eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Tracheostomy: Treatment

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

Treatment

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.

• 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, microdébridement) 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) elects 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.

In 2006, Tibballs et al reported complications using the Bivona tracheotomy tube.¹ 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.

Complications

Immediate complications of tracheostomy

• 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.
• Endotracheal tube ignition: This rare complication is associated with opening the trachea with electrocautery or laser.²

Early complications of tracheostomy

• 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 of tracheostomy

• 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.

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