Tracheostomy
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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.
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.
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.
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.
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).
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).
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.
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.
Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013 Jan. 148(1):6-20. [Medline].
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MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001 Dec. 120(6 Suppl):375S-95S. [Medline].
Cheng E, Fee WE Jr. Dilatational versus standard tracheostomy: a meta-analysis. Ann Otol Rhinol Laryngol. 2000 Sep. 109(9):803-7. [Medline].
Koitschev A, Simon C, Blumenstock G, Mach H, Graumuller S. Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients. Anaesthesia. 2006 Sep. 61(9):832-7. [Medline].
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Myers EN, Johnson JT. Tracheostomy. Airway Management, Communication and Swallowing. 2nd ed. San Diego, Calif: Plural Publishing, Inc; 2008.
Tibballs J, Robertson C, Wall R. Tracheal ulceration and obstruction associated with flexible Bivona tracheostomy tubes. Anaesth Intensive Care. 2006 Aug. 34(4):495-7. [Medline].
Tippet DC. Tracheostomy and Ventilator Dependency. New York, NY: Thieme; 2000.
Young PJ, Pakeerathan S, Blunt MC, Subramanya S. A low-volume, low-pressure tracheal tube cuff reduces pulmonary aspiration. Crit Care Med. 2006 Mar. 34(3):632-9. [Medline].
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Scalabrino N, Crespi L, Bosco M, Troisi E, Vezzaro G, Baravelli M. [Diagnosis and management of dysphagia in patients with tracheostomy tube after cardiac surgery: an early screening protocol]. Monaldi Arch Chest Dis. 2010 Jun. 74(2):70-5. [Medline].
Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019 Feb. 37 (1):109-119. [Medline].
Cramer JD, Graboyes EM, Brenner MJ. Mortality associated with tracheostomy complications in the United States: 2007-2016. Laryngoscope. 2018 Nov 19. [Medline].
Kashlan KN, Williams AM, Chang SS, Yaremchuk KL, Mayerhoff R. Analysis of patient factors associated with 30-day mortality after tracheostomy. Laryngoscope. 2018 Nov 22. [Medline].
Villarroya Gonzalez A, Longas Valien J, Vicente Armijo JJ, Cuartero Lobera J. [Orotracheal tube ignited by an electrocautery device during tracheostomy]. Rev Esp Anestesiol Reanim. 2009 Jan. 56(1):47-9. [Medline].
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Fernandez R, Tizon AI, Gonzalez J, Monedero P, Garcia-Sanchez M, de-la-Torre MV, et al. Intensive care unit discharge to the ward with a tracheostomy cannula as a risk factor for mortality: a prospective, multicenter propensity analysis. Crit Care Med. 2011 Oct. 39(10):2240-5. [Medline].
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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
Jonathan P Lindman, MD Otolaryngology-Head and Neck Surgeon, Piedmont Ear, Nose, Throat and Related Allergy
Jonathan P Lindman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Phi Beta Kappa, American Academy of Sleep Medicine, Triological Society
Disclosure: Nothing to disclose.
Ruben Peralta, MD, FACS Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic
Ruben Peralta, MD, FACS is a member of the following medical societies: American Association of Blood Banks, American College of Surgeons, American Medical Association, Association for Academic Surgery, Massachusetts Medical Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Eastern Association for the Surgery of Trauma, American College of Healthcare Executives
Disclosure: Nothing to disclose.
Ravindhra G Elluru, MD, PhD Professor, Wright State University, Boonshoft School of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Dayton Children’s Hospital Medical Center
Ravindhra G Elluru, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American Bronchoesophagological Association, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, Society for Ear, Nose and Throat Advances in Children, Triological Society, American Society for Cell Biology
Disclosure: Nothing to disclose.
Muhammad Kamaal Khan, MBBS, MRCSEd, DOHNS, FRCS(ORL-HNS) Consultant ENT, Department of ENT Head and Neck Surgery, Freeman Hospital, Newcastle upon Tyne, UK
Muhammad Kamaal Khan, MBBS, MRCSEd, DOHNS, FRCS(ORL-HNS) is a member of the following medical societies: British Association of Otorhinolaryngologists, Head and Neck Surgeons, British Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Royal Society of Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Karen H Calhoun, MD, FACS, FAAOA Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine
Karen H Calhoun, MD, FACS, FAAOA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Association for Research in Otolaryngology, Southern Medical Association, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, Texas Medical Association
Disclosure: Nothing to disclose.
Guy W Soo Hoo, MD, MPH Clinical Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, West Los Angeles Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System
Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society, Society of Critical Care Medicine, California Thoracic Society, American Association for Respiratory Care
Disclosure: Nothing to disclose.
Charles E Morgan, DMD, MD Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Alabama at Birmingham School of Medicine
Charles E Morgan, DMD, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
John Schweinfurth, MD Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Laryngological Association, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Susan Dixon, MD, to the development and writing of this article.
Medscape Reference also thanks Ravindhra G Elluru, MD, PhD, Associate Professor, Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine; Pediatric Otolaryngologist, Department of Otolaryngology, Cincinnati Children’s Hospital Medical Center, for assistance with the video contribution to this article.
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