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Tracheostomy

  • Author: Jonathan P Lindman, MD; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Jan 21, 2015
 

Background

Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea. It is most often performed in patients who have had difficulty weaning off a ventilator, followed by those who have suffered trauma or a catastrophic neurologic insult.[1] Infectious and neoplastic processes are less common in diseases that require a surgical airway.

Tracheostomy is a utilitarian surgical procedure of access; therefore, it 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.

The traditional semantic difference between tracheostomy and tracheotomy is now blurred 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 can be performed. 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.

The trachea is nearly but not quite cylindrical but is flattened posteriorly. In cross-section, it is D-shaped, with incomplete cartilaginous rings anteriorly and laterally, and a straight membranous wall posteriorly. The trachea measures about 11 cm in length and is chondromembranous. This structure starts from the inferior part of the larynx (cricoid cartilage) in the neck, opposite the 6th cervical vertebra, to the intervertebral disc between T4-5 vertebrae in the thorax, where it divides at the carina into the right and left main stem bronchi. For more information about the relevant anatomy, see Trachea Anatomy.

Indications

The advent of the antibiotic era and advances in anesthesia have made tracheostomy a commonly performed elective procedure. Indications include the following:

  • Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
  • Upper airway foreign body that cannot be dislodged with Heimlich and basic cardiac life support 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
  • Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the mid face and mandible)
  • Upper airway edema from trauma, burns, infection, or anaphylaxis
  • Prophylaxis (as in preparation for extensive head and neck procedures and the convalescent period)
  • Severe sleep apnea not amendable to continuous positive airway pressure devices or other less invasive surgery

Tracheostomy may also be performed to provide a long-term route for mechanical ventilation in cases of respiratory failure or to provide pulmonary toilet in the following cases:

  • 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 investigators argue that the risk of aspiration is not actually lessened, as secretions can leak around the cuffed tube and reach the lower airway.

The Council on Critical Care of the American College of Chest Physicians recommends tracheostomy in patients who are expected to require mechanical ventilation for longer than 7 days.[2] However, the final decision is made on an individual basis based on comorbidities and the patient’s current condition.

Contraindications

No absolute contraindications exist for 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.

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Technical Considerations

Procedure Planning

Tracheostomies can be performed through with an open or percutaneous technique. Open tracheostomy is one of the oldest procedures described in the literature and is still the procedure of choice for some trauma centers. However, the use of percutaneous tracheostomy has been increasing since its introduction in the 1980s.

Studies have supported percutaneous over open tracheostomies. However, the final technique depends on the surgeon’s experience and comfort, in addition to guidelines of the facility where this procedure is to be performed.

Complication Prevention

The cricothyroid muscle, vocal muscles, and the vocal cords are vulnerable to injury during tracheostomy (see the image below).

Anterior anatomy of the larynx and trachea (in sit Anterior anatomy of the larynx and trachea (in situ).

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 (see the image below). The recurrent laryngeal nerve is also vulnerable to injury from the cuff of the tracheostomy tube, particularly if the cuff is overinflated.

Posterior view of paratracheal structures. The ast Posterior view of paratracheal structures. The asterisk indicates structures at risk from paratracheal dissection.

The great vessels (ie, carotid arteries, internal jugular veins) could be damaged should dissection go far afield, which is a real risk in pediatric or obese patients. 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.

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Contributor Information and Disclosures
Author

Jonathan P Lindman, MD Otolaryngology-Head and Neck Surgeon, Piedmont Ear, Nose, Throat and Related Allergy

Jonathan P Lindman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Phi Beta Kappa, American Academy of Sleep Medicine, Triological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Charles E Morgan, DMD, MD Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Alabama at Birmingham School of Medicine

Charles E Morgan, DMD, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Ruben Peralta, MD, FACS Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic

Ruben Peralta, MD, FACS is a member of the following medical societies: American Association of Blood Banks, American College of Surgeons, American Medical Association, Association for Academic Surgery, Massachusetts Medical Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Eastern Association for the Surgery of Trauma, American College of Healthcare Executives

Disclosure: Nothing to disclose.

Ravindhra G Elluru, MD, PhD Professor, Wright State University, Boonshoft School of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Dayton Children's Hospital Medical Center

Ravindhra G Elluru, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society, American Society for Cell Biology

Disclosure: Nothing to disclose.

Muhammad Kamaal Khan, MBBS, MRCSEd, DOHNS, FRCS(ORL-HNS) Consultant ENT, Department of Otolaryngology and Head and Neck Surgery, Cumberland Infirmary, Carlisle, UK

Muhammad Kamaal Khan, MBBS, MRCSEd, DOHNS, FRCS(ORL-HNS) is a member of the following medical societies: British Medical Association, Royal Society of Medicine, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, British Association of Otorhinolaryngologists, Head and Neck Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

John Schweinfurth, MD Professor, Department of Otolaryngology, University of Mississippi Medical Center

John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Laryngological Association, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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

Medscape Reference also thanks Ravindhra G Elluru, MD, PhD, Associate Professor, Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Cincinnati Children's Hospital Medical Center, for assistance with the video contribution to this article.

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Anterior anatomy of the larynx and trachea (in situ).
Posterior view of paratracheal structures. The asterisk indicates structures at risk from paratracheal dissection.
Parasagittal view through larynx. The asterisk indicates structures at risk during cricothyrotomy.
Operative view of tracheostomy. The thyroid isthmus is divided with electrocautery.
Operative view of tracheostomy. These are options for tracheal incision.
Operative view of tracheostomy. These are special techniques in the patient with obesity.
This video demonstrates the results of rigid direct laryngoscopy and flexible tracheal endoscopy in a patient with significant tracheal stenosis.
This video demonstrates the 90-degree endoscopic view in 2 patients with tracheal stenosis.
This video of a 90-degree endoscopic tracheal view was obtained from a patient with postintubation tracheal stenosis.
This video demonstrates the 90-degree endoscopic view in 2 patients with tracheal stenosis.
Surgical technique for a tracheostomy. Video courtesy of Ravindhra G Elluru, MD, PhD.
Percutaneous Tracheostomy.
Surgical cricothyroidotomy Seldinger. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
Uncuffed (A) and cuffed (B) single-cannula tubes.
Double-cannula tube shown with choice of fenestrated and nonfenestrated inner cannulae. Obturator for insertion is also included at the bottom.
Inner cannulae shown with and without 15-mm connector, fenestrated and nonfenestrated designs.
Cuffed tube with pilot balloon.
Fenestrated cuffed and uncuffed tubes.
Adult swivel, neonatal, and pediatric neck flanges.
Bivona and Portex adjustable-neck-flange tubes.
Decannulation cap (top). Decannulation caps attached to inner cannulae of cuffed and uncuffed tubes.
Single-cannula tube made of silver with speaking valve.
Table 1. Tracheostomy Tube Materials
Material Description Comments Examples
Polyvinyl chloride (PVC) PVC is produced by polymerization of vinyl chloride monomer



Depending on the additives used, properties such as flexibility, opacity, color, heat stability, density, and chemical resistance can be controlled and modified



Has a high degree of biocompatibility and flexibility under changing temperatures and humidity[3]



Easily sterilized but prone to retention of bacteria and is therefore for single use/disposable



Excellent water and chemical resistance



Portex Blue Line Ultra, RÜSCH
Silicone Silicone is a synthetic polymer and is produced by a cross-linked polymer reinforced with silica



Further cross-linking takes place by heating with a particular catalyst (ie, peroxide), to produce the required properties



Reduces adherence of secretions and bacteria to the tube by promoting easier passage for mucus



Can be sterilized but confined to single patient use



Cost effective for long-term use



Bivona range
Siliconized PVC PVC with silicone coating Thermosensitive PVC, provides sufficient rigidity for initial insertion, and then softens at body temperature to accommodate to individual patient’s anatomy



With proper humidification, secretions are less likely to adhere to the tube, making it easier to clean



Portex Blue Line range
Silver Pure silver or other alloys with silver coating are used Metal walls can be kept thin, allowing double-lumen construction designs



Some antibacterial property



Cost effective in long term



May need changing every 5 years



Negus, Chevalier, Jackson, and Alderhey
Silastic Silicone elastomers and some cross-linked polydimethylsiloxane materials Offer great comfort and flexibility; easily conforms to the anatomy



Autoclavable; for single patient use



Lack sufficient rigidity



Kapitex, Moore
Armored tubes Combination of siliconized PVC tube reinforced with stainless steel Soft and flexible but stable



Prevents kinking and compression



RÜSCH Tracheoflex, Tracflex
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