Tracheostomy 

Updated: Dec 28, 2018
Author: Jonathan P Lindman, MD; Chief Editor: Guy W Soo Hoo, MD, MPH 

Overview

Background

Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea.[1, 2] 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.[3] 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. Important to note, however, is that there are situations when tracheostomy is quite urgent or emergent. This typically involves patient who is immediate need of a surgical airway because of impending airway obstruction.

General 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.[4] However, the final decision is made on an individual basis based on comorbidities and the patient’s current condition.

It is also important to outline what tracheostomy does not or will not do for the patient. Specifically, tracheostomy does not prevent aspiration of airway or other secretions.

Additional diagnoses for which tracheostomy is often considered early in the course include botulism, amyotrophic lateral sclerosis, and cervical spine injury, among others.

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.

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.

Patient selection - 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.[5]

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 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 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.[6]

The following patients are commonly recognized to be unfavorable candidates:

  • Patients with obesity

  • Patients with abnormal or poorly palpable midline neck anatomy

  • Patients who need emergency airways

  • Patients with coagulopathy

  • Pediatric patients

  • Patients with enlarged thyroids

Kost reported on the use of this procedure in 500 consecutive intubated adults in the intensive care unit.[7] When this procedure was performed in conjunction with bronchoscopy, the complication rate was acceptably low (9.2%). No serious complications (eg, pneumothorax, pneumomediastinum, death) occurred. The 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).

Complication prevention

Potential complications are due to direct injury. Bedside ultrasound is often used to survey the tracheostomy site during the planning stage, especially for percutaneous tracheostomies. This is to identify vessels that may be under the intended incision and to help avoid injury.

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.

 

Periprocedural Care

Patient Education and Consent

Patient instructions

Tracheostomy is still 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.

Elements of informed consent

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.

Equipment

A tracheostomy tube is a hollow tube, with or without a cuff, that is electively inserted directly into the trachea through a surgical incision or with a wire-guided progressive dilatation technique. A number of tracheostomy tubes are available.

See Pediatric Tracheostomy for information about tubes for pediatric and neonatal patients.

Tracheostomy tubes are made of various materials, as described in the table below.

Table. Tracheostomy Tube Materials (Open Table in a new window)

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[8]

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

 

The ideal tracheostomy tube should be rigid enough to maintain an airway and yet flexible to limit tissue damage and maximize patient comfort.[9] The tracheostomy tube is arc-shaped or angled, which allows a correct entry angle into the trachea and reduces the risk of trauma to the tracheal wall.

Tracheostomy tubes often have specifications imbedded on their neck flange. Information often includes the model number and internal and external diameter. The package insert often has information about the length of the tube, its angle, and its proximal and distal tube dimensions.

In some institutions, open tracheostomy kits are available. These kits consist of sterile towels with prep-drape kit and sterile gloves, no. 15 or 10 blades with handle, electrocautery Bovie, Adson pickups, Richardson retractors, tracheal spreader, tracheostomy tube, hemostats, suctioning device, and ties.

Tube size

The ideal tube size for a patient is one that maximizes the functional internal diameter while limiting the outer diameter to approximately three quarters of the internal diameter of the trachea. This reduces airway resistance and the work of breathing while facilitating airflow around the tube. Ideally, the end of the tracheostomy tube should be 2-3 cm from the carina to avoid the potential for the tube to enter the mainstem bronchus with neck flexion. Additionally, in very obese patients, the length of the tube needs to be factored into the depth of insertion, because in a few patients, the tube may just barely enter the trachea.

In patients of average habitus, a no. 6 Shiley cuffed tracheostomy tube is appropriate for most women and no. 8 Shiley cuffed tracheostomy tube 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.

Extra-long tracheostomy tubes are available to use in certain situations. Extraproximal-length tubes facilitate placement in patients with large necks, and extradistal-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.

Bivona and Portex adjustable-neck-flange tubes. Bivona and Portex adjustable-neck-flange tubes.

In 2006, Tibballs et al reported complications using the Bivona tracheotomy tube.[10] They cited 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).

Cannulae

The outer cannula is the main body of the tube that passes into the trachea. Single-lumen tubes contain only the outer cannula (see image below). The stated size of the tube usually refers to the inner diameter of this outer cannula expressed in millimeters.

Uncuffed (A) and cuffed (B) single-cannula tubes. Uncuffed (A) and cuffed (B) single-cannula tubes.

Some tracheostomy tubes allow an inner tube, which is removable. This allows maintenance of a clear airway by removing just the inner tube to clear secretions. There are a variety of re-usable, disposable, plain, and fenestrated inner tubes.

Double-cannula tube shown with choice of fenestrat 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 connec Inner cannulae shown with and without 15-mm connector, fenestrated and nonfenestrated designs.

Cuffed tubes

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 (four times a day) to prevent pressure necrosis.

Important to note is that cuff pressures should be checked regularly in patients on mechanical ventilation. The main reason to monitor cuff pressures is that high pressures are transmitted to the trachea, which, in turn, can lead to mucosal ischemia and eventual injury and complications such as tracheal stenosis, tracheal necrosis, ulcers, bleeding, and, in the worst case scenario, erosion to adjacent vascular structures. The cuff pressure threshold typically is 25 cm water.

Cuffed tube with pilot balloon. Cuffed tube with pilot balloon.

Indications for a cuffed tracheostomy tube include the following[11, 12, 13, 14] :

  • Risk of aspiration

  • Newly formed stoma in adult

  • Positive-pressure ventilation

  • Bleeding (eg, in a multiple-trauma patient)

  • Unstable condition

Contraindications for a cuffed tracheostomy include the following[11, 12, 13, 14] :

  • Child younger than 12 years

  • Significant risk of tracheal tissue damage from cuff

Indications for an uncuffed tracheostomy tube include the following:

  • Stable stoma

  • Pediatric and neonatal patients

  • Upper-airway obstruction due to tumors or neuromuscular disorders causing vocal cord palsy

Contraindications for an uncuffed tracheostomy include the following:

  • Dependent on positive-pressure ventilation

  • Significant risk of aspiration

  • Newly formed tracheostomy

Fenestrated tubes

Some tubes have single or multiple fenestrations on the superior curvature of the shaft (see image below). Fenestrations permit airflow, which, in addition to air leaking around the tube, allows the patient to phonate and cough more effectively. That these tubes allow for patient speech is an important feature. Fenestrated and nonfenestrated inner tubes are supplied with these tubes.

Double-cannula tube shown with choice of fenestrat 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 connec Inner cannulae shown with and without 15-mm connector, fenestrated and nonfenestrated designs.

Cuffed fenestrated tubes are particularly used in patients who are being weaned off their tracheostomy when a period of cuff inflation and deflation is required. Uncuffed fenestrated tubes are used in patients who no longer depend on a cuffed tube.

Fenestrated cuffed and uncuffed tubes. Fenestrated cuffed and uncuffed tubes.

Fenestrated tubes are contraindicated in patients who require positive-pressure ventilation, as some of the air will leak out of the fenestrations.

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.

Flange or neck plate

The neck plate attached to the proximal end of the tube prevents the tube from descending into the trachea and allows for securing the tube with tapes, ties, or sutures. The tube size and type is often imprinted on the neck plate for easy identification. Certain tubes have a swivel neck plate that rotates on two planes and facilitates dressing and wound care.

Adult swivel, neonatal, and pediatric neck flanges Adult swivel, neonatal, and pediatric neck flanges.

Certain tubes have an adjustable flange that allows variable tube length and may be useful in patients with larger necks. These also allow distal tracheal obstructions to be bypassed through a conventional tracheostomy.

Bivona and Portex adjustable-neck-flange tubes. Bivona and Portex adjustable-neck-flange tubes.

Pilot balloon

Cuffed tubes have an external balloon that is connected to the internal cuff by an inflation line. When the external balloon is inflated, the distal cuff inflates and provides a tight seal against the wall of the trachea.

Introducer/obturator

This is a bevel-tipped shaft, which is placed inside the outer cannula of the tube during tube insertion. It has a smooth rounded tip that reduces trauma to the trachea during tube placement.

Adaptor, 15-mm

Single-lumen tubes and the inner cannula of the double-lumen tubes have a universally sized 15-mm hub that allows attachment to the ventilation equipment. When the patient’s condition stabilizes, these tubes are exchanged for a tube that lies flush with the neck and improves cosmetic appearance.

Custom tube designs

When a standard tracheostomy tube does not provide an adequate fit for a patient, almost all manufacturers offer custom tube services. Modification such as longer or shorter tube shafts, additional sizes, customized cuffs, modified neck flanges, curvatures, and fenestration locations are possible.

Equipment list for procedure

When a percutaneous tracheostomy is being performed, the following equipment can be used:

  • A percutaneous dilatational tracheostomy kit, which includes a 22-gauge needle and syringe; 11-F short punch dilator; 1.32-mm guidewire; 8-F guiding catheter; 18-F, 21-F, 24-F, 28-F, 32-F, 36-F, and 38-F dilators; Shiley no. 8 double-cannula tracheostomy tube; and fiberoptic bronchoscope

  • A guidewire dilating forceps kit, which includes a 14-gauge needle and syringe, J-tipped Seldinger guidewire, scalpel, Howard-Kelly forceps modified to produce a pair of guidewire dilating forceps, and Shiley no. 8 double-cannula tracheostomy tube with curved obturator

  • A Rapitrach kit (Fresenius, Runcorn, Cheshire, UK), which includes a 12-gauge needle and syringe, short guidewire, scalpel, Rapitrach percutaneous tracheostomy dilator, and standard Portex 8-mm tracheostomy tube with curved obturator

  • Ciaglia Blue Rhino kit (Cook Critical Care, Bloomington, IN), which includes a 14-gauge catheter introducer needle and syringe, J-tipped Seldinger guidewire, guiding catheter, introducer dilator, loading dilators, single tapering Blue Rhino dilator, Shiley no. 8 double-cannula tracheostomy tube with curved obturator, and fiberoptic bronchoscope

The above list is for percutaneous tracheostomy, not open or surgical tracheostomy. Much different staffing and anesthesia services are required based on the type of tracheostomy performed. The kits are different because the techniques for entry into the trachea and dilation of the tracheostomy stoma differ.

The vast majority of these are performed using bronchoscopic guidance for safety purposes. 

Patient Preparation

Anesthesia

Unless the patient is comatose, and generally even if comatose, some sort of anesthesia is preferable. Even local anesthesia is used for most emergent cases at the incision site as mixtures of lidocaine and epinephrine help minimize bleeding.

In elective situations, local anesthetic is indicated. Lidocaine or lidocaine with epinephrine (lidocaine 1% with 1:150,000 parts epinephrine) can be used. The standard recommended doses are 3-4 mL/kg of lidocaine alone or 5-7 mL/kg of lidocaine in combination with epinephrine. However, many patients who require a tracheostomy are already in an intensive care setting under multiple drips (sedatives/analgesics). For these patients, the procedure can be done under conscious sedation.

Some patients require deeper sedation. In addition to sedatives and analgesics, most patients are also given a short-acting paralytic.

Complications

Several complications have been described during open and percutaneous tracheostomies. Most of the complications are life-threatening. For this reason, prevention, early diagnosis, and treatment are key factors during this procedure.[15, 16]  One retrospective study reported that three comorbidities that independently affect 30-day mortality in tracheostomy patients are severe liver disease, congestive heart failure, and peripheral vascular disease.[17]

Immediate complications of tracheostomy

Apnea due to loss of hypoxic respiratory drive is mainly important in the awake patient. Ventilatory support must be available.

Intraoperative bleeding may arise 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 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.

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.

Although rare, a transient pulmonary edema can occur after tracheostomy, which provides relief of upper airway obstruction.

Endotracheal tube ignition is a rare complication associated with opening the trachea by electrocautery or laser.[18]

Early complications of tracheostomy

Early bleeding 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). 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.

The use of dual cannula tubes lessens the threat of mucus plugging 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.

To some degree, tracheitis is present in all patients with fresh tracheostomies. Humidification, minimization of the fraction of inspired oxygen (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.

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.

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 that 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 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.

An overly long tube can mimic a unilateral mainstem intubation, causing atelectasis or collapse of the opposite lung.

Late complications of tracheostomy

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. Half the patients with significant bleeding more than 48 hours after the procedure have tracheoinnominate erosions. This occurs in 0.6-0.7% of patients with tracheostomies, and the mortality rate of this complication approaches 80% depending on the aggressiveness of treatment. However, it is important to note that tracheoinnominate fistulas are typically complications that occur after long-standing (months) tracheostomy tube placement.

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 is usually caused by a tube that fits poorly. Improved fit may allow recovery of the softened cartilage.

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. Modern high-volume low-pressure cuffs have reduced the rate of post-tracheostomy stenosis. 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 subacute distress and is often mistaken for bronchitis. Treatment is surgical and ranges from formal resection and reconstruction to less invasive means of debridement or stenting for palliation. Videos of tracheal stenosis are included below.

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.

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.

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 this 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 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.

Both vertical and horizontal incisions heal with small but visible scars that can be revised if they bother the patient.

Sometimes, plugging trials or even decannulation fails for no apparent reason. Possibilities to consider include obstructing granuloma previously held out of the way with the tube, bilateral vocal cord paralysis, in fractured 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.

In 2009, Tobin proposed that the use of a tracheostomy team may reduce morbidity of this indwelling respiratory device.[19]

Percutaneous tracheostomy versus open surgical tracheostomy

Numerous articles have been published comparing several techniques of percutaneous tracheostomy with open surgical tracheostomy, as well as with one another. In general, most have shown similar complication rates.

In a meta-analysis of studies, Dulguerov et al[20] found more frequent perioperative complications in the percutaneous cohort (10% vs 3%) but more postoperative complications with the surgical approach (10% vs 7%). Also noted was a higher incidence of perioperative death (0.44 vs 0.03%) and serious cardiorespiratory events (0.33% vs 0.06%) in the percutaneous group.

Cheng and Fee[21] analyzed 4 studies showing percutaneous tracheostomy required shorter operative times (8 minutes vs 20.9 minutes), produced less intraoperative minor bleeding (9% vs 25%) and postoperative bleeding (7% vs 18%), and resulted in fewer overall postoperative complications (14% vs 60%), including stomal infection (4% vs 29%), pneumothorax (1% vs 4%), and death (0% vs 3%).

Freeman et al[22] analyzed 5 studies and found that the percutaneous method was associated with shorter operative time (absolute difference of 9.84 minutes), less perioperative bleeding, lower overall postoperative complication rate, and lower postoperative incidence of bleeding and stomal infection. No difference was identified in overall operative complications, days intubated prior to tracheostomy, or death.

Higgins and Punthakee published a meta-analysis that showed no significant difference when comparing overall complications, with a trend toward favoring percutaneous method. However, the more serious and life-threatening complication of decannulation/obstruction was more likely to occur with the percutaneous technique and false passage trended toward favoring the open procedure. Nevertheless, no significant difference was shown between the two methods in regards to death.

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.

With antibiotics, total parenteral nutrition, 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.

The 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. In a study of tracheotomy in mechanically ventilated adult patients in an intensive care unit, Terragni et al found no statistically significant difference in the rates of ventilator-associated pneumonia with early tracheotomy (after 6-8 days of laryngeal intubation) versus late tracheotomy (after 13-15 days of laryngeal intubation).[23]

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.[24]

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.

Studies have shown a change in the indications and outcomes of pediatric tracheotomies. Pediatric tracheotomy is more frequently performed today for chronic diseases than for acute infections such as supraglottitis, as was the case in the 1970s. This change in indications is associated with an increase in the duration of these tracheostomies and a decreased decannulation rate.

See Pediatric Tracheostomy.

Monitoring & Follow-up

A tracheostomy can be used for days or, with proper care, for years. Most tracheostomies are temporary in intent. Research indicates that patients can be discharged from the intensive care unit with a tracheotomy cannula without adding morbidity or mortality.[22]

Postoperative care is critical. The recently insulted trachea produces copious secretions, so irrigation with saline and suctioning every 15 minutes is not initially unreasonable. Suctioning should be limited to the length of the tube to avoid tracheal ulceration and tracheitis. Suctioning should be performed under aseptic conditions with the patient sitting upright, when possible. Suctioning should be performed with the inner tube in situ and ideally with a nonfenestrated inner tube. The suction catheter should have a diameter no greater than half the internal diameter of the tracheostomy tube. The sizing formula is as follows: Suction catheter size (Fg) = 2 X (size of tracheostomy tube - 2)

The lowest possible vacuum pressure should be used to minimize atelectasis. Patients with a high oxygen demand may require preoxygenation. The suction catheter should be advanced 10-15 cm into the tube before applying suction and slowly withdrawn. Suction should not be applied for more than 10 seconds. If any difficulty in passing the suction catheter is encountered, tube displacement and/or tube blockage should be suspected.

The pressure within the cuff should be checked regularly with a handheld pressure manometer and maintained ideally between 20 and 25 cm water.[6] It should never exceed 25 cm water. If an air leak occurs with the cuff pressure at the maximum recommended, the tracheostomy may have become displaced and may require changing. Ideally, the cuff should be deflated as soon as the patient is able to deal with secretions and the risk of aspiration is reduced.

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.

Decannulation

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. The wound should heal within 5-7 days.

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.

Some providers proceed with progressively smaller-diameter tubes, capping trials, or tracheal buttons. There is no single consensus approach.

Speaking and swallowing

Phonation is an important process that should be encouraged as soon as the patient is in adequate condition to tolerate passive closure sessions of the tracheostomy site. 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 are rarely in the correct place. Simply deflating the cuff or, preferably, downsizing to a cuffless tracheostomy tube should suffice for audible speech.

Swallowing is another mechanism that should be tested as soon as the patient is in adequate condition to start taking oral feeding. 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.

Special teams dedicated to speech and swallow functions are usually involved to evaluate this process. They can recommend if the patient is in good condition to start oral feeding, as well as an appropriate diet for the particular condition to prevent aspiration and further complications.

 

Technique

Approach Considerations

Alternatives or adjuncts to cricothyrotomy or tracheostomy

Endoluminal

Intubation may replace or precede tracheostomy and is comparably easy, more rapidly performed, and well tolerated for short periods (generally 1-3 weeks). 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. 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, depending on local trauma and the logistics of planned operative intervention.

Percutaneous transtracheal jet ventilation

In percutaneous transtracheal jet ventilation (PTJV),[25] 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.[26] Only one pneumothorax (a tracheotomy and left chest tube were performed) and one episode of minor subcutaneous emphysema occurred.

Pulmonary toilet

For 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.

Emergent cricothyrotomy

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 the scalpel or 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

Cricothyrotomy has enjoyed a renaissance in cardiothoracic surgery. Studies have rehabilitated its image and raised questions about its inherent risks (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.

With the Seldinger technique (see the video below), 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.

Surgical cricothyroidotomy Seldinger. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

Emergent tracheostomy

Emergent tracheostomy 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 tracheostomy

Patients in acute respiratory distress may need acute surgical intervention. Urgent tracheostomy 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 tracheostomy

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.

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 (see the image below).

Parasagittal view through larynx. The asterisk ind Parasagittal view through larynx. The asterisk indicates structures at risk during cricothyrotomy.

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.

Open Tracheostomy

Tracheostomy is best performed in an operating room with adequate equipment and assistance. 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.

Note, however, that open tracheostomies can also be done at the bedside in the intensive care unit and do not necessarily require the operating room.

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 a 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 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 in some cases. 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 (see the image below).

Operative view of tracheostomy. The thyroid isthmu Operative view of tracheostomy. The thyroid isthmus is divided with electrocautery.

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 (see the image below).

Operative view of tracheostomy. These are options Operative view of tracheostomy. These are options for tracheal incision.

For a 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. Also see Tracheostomy Tube Change and Dislodged Tracheostomy Positioning Technique.

For a 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.

Do note, however, that a simple horizontal incision between the tracheal rings can be used in a more basic procedure, such as the bedside tracheostomy. Removal of the tracheal rings and anterior tracheal wall resection may be excessive for most tracheostomies, and this more involved procedure is reserved for an operating room procedure.

A permanent stoma can be created 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 the patient 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.

The video below depicts a tracheostomy being performed.

Surgical technique for a tracheostomy. Video courtesy of Ravindhra G Elluru, MD, PhD.

Percutaneous Tracheostomy

Percutaneous tracheostomy is generally carried out in the intensive care unit on a patient who is intubated and ventilated with continuous monitoring under deep intravenous sedation/analgesia (see the video below).

Percutaneous Tracheostomy.

Personnel requirements include the surgeon, someone to manage the sedation/analgesia, someone to manage the ventilator, a bronchoscopist, and an assistant. An airway cart with instruments for an urgent surgical tracheostomy or urgent intubation should be readily available. Percutaneous tracheostomy tube placement can performed by a number of trained providers. These include general surgeons as well as head and neck surgeons and thoracic surgeons, but also those with an internal medicine background such as pulmonologists and intensivists.

The patient is preoxygenated with 100% oxygen, which is continued during the procedure. A shoulder roll is placed to extend the patient's neck.

A 1.5- to 2-cm incision is made through the skin of the neck approximately 2 cm below the palpable cricoid cartilage. Blunt horizontal and vertical dissection with a hemostat is used to carry the dissection down to a pretracheal plane, attempting to sweep the thyroid isthmus (which should not be enlarged) inferiorly. Finger dissection is used to palpate the cricoid cartilage and tracheal rings.

A small-caliber, flexible bronchoscope attached to a video camera and monitor is passed via a swivel adaptor down the endotracheal tube, allowing for ventilation around the scope. The bronchoscopist withdraws the endotracheal tube and bronchoscope, after deflating the endotracheal tube cuff, to a subglottic level. Care should be taken not to completely withdraw the tube from the larynx.

During this maneuver, ventilator settings may have to be modified to accommodate the air leak or space taken up by the bronchoscope. The surgeon can use the light from the bronchoscope and digital palpation to guide passage of the needle from the percutaneous tracheotomy kit through the anterior tracheal wall under direct bronchoscopic visualization.

Ideally the puncture should be made between the second and third tracheal rings. High placement of the tracheotomy in the immediate subcricoid position is associated with fracture of the cricoid cartilage and subglottic stenosis and should be avoided.

The wire guide is then inserted, the tract is dilated per the kit instructions, and the tracheostomy tube is inserted over a special introducer that is then withdrawn. The endotracheal tube and bronchoscope are withdrawn from the mouth, and the tracheostomy tube is sutured into position and secured with a tracheostomy tube tie. It is essential that the surgeon be intimately familiar and trained in the nuances of the specific kit being used.

Conversion of Cricothyrotomy to Tracheostomy

Cricothyrotomy is accepted only as an emergent procedure used for ease of performance in the field. The entry point to the trachea for cricothyrotomy is much different from a tracheostomy.

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.[27] 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.

Important things that must be considered in decision making include issues with subsequent tracheal stenosis and speech.

The Patient with Obesity

In particular, the patient with obesity and obstructive sleep apnea poses a challenge. The apnea can be corrected with a tracheostomy. Until the acceptance of uvulopalatopharyngoplasty and the availability of continuous positive airway pressure, 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 (see the image below).

Operative view of tracheostomy. These are special Operative view of tracheostomy. These are special techniques in the patient with obesity.

Skin flaps are raised and subcutaneous fat is removed. Skin flaps 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.

Performance of tracheotomy on a child is similar to the procedure on an adult. For children, however, a simple vertical incision in the trachea is best. The incision is made in the second and third tracheal rings. Excision of any anterior tracheal wall or the use of a Björk flap traditionally has been avoided in operations on children. A starplasty tracheotomy technique, which creates a matured permanent tracheostoma, has been recommended because of the increased safety and prevention of tracheotomy-related complications it affords in infants. Subsequent closure of the fistulas has been possible.

If at all possible, tracheotomy on children is performed only with a secured airway either from intubation with an endotracheal tube or over a ventilating bronchoscope. As in the treatment of adults, emergency tracheotomy is avoided if possible. The smaller diameter, shorter length, greater deformability, and limited stability of the infantile trachea and the greater mobility of the soft tissues of the neck in a child call for special techniques.

During tracheostomy on a child, it is wise to place two sutures, one on either side of the vertical incision in the trachea, to serve as guides if the tracheostomy tube accidentally comes out of the trachea. If such a technique is used, it is essential that the personnel taking care of the child in the hospital be trained in the proper use of these guide sutures. In a panic, it is easy to pull the sutures out. With gentle pulling on the sutures, the trachea can be elevated into the wound and the incision in the trachea can be slightly opened to assist reinsertion of the tube. A small 4-0 or 5-0 nonabsorbable monofilament suture usually is used. It is removed at the first tracheostomy tube change 3 or 4 days after tracheotomy.

Polyvinyl chloride or polymeric silicone tubes tend to collect fewer secretions than do metal tubes. The plastic tubes, however, have no inner cannula and are prone to accidental decannulation owing to intrinsic malleability, which allows the tip to come out of the trachea while the body of the tube remains in the neck wound. Pediatric tracheostomy tubes usually have no cuff.

 

Questions & Answers

Overview

When is a tracheostomy most often performed?

Which problem does a tracheostomy address?

How does a tracheostomy correct airway obstruction?

What are the differences between tracheostomy and tracheotomy?

What is the anatomy of the trachea?

What are the indications for tracheostomy?

When is tracheostomy indicated for pulmonary hygiene?

What is the role of a cuffed tube in a tracheostomy?

When is a tracheostomy procedure recommended by the American College of Chest Physicians?

What is the role of tracheostomy in the prevention of aspiration?

For which conditions is tracheostomy considered at diagnosis?

What are the contraindications for tracheostomy?

Which end-of-life issues should be considered prior to tracheostomy?

What are the differences between an open and percutaneous technique tracheostomy?

How should tracheostomy technique be selected?

What are the advantages and disadvantages of percutaneous tracheostomy?

Which patients are unfavorable candidates for tracheostomy?

What are is he complication rate for tracheostomy procedures?

What is the role of ultrasonography in tracheostomy?

Which muscles are vulnerable to injury during a tracheostomy?

Which nerves, and veins are vulnerable to injury during tracheostomy?

Which great vessels are vulnerable to injury during tracheostomy?

Which tissue should be divided carefully during a tracheostomy?

Periprocedural Care

What patient education about tracheostomy care must be given prior to hospital discharge?

What discussion should the surgeon, patient, and family have before a tracheostomy procedure?

What is a tracheostomy tube?

What are the ideal characteristics of a tracheostomy tube?

What should be included in a tracheostomy kit?

How is tracheostomy tube size determined?

How do tracheostomy tubes differ among patients?

What can occur if a tracheostomy tube is too long or short?

When is use of an extra-long tracheostomy tube indicated?

What are the advantages and disadvantages of the Bivona tracheostomy tube?

What is the cannulae of a tracheostomy tube?

What are the benefits of a removable tracheostomy tube?

What is the purpose of a cuffed tracheostomy tube?

Why must cuffed tracheostomy tubes be regularly monitored in patients on mechanical ventilation?

What are the indications for a cuffed tracheostomy tube?

What are the contraindications for a cuffed tracheostomy tube?

What are the indications and contraindications for an uncuffed tracheostomy tube?

What are fenestrated tracheostomy tubes?

What is purpose of a neck plate on a tracheostomy tube?

What are the benefits of an adjustable flange on a tracheostomy tube?

What is the role of the pilot balloon on a cuffed tracheostomy tube?

What is the role of the introducer/obturator in a tracheostomy procedure?

When are tubes replaced to improve cosmetic appearance after a tracheostomy procedure?

What modifications are possible to tracheostomy equipment to improve fit?

Which equipment is used to perform percutaneous tracheostomy?

Which type anesthesia is needed in a tracheostomy procedure?

Which anesthesia is used in elective tracheostomy procedure?

Which anesthesia should be used for deep sedation during tracheostomy procedures?

How are serious complications of a tracheostomy prevented?

What is a common respiratory complication during tracheostomy?

What steps should be taken to care for intraoperative bleeding during tracheostomy?

What causes pneumothorax in tracheostomy?

What paratracheal structures are vulnerable to injury during a tracheostomy?

Although rare, which complications can occur after a tracheostomy procedure?

What steps should be taken if bleeding occurs immediately following tracheostomy?

What lowers the risk of mucus plugging following tracheostomy?

How is tracheitis managed following tracheostomy?

How are post-tracheostomy infections prevented?

How should tracheostomy tubes be replaced?

Which airway management techniques are used following tracheostomy?

What cause subcutaneous emphysema following tracheostomy?

What causes atelectasis following tracheostomy?

What is the prevalence and mortality rate of tracheoinnominate fistula following tracheostomy?

What are the signs of impending tracheoinnominate fistula following tracheostomy?

What is the treatment of catastrophic bleeding from a post-tracheostomy tracheoinnominate fistula?

How is bleeding at the tip of the tracheostomy tube detected and treated?

What causes tracheomalacia following tracheostomy?

What causes laryngeal stenosis following tracheostomy?

What causes tracheal stenosis following tracheostomy?

What causes tracheoesophageal fistula following tracheostomy?

Where can granulation occur following tracheostomy?

Can visible tracheostomy scars be treated?

What causes plugging trials or decannulation to fail following tracheostomy?

What are the complication rates of percutaneous and open tracheostomy procedures?

What are the possible complications of prolonged intubation following tracheostomy?

Does tracheostomy increase the risk of pneumonia compared to intubation?

When is the timing of a tracheostomy controversial?

What are indications for pediatric tracheotomy?

How long does a patient typically retain a tracheostomy?

What is the recommended postoperative care for a tracheostomy?

What are the steps for suctioning a tracheostomy?

What is the ideal pressure within a cuffed tracheostomy tube?

How are mucus secretions managed following tracheostomy?

When should the tracheostomy tube be removed?

When should a patient begin speaking following tracheostomy?

When can a patient begin to swallow following tracheostomy?

Technique

Can intubation replace or precede tracheostomy?

What are supplements to intubation as an alternative to tracheostomy?

What is a percutaneous transtracheal jet ventilation (PTJV)?

What is an alternative to tracheostomy for improved pulmonary hygiene?

What are the advantages and disadvantages of emergent cricothyrotomy?

What are the advantages and disadvantages of elective cricothyrotomy?

When is emergent tracheostomy indicated?

When should an urgent tracheostomy be performed?

When is elective tracheostomy performed?

How is cricothyrotomy performed?

What position should the patient be placed in for an open tracheostomy?

How is an open tracheostomy performed?

In an open tracheostomy, what should be done following preparation for transfer of circuitry tubes?

In an open tracheostomy, what should be done for a T-shaped tracheal opening?

In an open tracheostomy, what should be done for a U or H-shaped tracheal opening?

In an open tracheostomy, when can a simple horizontal incision be used for?

In a tracheostomy, how is a permanent stoma created?

In a tracheostomy, what steps are completed after the trachea is entered?

How is percutaneous tracheostomy performed?

When should a cricothyrotomy be performed?

Which factors should be considered when deciding between cricothyrotomy and tracheostomy?

What are risks and benefits of tracheostomy in obese patient?

What tracheostomy techniques used to create a permanent airway in obese patients?

Which pediatric patients are at higher risk for operative and postoperative complications?

What are the challenges in performing pediatric tracheostomy?

What techniques are used in pediatric tracheostomy?

When should a pediatric tracheostomy be performed?

How is pediatric tracheostomy sutured?

What type of tracheostomy tubes are used for pediatric patients?