eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology
Tracheostomy
Updated: Apr 22, 2009
Introduction
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.
Anterior anatomy of the larynx and trachea (in situ).
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 heatstroke. 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 those who have suffered trauma or some catastrophic neurologic insult. Infectious and neoplastic processes are less common in diseases that require a surgical airway.
Presentation
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)
Indications
The advent of the antibiotic era coupled with great advances in anesthesia have made tracheotomy or tracheostomy a 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
- 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
Relevant Anatomy
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 the Surgical therapy section).
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.
Contraindications
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. Temporary tracheostomy may be performed just under the first tracheal ring in anticipation of a laryngectomy at a later time.
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."
More on Tracheostomy |
 Overview: Tracheostomy |
| Workup: Tracheostomy |
| Treatment: Tracheostomy |
| Follow-up: Tracheostomy |
| Multimedia: Tracheostomy |
| References |
| Further Reading |
| Next Page » |
References
Tibballs J, Robertson C, Wall R. Tracheal ulceration and obstruction associated with flexible Bivona tracheostomy tubes. Anaesth Intensive Care. Aug 2006;34(4):495-7. [Medline].
Villarroya Gonzalez A, Longas Valien J, Vicente Armijo JJ, Cuartero Lobera J. [Orotracheal tube ignited by an electrocautery device during tracheostomy]. Rev Esp Anestesiol Reanim. Jan 2009;56(1):47-9. [Medline].
Tobin AE. Tracheostomy teams - filling a void. Crit Care Resusc. Mar 2009;11(1):3-4. [Medline].
Scales DC, Thiruchelvam D, Kiss A, Redelmeier DA. The effect of tracheostomy timing during critical illness on long-term survival. Crit Care Med. Sep 2008;36(9):2547-57. [Medline].
Brantigan CO, Grow JB Sr. Cricothyroidotomy: elective use in respiratory problems requiring tracheotomy. J Thorac Cardiovasc Surg. Jan 1976;71(1):72-81. [Medline].
Solares CA, Krakovitz P, Hirose K, Koltai PJ. Starplasty: revisiting a pediatric tracheostomy technique. Otolaryngol Head Neck Surg. Nov 2004;131(5):717-22. [Medline].
Hartnick CJ, Bissell C, Parsons SK. The impact of pediatric tracheotomy on parental caregiver burden and health status. Arch Otolaryngol Head Neck Surg. Oct 2003;129(10):1065-9. [Medline].
Reed JP, Kemph JP, Hamelberg W, Hitchcock FA, Jacoby J. Studies with transtracheal artificial respiration. Anesthesiology. Jan 1954;15(1):28-41. [Medline].
Gulleth Y, Spiro J. Percutaneous transtracheal jet ventilation in head and neck surgery. Arch Otolaryngol Head Neck Surg. Oct 2005;131(10):886-90. [Medline].
Toy FJ, Weinstein JD. A percutaneous tracheostomy device. Surgery. Feb 1969;65(2):384-9. [Medline].
Koitschev A, Simon C, Blumenstock G, Mach H, Graumüller S. Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients. Anaesthesia. Sep 2006;61(9):832-7. [Medline].
Kost KM. Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases. Laryngoscope. Oct 2005;115(10 Pt 2):1-30. [Medline].
Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. Jul 2004;59(7):675-94. [Medline].
Alberti PW. Tracheotomy versus intubation. A 19th century controversy. Ann Otol Rhinol Laryngol. Jul-Aug 1984;93(4 Pt 1):333-7. [Medline].
Bailey BJ. Head and Neck Surgery--Otolaryngology. 2nd ed. Philadelphia: Lippincott Raven; 1998.
Ballenger JJ. Diseases of the Nose, Throat, Ear, Head and Neck. 14th ed. Philadelphia: Lea & Febiger; 1991.
Bernard AC, Kenady DE. Conventional surgical tracheostomy as the preferred method of airway management. J Oral Maxillofac Surg. Mar 1999;57(3):310-5. [Medline].
Berrouschot J, Oeken J, Steiniger L, Schneider D. Perioperative complications of percutaneous dilational tracheostomy. Laryngoscope. Nov 1997;107(11 Pt 1):1538-44. [Medline].
Cummings CW. Otolaryngology, Head and Neck Surgery. 3rd ed. St. Louis: Mosby Yearbook; 1998.
Flory FA, Hamelberg W, Jacoby JJ, Jones JR, Ziegler CH. Transtracheal resuscitation. J Am Med Assoc. Oct 13 1956;162(7):625-8. [Medline].
Griffen MM, Kearney PA. Percutaneous dilational tracheostomy as the preferred method of airway management. J Oral Maxillofac Surg. Mar 1999;57(3):316-20. [Medline].
Hill BB, Zweng TN, Maley RH, Charash WE, Toursarkissian B, Kearney PA. Percutaneous dilational tracheostomy: report of 356 cases. J Trauma. Aug 1996;41(2):238-43; discussion 243-4. [Medline].
Kane TD, Rodriguez JL, Luchette FA. Early versus late tracheostomy in the trauma patient. Respir Care Clin N Am. Mar 1997;3(1):1-20. [Medline].
Koitschev A, Simon C, Blumenstock G, Mach H, Graumuller S. Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients. Anaesthesia. Sep 2006;61(9):832-7. [Medline].
Mickelson SA. Upper airway bypass surgery for obstructive sleep apnea syndrome. Otolaryngol Clin North Am. Dec 1998;31(6):1013-23. [Medline].
Moe KS, Stoeckli SJ, Schmid S, Weymuller EA Jr. Percutaneous tracheostomy: a comprehensive evaluation. Ann Otol Rhinol Laryngol. Apr 1999;108(4):384-91. [Medline].
Powell DM, Price PD, Forrest LA. Review of percutaneous tracheostomy. Laryngoscope. Feb 1998;108(2):170-7. [Medline].
Scheinhorn DJ, Stearn-Hassenpflug M. Provision of long-term mechanical ventilation. Crit Care Clin. Oct 1998;14(4):819-32, viii. [Medline].
Stock CR. What is past is prologue: a short history of the development of tracheostomy. Ear Nose Throat J. Apr 1987;66(4):166-9. [Medline].
Wood DE. Tracheostomy. Chest Surg Clin N Am. Nov 1996;6(4):749-64. [Medline].
Wright CD. Management of tracheoinnominate artery fistula. Chest Surg Clin N Am. Nov 1996;6(4):865-73. [Medline].
Further Reading
In 2004, the Difficult Airway Society published its guidelines for management of the unanticipated difficult intubation. 13
Keywords
tracheostomy, tracheotomy, 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, airway
