Tracheostomy is a common operative procedure done to create a temporary surgical airway. The terms tracheostomy and tracheotomy essentially signify the same procedure; we will use the term tracheostomy for this module. The airway is usually created in the cervical area in patients who are either not able to wean off the endotracheal tube or who need more aggressive clearing of their oral secretions. Tracheostomy requires creating an opening in the cervical trachea and inserting a cannula. A mature tract from the skin usually takes seven to 10 days to form.1
In the past, tracheostomy was a barbaric procedure that involved slashing the throat with a sharp knife in emergency situations such as diphtheria or traumatic injury to the face. Throughout the centuries, complications with tracheostomy persisted, chiefly because of the lack of suitable anesthesia, poor knowledge about the anatomy, and poor surgical technique.
In the last 40 years, the procedure has been refined technically and is considered a minor surgical procedure; however, great care is required to avoid catastrophic complications. The procedure may be performed under open conditions in an OR, or by a percutaneous dilational procedure performed at the patient’s bedside. The decision of which procedure to use may be influenced by multiple factors, but ultimately rests with the preference and experience of the surgeon.2 This CE module will focus mainly on the open technique.
Indications for Tracheostomy
The most frequent indication for performing a tracheostomy is failure of a patient to wean from mechanical ventilation effectively.2,3
Other frequent causes for a tracheostomy include significant neurologic events (e.g., stroke), traumatic injuries to the face and upper airway, and some types of paralysis (e.g., Guillain-Barré Syndrome
). Tracheostomy is less frequently performed for airway obstructions resulting from infections such as epiglottitis and cancers of the oral cavity.2
With better and more effective antibiotics, the role of tracheostomy for the treatment of diphtheria, botulism and even epiglottitis is minimal.
In neonates and young children, tracheostomy may be used to bypass congenital malformations such as a hemangioma
or a laryngeal mass (polyp). Although most foreign bodies can be removed by bronchoscopy, those that cannot be removed may require a temporary tracheostomy. Cases where there is bilateral recurrent laryngeal nerve injury resulting in vocal cord paralysis require a permanent tracheostomy.1
In the ED, neck trauma is probably one of the leading causes of tracheostomy. Any type of neck trauma that leads to injury to the face or upper neck and obstructs the upper airways requires an immediate tracheostomy. Fractures of the mandible, larynx and midface also can cause massive edema of the upper airways. Rarely, individuals with facial burns, lye injuries or anaphylaxis may develop severe swelling of the face that requires a tracheostomy.4
Another common indication for a tracheostomy is to help the patient with pulmonary toilet
. Some patients have a very weak cough and develop repeated episodes of aspiration because of their inability to handle oral secretions. These patients may benefit from a prophylactic tracheostomy to help remove thick, viscous secretions. Prophylactic tracheostomy is also sometimes done in patients who undergo a laryngectomy. The tracheostomy helps with healing and can be closed when the facial and neck edema and swelling have subsided. Finally, some patients with sleep apnea may benefit from a tracheostomy. However, a tracheostomy in these patients is only done after all other conservative methods of treatment have failed.5
is a hollow tube that starts at the level of the larynx at the fifth cervical vertebrae. It extends down into the chest and bifurcates at the level of the carina into the two main bronchi. This level of bifurcation is fairly constant and occurs at T4
vertebrae. In an adult, the trachea’s internal diameter varies from 21 mm to 27 mm and the length is 10 cm to 17 cm. The trachea is made up of 15 to 20 incomplete C-shaped cartilaginous rings that reinforce the anterior and lateral segments. It is membranous posteriorly but formed of cartilage in the anterior portion. The cartilage rings protect the airway from complete collapse during swallowing. The only complete tracheal ring is the first ring. In between each ring is the trachealis muscle, which contracts during coughing. The esophagus runs posterior to the trachea. The opening of the larynx has a flap-like covering known as the epiglottis, which closes during swallowing to prevent aspiration. Because the tracheal blood supply is on the lateral sides, dissection should NOT be performed here; dissection could easily lead to devascularization and necrosis of the tracheal cartilage.6
The recurrent laryngeal nerves travel in the tracheoesophageal groove and the right nerve is very vulnerable to injury when dissection is done far laterally. In young children, the trachea is related intimately to the arch vessels; extensive dissection in the mediastinum can lead to torrential bleeding if any of these vessels is injured. The thyroid gland sits on top of the trachea at the level of the second to third tracheal rings. Because the thyroid is a very vascular structure, good hemostasis is a requisite when performing a tracheostomy.6
There are no absolute contraindications to performing a tracheostomy; however, it is important to check the coagulation profile prior to performing this procedure, especially as intraoperative bleeding must be controlled carefully from this highly vascularized region.2 However, it has been demonstrated that percutaneous tracheostomy is safe even in patients receiving anticoagulation therapy.7 A relatively strong contraindication exists in patients who have obstructing head and neck cancers within the larynx, as manipulation of a tumor must be avoided prior to ultimate removal in an attempt to prevent cancer seeding to the tracheostomy site. 2 Tracheostomy is not palliative surgery and must be considered when making end-of-life decisions. Family members and health professionals must be involved in decision-making when such situations arise. Ultimately, tracheostomy is better tolerated than an endotracheal tube and provides good hygiene, but it may not change the requirements for mechanical ventilation.2
Timing of Surgery
The majority of patients who undergo a tracheostomy are already intubated with an endotracheal tube.8 Ample time and opportunity is given to the patient to come off the ventilator. The exact timing for performing a tracheotomy after a patient undergoes mechanical ventilation should be considered on an individual basis; in general, it is recommended strongly to consider tracheostomy in patients requiring mechanical ventilation for 10 days.9 Only in certain cases is early tracheostomy performed following oral intubation, such as severe neurologic injury, or in trauma. 9 In children, most surgeons will not perform a tracheostomy for at least four weeks. Surgeons do agree that a prior oral intubation facilitates a tracheostomy. Control of the airways by an oral tube provides comfort that the patient still has an airway should anything happen during the procedure. A few situations when a tracheostomy may be done immediately without prior oral intubation include C spine fracture, disrupted/obstructed larynx or severe facial trauma.1
Most tracheostomies are done on an elective basis in a controlled environment with trained OR staff. Emergent tracheostomy or slash procedure is only done in dire circumstances, such as when a cricothyrotomy is impossible.10 Emergent tracheostomy is sometimes done in patients with acute respiratory distress from epiglottitis or foreign body obstruction. The procedure can be performed in the ED under local anesthesia, but it is vital that an anesthesiologist be present to monitor the airway and provide guidance. Most patients require some type of IV sedation or even the use of paralytic agents. Moreover, the surgeon should have steady hands because a tracheostomy in a conscious patient is very stressful and demanding. There is little room for error and the procedure can be challenging.6 Emergent tracheostomy is associated with extremely high morbidity and mortality, and should be avoided if at all possible.
Consent MUST be obtained from all patients who will undergo a tracheostomy. The general preoperative rules must be followed, and blood work must be done to ensure a normal coagulation profile. The procedure’s safety and its potential complications must be discussed with the family.
Percutaneous dilational tracheostomy. At present, several techniques of percutaneous dilatational tracheostomy have been developed.9 In order to be considered for this procedure, patients should be able to hyperextend their neck for appropriate positioning, have appropriate anatomy with identifiable landmarks, and have the ability to withstand possible temporary hypoxemia. While there are no absolute contraindications, inability to meet the above criteria can be considered a relative contraindication. 9
Most devices are supplied in pre-packaged kits, including all necessary equipment to perform the procedure. Assistance from bronchoscopy or ultrasound may be used to minimize complications and confirm correct placement, particularly in those patients with difficult anatomic landmark identification. This technique may be performed at the bedside in a shorter amount of time, without incurring the potential scheduling difficulties or increased costs associated with an open technique performed in the operating room. It appears to have a similar safety profile.9
Open tracheostomy. Even though tracheostomy is a minor procedure, it should be done with a great deal of thought and care. It is definitely not a recommended procedure for the ED if there is no surgical support. In the ED, lighting is usually poor, and proper help from surgical technologists and nurses may be lacking. If possible, tracheostomy should be done on a semi-elective basis in the regular OR.11 An anesthesiologist should always be present during the performance of a tracheostomy. The patient will need to have reasonable IV access and be attached to the various monitors such as heart rate, ECG and pulse oximetry. The patient should be placed supine with the neck slightly extended. In obese patients or patients with a short neck, a small roll placed under the neck may be helpful.
Patients who are awake and undergoing tracheostomy with only local anesthesia may not tolerate the shoulder roll; they may need to have their head elevated. Overextension of the neck should also be avoided because it tends to narrow the tracheal diameter. Moreover, overextension can result in the trachea being pulled out of the mediastinum and can lead to performance of a tracheostomy in the fourth to fifth ring, which is dangerously close to the innominate artery. This is a common mistake when performing tracheostomy in children.12
The entire neck and chest area should be draped and prepped. Before making an incision, the anatomical landmarks should be identified and marked. This includes the sternal notch, the cricoid cartilage and the midline trachea. Local anesthesia (lidocaine with or without epinephrine) should be used to infiltrate the skin and subcutaneous tissues. Epinephrine provides excellent hemostasis. A small (2- to 3-inch) horizontal skin incision is made along the skin tension lines to afford good cosmesis. Because the skin around the neck is very vascular, complete hemostasis should be obtained before dissecting deeper in the tissues. The subcutaneous tissue can be incised using electrocautery. Once the platysma is reached, the trachea should be palpated. The neck muscles should then be opened up only in the midline, and a retractor used to expose the thyroid gland. All small blood vessels should either be cauterized or ligated. The most critical part of dissection is to remain in the midline, where there is little chance of finding major blood vessels. Once the strap muscles are retracted, the thyroid isthmus can be viewed.6
Sometimes the thyroid isthmus is thick, and may have to be divided and ligated. In other cases, the isthmus stalk may be long and can be retracted superiorly to perform the tracheostomy.13 Most surgeons prefer to ligate and divide the thyroid isthmus so that it does not interfere with the tracheostomy in the future. Once the trachea has been identified, the overlying fascia should be excised to give exposure to the tracheal rings. Next, the surgeon should obtain complete hemostasis and prepare the tracheostomy site. Communication with the anesthesiologist is vital at this stage. The tracheal rings should be counted and the tracheostomy should be performed between the second and third rings.
The tracheostomy tube (including the stylet, the dilator and the syringe to inflate the balloon) should be prepared. The surgeon should make sure that the balloon works and should apply lubricating gel or lidocaine to the tip of the tube. A hook is used to retract the cricoid cartilage superiorly. This also elevates the trachea and brings the field into view.6
With a No. 11 blade, a T-shaped or cruciate incision is made between the second and third tracheal rings. Using Mayo scissors, the surgeon may need to cut small segments of the cartilage or create a larger opening with the tracheal dilator. Heavy silk sutures can be placed on either side of the trachea for retraction; these should be taped safely on the side of the neck. Once the tracheal opening is made, air and secretions will usually gush out. These should be suctioned and then the endotracheal tube can be viewed. The anesthesiologist should be asked to deflate the balloon and pull the endotracheal tube until just the tip is seen at the tracheal opening. The tracheostomy tube should then be inserted into the opening and the stylet removed. The tube should be connected to the airways and the chest should be observed for symmetrical expansion. The anesthesiologist should confirm placement with carbon dioxide return. At this point, the endotracheal tube can be removed. The tracheostomy tube should then be secured with permanent sutures. The surgeon can attach a tracheostomy collar with the patient’s head flexed to ensure that there is no slack or redundancy in the collar. The tracheal opening may be packed with some Surgicel but the skin should not be closed; closure of the skin will inevitably result in subcutaneous emphysema. The choice of dressing varies; some physicians prefer iodine, others prefer petrolatum gauze between the skin and the phalange of the tube. Once the tube is secured, the patient is returned to his or her room.6
A chest X-ray is always ordered after a tracheostomy.6
Selection of Tracheostomy Tube
In general, the smallest size tube that can accommodate the trachea should be used.14 The general rule of thumb is that the tube should occupy 80% of the tracheal diameter. A size 6 Shiley-cuffed tracheostomy tube is appropriate in most average-sized women; a size 7/8 is appropriate in most adult males. If a bronchoscopy for secretion clearance is planned, then a size 7/8 tube is required. Those who have a short neck or are obese can be difficult to assess for tube size. If the tube length is too short, it will abut the posterior wall. This will result in obstruction and delayed ulcerations. A tube that is too long will curve forward and erode into the anterior tracheal wall. Long tubes have also been reported to erode into the innominate artery.15
In general, cuff tubes allow positive pressure ventilation and even prevent aspiration. However, the cuff can irritate the mucosa and trap secretions. Even the new generation of cuff tubes need to be deflated at least four to six times per day to prevent pressure necrosis.