cm vertical incision that extends inferiorly from the cricoid cartilage and infiltrate lidocaine (1%) with 1:150,000 parts epinephrine. This is sufficient anesthesia in awake patients and facilitates hemostasis in all patients. Make the vertical incision. Many advocate the horizontal skin incision, which is made along relaxed skin tension lines and gives better cosmesis. A horizontal incision may trap more secretions. Meticulous hemostasis is important throughout, beginning with the skin edges.
Subcutaneous fat may be removed with electrocautery to aid in exposure and to prevent later fat necrosis. Dissection proceeds through the platysma until the midline raphe between the strap muscles is identified. Palpate the inferior limit of the field to assess the proximity of the innominate artery. Cauterize or ligate aberrant anterior jugular veins and smaller vessels. Midline dissection is essential for hemostasis and avoidance of paratracheal structures. The strap muscles are separated and retracted laterally, exposing the pretracheal fascia and the thyroid isthmus. The lateral retraction also serves to stabilize the trachea in the midline.
Although, in some cases, the thyroid isthmus, which typically lies anteriorly over the first 2-3 tracheal rings, may be retracted out of the field, it must often be divided. A retracted isthmus may be irritated if it rubs against the tracheostomy tube in the postoperative period, causing bleeding. Division is performed sharply or with electrocautery and suture ligature. Elevate the isthmus off the trachea with a hemostat and divide it. Attention is turned to drying the field. Clean the remaining fascia off of the anterior face of the trachea and warn the anesthesiologist of impending airway entry.
When preparations for transfer of circuitry tubes are complete, deflate the endotracheal tube balloon and enter the trachea. Injection of topical anesthesia can stem the cough reflex of an awake patient. Absolute hemostasis before this point obviates the threat that blood could enter the trachea and exacerbate the cough reflex. Securing the cricoid with a hook and elevating it superiorly facilitates control of the tracheal entry. Several options for the tracheal stoma are available, including the following:
- T-shaped tracheal opening: Make a 2-cm incision horizontally through the membrane between the second and third or third and fourth tracheal rings. Use heavy scissors to cut vertically and inferiorly in the midline through the distal 1-2 tracheal rings. With this incision, a silk stay suture can be placed through the tracheal wall on each side and taped to the neck skin on either side. This facilitates tube replacement should it dislodge in the immediate postoperative period. Marking the tape that holds these sutures to the skin with "Do not change or remove" is prudent. These sutures are removed after the first tracheostomy tube change 5-7 days postoperatively.
- U- or H-shaped tracheal opening: Reflect tracheal flaps inferiorly or both inferiorly and superiorly. These can be tacked to skin edges with absorbable sutures to create a semipermanent stoma, or silk stay sutures can be placed in each tracheal flap and taped to the chest and neck skin, facilitating replacement of a displaced tube in postoperative care. This is beneficial in the patient with obesity.
- Permanent stoma: Create a permanent stoma with skin flaps developed and sutured to a rectangular tracheal opening. Removal of small anterior portions of the tracheal rings is required. This is desirable only in patients who are expected to require secure transluminal access indefinitely (eg, patients with sleep apnea, terminal illnesses). Resecting part of the anterior tracheal wall predisposes to stenosis; thus, this resection is unwise in a temporary tracheostomy.
After the trachea is entered, suction secretions and blood out of the lumen and slowly withdraw the endotracheal tube to a point just proximal to the opening. Replace the lateral retractors into the trachea and insert the previously tested tracheostomy tube. After the airway is confirmed intact based on carbon dioxide return and bilateral breath sounds, secure the tracheostomy tube to the skin with 4-0 permanent sutures. Attach a tracheostomy collar with the head flexed to avoid unnecessary slack in the collar. To avoid the risk of subcutaneous emphysema and subsequent pneumomediastinum, the skin is not closed. Place a sponge soaked with iodine or petrolatum gauze between the skin and the flange for 24 hours to deflect infection and anxiety about minor oozing of the skin edge.
Choice of tube
Typically, the smallest feasible tube should be used. A rule is that the tube should be three fourths of the diameter of the trachea. In patients of average habitus, a #6 Shiley cuffed tracheostomy tube (SCT) is appropriate for most women, and #8 SCT is appropriate for most men. More care must be taken in the patient with obesity; a flexible single-lumen variable-length tube may be most appropriate. A tube that is too short abuts the posterior tracheal wall, causing obstruction and ulceration. A tube that is too long curves forward and erodes the anterior tracheal wall, which can be perilously close to the innominate artery.
Cuffed tubes allow positive pressure ventilation and prevent aspiration. If the cuff is not necessary for those reasons, it should not be used because it irritates the trachea and provokes and trap secretions, even when deflated. Even modern low-pressure cuffs should be deflated regularly (qid) to prevent pressure necrosis. Standard fenestrations are rarely in the right place; if flush with the tracheal wall, they instead cause irritation and granulation and should not be used.
Extra-long tracheostomy tubes are available to use in certain situations. Extra–proximal-length tubes facilitate placement in patients with large necks, and extra–distal-length tubes facilitate placement in patients with tracheal anomalies. Several tube designs have a spiral wire reinforced flexible design and have an adjustable flange design to allow bedside adjustments to meet extra-length tracheostomy tube needs.
The Bivona tracheostomy tube is much like a foreshortened endotracheal tube. It has a grip that secures the tube at the desired position. One disadvantage is that the Bivona tracheostomy tube is a single-lumen tube. Meticulous care must be taken because this tube does not have an inner cannula to remove for cleaning. Additionally, obstruction of the tube by secretions necessitates removal of the outer cannula in the patient with a difficult airway. The variable length of the tube requires that placement be checked, either endoscopically or radiographically, to avoid mainstem ventilation.
Recently, Tibballs et al reported complications using the Bivona tracheotomy tube. They cite problems related to the tube's tendency to straighten itself once it is bent and inserted into the trachea through the tracheostoma. These problems include tracheal ulceration (1 case), distortion of tracheal soft tissue (1 case), and airway obstruction when the tip embedded into the tracheal wall (1 case).
Postoperative details
Postoperative care is critical. The recently insulted trachea produces copious secretions, and irrigation with saline and suctioning every 15 minutes are not initially unreasonable. Suctioning should be limited to the length of the tube to avoid tracheal ulceration and tracheitis and should be limited to no more than 15 seconds because the act of suctioning blocks the airway and sucks the air out of the lungs. Humidified oxygen helps prevent inspissation of the secretions. Additional mucolytic agents (eg, acetylcysteine [Mucomyst], guaifenesin) may be used. If uncorrected, mucus that plugs the inner cannula can cause a life-threatening obstruction.
The original tube is left sutured in place for 5-7 days to allow the tract to heal. The sutures are then removed, and the tube is replaced. For patients in whom the tracheostomy was an acute intervention, this is an opportunity to downsize the tube or to change to a metal (Jackson) tube. The site should be kept clean and dry to minimize infection from what is a chronically colonized location. Patient and family education should begin as soon as possible.
Follow-up
- Speaking: As soon as the cuff can be deflated, the patient should be encouraged to occlude the tube with a finger and to begin to phonate. As long as no significant edema is present, enough air should pass by the tube and through the vocal cords. This also encourages the patient to reestablish normal airflow through the upper airway and diminishes psychological reliance on the lesser resistance of the tracheostomy.
- Passy-Muir valves are special 1-way valve caps that allow automatic occlusion with exhalation for speech. Negative pressure (inspiration) opens the valve.
- Fenestrations: These are rarely in the correct place. Simply deflating the cuff or, preferably, downsizing to a cuffless tracheostomy tube should suffice for audible speech.
- Plugging: In preparation for decannulation, the tracheostomy tube may be plugged. The patient must be able to remove the plug should dyspnea develop. Patients with sleep apnea frequently keep their tubes plugged except when they go to sleep.
- Swallowing: Swallowing is more difficult while the tube is in place because of decreased laryngeal elevation; however, oral intake is certainly possible. Thoroughly evaluate the patient's risk of aspiration before feeding begins.
- Home care and equipment: Tracheostomy remains socially stigmatized and can intimidate both the patient and the family. The family's understanding and comfort are most important. Education must begin early, and preparations for discharge must be complete. Before leaving the hospital, all members of the household should feel comfortable with replacing the outer cannula. Equipment includes saline, suction catheters, and a suction machine for hygiene; replacement inner cannulas; and a spare tube with an obturator. Occasionally, a patient requires humidification via tracheal collar. The most commonly overlooked or misunderstood item is the obturator, which is important in the atraumatic reinsertion of the outer cannula.
Immediate complications
- Apnea due to loss of hypoxic respiratory drive: This is mainly important in the awake patient. Ventilatory support must be available.
- Bleeding: Intraoperative bleeding arises from the cut edges of the very vascular thyroid gland and from lacerated vessels in the field that should be cauterized or ligated. Care should be taken to stop all thyroid bleeding before the cut edges are allowed to retract laterally, which makes them difficult to expose.
- Pneumothorax or pneumomediastinum: These can result from direct injury to the pleura or the cupola of the lung (especially in children) or from high negative inspiratory pressures of patients who are awake and distressed. Early recognition is critical, and routine postoperative chest radiography should be considered after tracheotomy.
- Injury to adjacent structures: The paratracheal structures vulnerable to injury are the recurrent laryngeal nerves, the great vessels, and the esophagus. This danger is most prevalent in children because the softness of the trachea hinders its identification if it is not distended with a rigid object.
- Postobstructive pulmonary edema: Although rare, a transient pulmonary edema can occur after tracheostomy, which provides relief of upper airway obstruction.
Early complications
- Early bleeding: This is usually the result of increased blood pressure as the patient emerges from anesthesia (and relative hypotension) and begins to cough. Although this may necessitate a return to the operating room, bleeding may be controlled with local packing and hypertension control. Packing should involve antibiotic-impregnated gauze (eg, iodophor), and the patient should be given antistaphylococcal antibiotics while the packing is in place. Bloody secretions that issue from the tube may represent diffuse tracheitis (most commonly), rundown bleeding from the skin or thyroid, or ulceration from an ill-fitting tube or overzealous suctioning.
- Plugging with mucus: The use of dual cannula tubes lessens this as a threat because the inner cannula can be removed for cleaning while the outer cannula safely maintains patency of the fresh tract. However, vigilance is still required, and all measures to thin and to remove secretions should be undertaken.
- Tracheitis: To some degree, tracheitis is present in all patients with fresh tracheostomies. Again, humidification, minimization of the fraction of inspired oxygen (FIO2) (because high oxygen levels exacerbate drying), and irrigation are essential. Moreover, motion of the tube within the trachea is extremely irritating and should be prevented with stabilization of the ventilator circuitry so that torsion is minimized.
- Cellulitis: The wound is colonized quickly; however, infection is unlikely if the incision has not been closed tightly and drainage is allowed. Opening the wound and instituting appropriate antibiotics should suffice to treat any early cellulitis.
- Displacement
- The need to replace a new tracheostomy tube is not uncommon. In this situation, remember the access that the upper airway still affords. Bag ventilate the patient and prepare for intubation if the tracheostomy tube cannot be replaced. Initial management includes passing an object (eg, smaller tube, clear nasogastric tube [which shows the fogging of respiration]) into the open wound.
- A physician may attempt recannulation. This is facilitated with placement of the tube over the fiberoptic laryngoscope and reentry of the trachea under direct vision. However, endotracheal intubation remains the mainstay of airway management and should not be ignored while an increasingly traumatized tracheostomy site is labored over. Misplacement of the tracheostomy tube into the dreaded false passage, usually in the pretracheal space, should be suspected in the presence of difficult ventilation or passage of a suction catheter or if subcutaneous air or pneumothorax develops.
- Subcutaneous emphysema: This results from a tight closure of tissue around the tube, tight packing material around the tube, or false passage of the tube into pretracheal tissue. It can progress to pneumothorax, pneumomediastinum, or both and should be treated with loosening of the closure or packing and with performance of a tube thoracotomy, if necessary. Incidence of pneumothorax after tracheostomy is 0-4% in adults and 10-17% in children; thus, postoperative chest radiography is recommended in children.
- Atelectasis: An overly long tube can mimic a unilateral mainstem intubation, causing atelectasis or collapse of the opposite lung.
Late complications
- Bleeding
- Bleeding more than 48 hours after the procedure may herald a tracheoinnominate fistula caused by a low (farther along the trachea toward the carina) tracheostomy or an ill-fitting long tube. One half of patients with significant bleeding more than 48 hours after the procedure have a tracheoinnominate erosion. This occurs in 0.6-0.7% of patients with tracheostomies, and the mortality rate of this complication approaches 80% if treated aggressively. Patients with an impending tracheoinnominate fistula may have a sentinel bleed (ie, brief episode of brisk bright red blood from the tracheostomy site) hours or days before catastrophic bleeding. Some physicians prefer to investigate all such episodes of bleeding with a careful tracheobronchoscopy, looking for suggestive areas in the appropriate area of the trachea.
- If diagnosis is made only when catastrophic bleeding occurs, management includes replacement of the tracheostomy tube with an endotracheal tube with the balloon inflated distally to the site of the bleeding to protect the airway. If the balloon does not tamponade the bleeding, a well-placed finger can temporize while the thoracic surgery team mobilizes for median sternotomy to locate and to control the bleeding vessel.
- Occasionally, granulation tissue at the tip of the tracheostomy tube can bleed vigorously. This can be identified via flexible laryngoscopy and can be treated with excision or cautery via bronchoscope in the operating room.
- Tracheomalacia: This is usually caused by a tube that fits poorly. Improved fit may allow recovery of the softened cartilage.
- Stenosis: Injury to the cricoid cartilage, the only circumferential ring in the trachea, can lead to laryngeal stenosis. Stenosis typically occurs at the site of the tracheostomy or at the area irritated by the cuff. Over the course of his life, Chevalier Jackson saw the incidence of posttracheostomy stenosis drop from 75% to 2%. Modern high-volume low-pressure cuffs have reduced the rate of this complication; however, care must still be taken not to overinflate these cuffs and to deflate them periodically. Tracheal stenosis typically develops several weeks after decannulation as a subacute distress, often mistaken for bronchitis. Treatment is surgical and ranges from formal resection and reconstruction to less invasive means of debridement or stenting for palliation.
- Tracheoesophageal fistula: A tracheoesophageal fistula, which is typically caused by friction between a posteriorly displaced tracheostomy tube or overinflated cuff and a rigid nasogastric tube, almost always requires surgical repair, possibly with a muscle flap, skin graft, or both. A tracheoesophageal fistula manifests as aspiration and subsequent chemical pneumonitis and should be evaluated with a plain film (which may show an air-filled esophagus) or barium swallow, followed by bronchoscopy. Preoperative management includes gastrostomy decompression and jejunostomy nutrition. This complication occurs in less than 1% of patients with tracheostomy.
- Tracheocutaneous fistula: Epithelialization of the tract from skin to trachea can result in a nonhealing fistula. This can be repaired with coring out of the epithelial layer and allowance of the wound to granulate in. Alternatively, a 3-layer closure can be performed but is associated with more complications. A persistent tracheocutaneous fistula can indicate proximal resistance or a remaining obstruction and should be evaluated via direct laryngoscopy.
- Granulation: This can occur at the site of the stoma and should be cauterized with silver nitrate. It can also occur distally, where it may cause partial or complete obstruction or cause this friable tissue to bleed. As granulation matures into fibrous scar, it can contribute to stenosis.
- Scarring: Both vertical and horizontal incisions heal with small but visible scars that can be revised if they bother the patient.
- Failure to decannulate: Sometimes, patients fail plugging trials or even decannulation for no apparent reason. Possibilities to consider include obstructing granuloma previously held out of the way with the tube, bilateral vocal cord paralysis, infractured cartilage, and anxiety. Evaluation should include fiberoptic laryngoscopy and bronchoscopy through the stoma, with visual inspection down at the carina, up at the glottis, and then through the nose to view the hypopharynx and the supraglottis.
Special cases
- The patient with obesity: In particular, the patient with obesity and obstructive sleep apnea (OSA) poses a challenge. The apnea can be corrected with a tracheostomy. Until the acceptance of uvulopalatopharyngoplasty and the availability of CPAP, tracheostomy was the standard treatment. Yet the same obesity that impairs ventilation also challenges the surgeon during the operation and the nursing staff during postoperative care. Techniques have been developed to facilitate the creation of and maintenance of the permanent airway. Skin flaps are raised and subcutaneous fat removed. They are then sutured circumferentially to corresponding tracheal flaps to create a permanent stoma. Intraoperatively, taping the chest down and the chin up may help. The reverse Trendelenburg position recruits the help of gravity.
- The pediatric patient: Infants and children have relatively short necks and are at high risk of tube displacement. This risk makes the operation and the postoperative course much more perilous. Use of a rigid bronchoscope or endotracheal tube in place to define the location of the trachea should be considered because paratracheal dissection is not uncommon. In particular, the infant's pleural spaces extend far superiorly into the paratracheal spaces and can easily be injured. Thus, postoperative chest radiography is necessary in infants and children. Tracheal stay sutures can be placed bilaterally in the incised tracheal wall and, when clearly identified, can be taped to the neck. In the event of displacement, these sutures can pull the trachea up into the field and facilitate replacement. Even today, long-term tracheostomy in an infant carries a mortality rate of 20%. Thus, judicious performance of these procedures and the use of every precaution are imperative.
- The patient who requires only improved pulmonary toilet: A tracheal fenestration, which is an oval opening, allows the passage of a suction catheter. This catheter, which is covered by an operculum when not in use, allows speech.
- Duration of tracheostomy: A tracheostomy can be used for days or, with proper care, for years.
- Decision to decannulate: The tracheostomy tube should be removed as soon as is feasible and, therefore, should be downsized as quickly as possible. This allows the patient to resume breathing through the upper airway and reduces dependence (psychological and otherwise) on the lesser resistance of the tracheostomy tube. Decannulation may be performed when the patient can tolerate plugging of the tracheostomy tube overnight while asleep without oxygen desaturation. After the tube is removed, the skin edges are taped shut, the patient is encouraged to occlude the defect while speaking or coughing, and the wound should heal within 5-7 days.
Prolonged intubation
- Prolonged mechanical ventilation has become possible and increasingly necessary as advances have been made in the care of patients with a critical illness.
- Antibiotics, total parenteral nutrition (TPN), and dialysis-current interventions allow almost indefinite support.
- Complications of prolonged intubation include ulceration, granulation tissue formation, subglottic edema, and tracheal and laryngeal stenosis.
- Pulmonary hygiene and oral hygiene are difficult.
- Communication is frustrating, and deglutition can be very difficult.
- The change from an endotracheal tube to a tracheostomy tube decreases dead space by 10-50%.
- Decreased resistance increases compliance and facilitates independent breathing.
- Work of breathing is significantly less through a 6- to 12-cm tracheostomy tube than through a 27-cm endotracheal tube. Weaning a patient off mechanical ventilation is greatly facilitated by this decreased work of breathing. Intermittent rests on the ventilator, usually at night, are also possible.
- Tracheostomy provides a more secure airway, is less likely to be displaced, and is more readily replaced than the traditional endotracheal tube.
- Tracheostomy has not been demonstrated to pose a greater risk of pneumonia than intubation because both interventions lead to colonization of the airway with potential pathogens.
Conversion of cricothyrotomy to tracheostomy
- The cricothyrotomy was condemned by Chevalier Jackson in 1921, and, since that time, it has been accepted only as an emergent procedure associated with ease of performance in the field.
- Jackson blamed cricothyrotomy, the high tracheostomy, for 93 of the 100 cases of laryngeal stenosis in his series.
- Brantigan and Grow published data on a large series of elective cricothyrotomies with a 6.1% complication rate, which is comparable to that for traditional tracheostomies. This research has raised the question of whether to convert cricothyrotomies to tracheostomies and whether to perform elective cricothyrotomies instead of tracheostomies. This study is limited because one third of the patients died before discharge and, therefore, were not included in the follow-up documentation.
Pediatric patients
- Indications for pediatric tracheotomy are similar to those for adults.
- Airway obstruction is the leading indication for tracheotomy, followed by ventilatory support and pulmonary toilet.
- Solares et al reported on their use of starplasty tracheotomy in pediatric patients. In 94 children aged 2 days to 14 years, fewer major complications, such as pneumothorax and accidental decannulation, developed; however, a higher incidence of persistent tracheocutaneous fistula exists.
- Hartnick et al investigated the effects of the placement of a pediatric tracheotomy tube on the degree of caregiver burden and overall health status of parents who use general and disease-specific instruments. The study concluded that parents who care for children with tracheotomy tubes experience significant caregiver burden.
Percutaneous transtracheal jet ventilation
- Jacoby et al and Reed et al first developed and introduced percutaneous transtracheal jet ventilation (PTJV) in the 1950s. As the name implies, a catheter is placed through the skin and into the trachea.
- This procedure is performed under local anesthesia and, once PTJV is in place, the patient can be oxygenated with jet ventilation maneuvers.
- This procedure is most commonly used in the management of the difficult airway (supraglottic and glottic obstruction) before the induction of general anesthesia.
- After surgery, the catheter can be left in place in case the patient needs future respiratory support.
- Complications of the procedure include barotraumas, kinking of the catheter, and soft tissue emphysema and pneumothorax.
- Spiro recently reported his experience in 43 consecutive PTJV procedures. Only one pneumothorax (a tracheotomy and left chest tube were performed) and one episode of minor subcutaneous emphysema occurred.
Percutaneous versus open tracheostomy
- In 1969, Toye and Weinstein described a technique of tracheostomy performed percutaneously at the bedside using essentially a Seldinger technique modified with progressive dilation.
- Its main advantage is that it can be performed at the bedside; therefore, the expense and logistics of transportation and operating room usage are eliminated. These advantages are mitigated because bedside anesthesia is required and recently advocated bronchoscopic visualization adds to the expense and personnel required. Moreover, preparation for the possibility of an emergent open tracheostomy is important.
- Its disadvantages stem from the decreased exposure and, thus, decreased visualization and control.
- The following patients are commonly recognized to be unfavorable candidates: individuals with obesity, those with abnormal or poorly palpable midline neck anatomy, those who need emergency airway, patients with coagulopathy, pediatric patients, and patients with enlarged thyroids.
- Kost recently reported on the use of this procedure in 500 consecutive intubated adults in the intensive care unit. When this procedure is performed in conjunction with bronchoscopy, she states the complication rate is acceptably low (9.2%). No serious complications (ie, pneumothorax, pneumomediatinum, death) occurred. The 2 most common complications were oxygen desaturation in 14 patients (defined as a drop [even transient] to less than 90%) and bleeding in 12 patients (when intervention was required to control the bleeding). See the cited article for figures that carefully outline the details of this procedure.
| Media file 1:
Anterior anatomy of the larynx and trachea (in situ). |
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| Media file 2:
Posterior view of paratracheal structures. The asterisk indicates structures at risk from paratracheal dissection. |
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| Media file 3:
Parasagittal view through larynx. The asterisk indicates structures at risk during cricothyrotomy. |
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| Media file 4:
Operative view of tracheostomy. The thyroid isthmus is divided with electrocautery. |
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| Media file 5:
Operative view of tracheostomy. These are options for tracheal incision. |
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Operative view of tracheostomy. These are special techniques in the patient with obesity. |
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Tracheostomy excerpt Article Last Updated: Oct 27, 2006
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