eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Tracheostomy: Follow-up

Author: Jonathan P Lindman, MD, Consulting Staff, Department of Otolaryngology, ENT Care Associates
Coauthor(s): Charles E Morgan, DMD, MD, Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Alabama at Birmingham
Contributor Information and Disclosures

Updated: Apr 22, 2009

Outcome and Prognosis

• 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.
• In 2009, Tobin proposed that the use of a tracheostomy team may reduce morbidity of this indwelling respiratory device.³

Future and Controversies

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.
• Timing of tracheostomy in patients who are critically ill and intubated is controversial. A large, retrospective cohort analysis including nearly 11,000 critically ill patients evaluated the impact of tracheotomy timing on mortality. The authors found a slight overall improvement in survival in patients who undergo tracheotomy within the first 10 days of intubation.⁴

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.⁵ 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.⁶
• 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.⁷ 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.⁸ 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.
• Gulleth and Spiro reported their experience in 43 consecutive PTJV procedures.⁹ 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, Toy and Weinstein described a technique of tracheostomy performed percutaneously at the bedside using essentially a Seldinger technique modified with progressive dilation.¹⁰
• 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. A recent study of 149 critically ill patients found a greater risk of severe (>50%) suprastomal stenosis developing as a late complication of percutaneous dilational tracheostomy versus surgical tracheostomy.¹¹
• 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.¹² When this procedure is performed in conjunction with bronchoscopy, she states the complication rate is acceptably low (9.2%). No serious complications (ie, pneumothorax, pneumomediastinum, 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.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Susan Dixon, MD, to the development and writing of this article.

• Search for CME/CE on This Topic »

• Pediatric Tracheostomy (Otolaryngology and Facial Plastic Surgery)
• Percutaneous Tracheostomy (Otolaryngology and Facial Plastic Surgery)
• Ventilation, Noninvasive (Pulmonology)
• Conservation Laryngeal Surgery, Vertical Partial Laryngectomy (Otolaryngology and Facial Plastic Surgery)

• Prompt Tracheostomy in ICU Patients Shortens Hospital Stay
• Laryngotracheoplasty a Reasonable Alternative to Tracheotomy in Infants
• FDA Recalls Portex Ventilation Tubes

• The Difficult Airway in Adult Critical Care
• Contemporary Considerations in Cranial-Base Surgery
• Effects of Staff Training on the Care of Mechanically Ventilated Patients: A Prospective Cohort Study