Tracheotomy

Author Credentials 

Karen Kölln, MD
Otolaryngology/Head and Neck Surgery Resident
Department of Otolaryngology/Head and Neck Surgery
University of North Carolina Hospitals
CB#7070
101 Manning Drive
Chapel Hill, NC 27599-7070
kkolln@unch.unc.edu

Mark Weissler, MD
Professor
Division Chief, Head & Neck Surgery
Department of Otolaryngology/Head and Neck Surgery
G0412 Neurosciences Hospital
University of North Carolina School of Medicine
CB #7020
101 Manning Drive
Chapel Hill, NC 27599-7070
Mark_Weissler@med.unc.edu

Module Summary

Establishing a safe and secure airway is one of the fundamental responsibilities of an otolaryngologist. Standard methods have been established for securing a surgical airway; and over the past 20 years advances have been made in percutaneous dilational tracheotomy that can be performed at the bedside. Special consideration needs to be taken in the pediatric population and a fundamental understanding of the patient’s underlying pathology will facilitate choosing the appropriate procedure for the patient.

Module Learning Objectives 

 

  1. List the indications for performing tracheotomy.
  2. Describe the surgical techniques used to perform an elective tracheotomy.
  3. Describe the surgical techniques used to perform percutaneous tracheotomy.
  4. Know the technique for establishing an airway emergently.
  5. Understand the special considerations of performing tracheotomy on a pediatric patient.
  6. Identify the complications of tracheotomy.
  7. Be able to compare the relative indications and risks of percutaneous versus open tracheotomy.

Anatomy

Learning Objectives 
  1. Know the anatomical landmarks important in performing tracheotomy.
    1. Thyroid notch
    2. Cricoid cartilage
    3. Sternal notch
  2. Know the anatomy of the anterior neck and trachea.
    1. Platysma muscle
    2. Anterior jugular vein
    3. Sternohyoid muscle
    4. Sternothyroid muscle
    5. Thyroid gland
    6. Cricoid cartilage
    7. Trachea
References 
  1. Cohen JI, Davidson BJ, Lydiatt WM, Rosenthal EL. Tracheotomy. In Cohen, JI, Clayman GL. (Eds.), Atlas of Head & Neck Surgery. Philadelphia: Elsevier.

Incidence

Learning Objectives 

Understand the incidence of tracheotomy in critically ill patient population is 12.6%.

References 
  1. Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) study. JAMA. 1995;274:639-644.

Patient Evaluation

Learning Objectives 

List the indications for tracheotomy:

  1. Upper airway obstruction
  2. Inability of patient to handle own secretions
  3. Facilitation with intubation
  4. Difficulties with intubation
  5. Prolonged intubation
  6. Adjunct to head and neck surgery with possible compromise of the airway
  7. Adjunct to management of severe facial fractures
  8. Neurologic disorders or trauma such as ALS, cervical fractures
  9. Assist in weaning from the ventilator
    1. Reduction in dead-space volume
References 
  1. Weissler MC, Couch ME. Tracheotomy and Intubation. In Bailey BJ, Johnson JT (Eds.), Head & Neck Surgery--Otolaryngology (Fourth ed.). Philadelphia: Lippincott Williams & Wilkins; 2006:785-801.

Measurement of Functional Status

Learning Objectives 

Be aware of underlying disease processes in chronically intubated patients:

  1. Chronic respiratory failure may lead to high CO2 levels leading to a decreased respiratory drive after tracheotomy.
  2. High airway pressure preoperatively can lead to decompensation after performing tracheotomy.
  3. Pulmonary edema may result in these situations.
References 
  1. Kost KM,  Myers EN. Tracheostomy. In Myers EN (Ed.), Operative Otolaryngology (2nd ed). Philadelphia: Saunders; 2008:577-594.

Treatment

Learning Objectives 

Know the various maneuvers to secure an emergent airway:

  1. Generally emergency tracheotomy or emergency cricothyroidotomy should be avoided if the airway can be stabilized by any other means (mask airway, intubation).
  2. Collaboration with all physicians caring for the patient is vital so that a tenuous airway is not converted to an emergent airway.
  3. Emergency tracheotomy
    1. Vertical incision
  4. Cricothyroidotomy
    1. Horizontal stab incision over cricothyroid membrane
  5. Transcricothyroid puncture
References 
  1. Altman KW, Waltonen JD, Kern RC. Urgent Surgical Airway Intervention: A 3 Year County Hospital Experience. Laryngoscope. 2005;115:2101-2104.
  2. Weissler MC, Couch ME. Tracheotomy and Intubation. In Bailey BJ, Johnson JT (Eds.), Head & Neck Surgery--Otolaryngology (Fourth ed.). Philadelphia: Lippincott Williams & Wilkins; 2006:785-801.

Surgical Therapies

Learning Objectives 
  1. Be familiar with the surgical technique of elective tracheotomy.
    1. Horizontal or vertical skin incision two centimeters inferior to the cricoid cartilage
    2. Divide the strap muscles (sternohyoid and sternothyroid) in midline
    3. Suture ligate or cauterize thyroid isthmus if large
    4. Place cricoid hook below cricoid cartilage to retract trachea superiorly and stabilize
    5. Perform tracheotomy
    6. Place tracheostomy tube
    7. Confirm proper placement by visualizing CO2 return through tube or with fiberoptic scope
  2. Be aware of the variety of incisions used for the tracheotomy.
    1. Window
      1. Removal of the anterior portion of third or fourth tracheal ring
    2. Björk flap
      1. An incision in the anterior trachea consisting of an inferiorly based incision including one tracheal ring that is subsequently sutured to the skin to decrease the morbidity of accidental decannulation in the postoperative period before a mature tract has formed between the skin and the trachea.
    3. Vertical incision
    4. Sideways H-shaped incision
  3. Describe the special techniques used with performing tracheotomy in a pediatric patient.
    1. Vertical tracheal incision
    2. Paired sutures on either side of the vertical incision to assist in re-establishing an airway if accidental decannulation occurs in the postoperative period before a mature tract is formed between the skin and the trachea.
  4. Be familiar with the technique of percutaneous tracheotomy.
    1. Bronchoscope recommended for visualization of airway during tracheotomy
    2. Horizontal or vertical skin incision 2 cm inferior to cricoid cartilage
    3. Dissection performed down to trachea in midline
    4. Kit included needle, wire, and dilator which are utilized via the Seldinger technique to place the tracheostomy tube between the second and third tracheal rings.
References 
  1. Barba CA, Angood PB, Kauder DR, et al. Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure. Surgery. 1995;118:879-883.
  2. Couch ME, Bhatti N. The current status of percutaneous tracheotomy. Advances in surgery. 2002;36:275-296.
  3. Moe KS, Stoeckli SJ, Schmid S, et al. Percutaneous tracheostomy. A comprehensive evaluation. Ann Otol Rhinol Laryngol. 1999;108:384-391.
  4. Kost, KM,  Myers, EN. (2008). Tracheostomy. In E. N. Myers (Ed.), Operative Otolaryngology. Philadelphia: Saunders; 2008:577-594. 
  5. Cohen, JI, Davidson, BJ, Lydiatt WM, Rosenthal EL. Tracheotomy. In JI Cohen, GL Clayman (Eds.), Atlas of Head & Neck Surgery. Philadelphia: Elsevier; 2011;49-57. 

Rehabilitation

Learning Objectives 

Understand the postoperative care in patients undergoing tracheotomy:

  1. Humidification
  2. Deep suctioning with saline
  3. Monitored setting
  4. Keep inner cannula clean and change frequently enough to avoid plugging.

Case Studies

  1. A 67-year-old white female presents with a subdural hematoma and altered mental status requiring surgical drainage and ventilator support. She remained intubated for seven days without improvement in her mental status. Upon evaluation for a tracheotomy she was found to have a thin neck with an easily palpable cricoid cartilage, minimal ventilator settings (positive end expiratory pressure = 5 cm H2O), and her neck was easily extended. Her family was consented for a percutaneous tracheotomy which was subsequently performed at the bedside.
  2. A 27-year-old construction worker fell from the second floor of a building and suffered numerous injuries including left pneumothorax, grade II liver laceration, C2-3 fracture, and epidural hematoma. His hospital course was complicated by ARDS and pneumonia was ventilator dependent. After two weeks of requiring high ventilator support the patient began to improve and was evaluated for a tracheotomy. He was not a candidate for percutaneous tracheotomy given his cervical spine fracture and was thus consented for a surgical tracheotomy that was subsequently performed in the operating theatre.
  3. A 59-year-old male with a history of a T2N0M0 squamous cell carcinoma of the true vocal folds treated with primary radiation therapy two years ago presents to the emergency department with a two-week history of increasing dyspnea and noisy breathing. On examination he has significant inspiratory stridor and his vital signs are stable. On flexible fiberoptic examination there is boggy edema of his glottis with true vocal fold fixation bilaterally and 90% obstruction of his airway. He was consented for an emergent awake tracheotomy and taken to the operating suite where he was given no intravenous sedation and the procedure was performed with no sequelae.

Complications

Learning Objectives 
  1. List the potential complications associated with elective tracheotomy.
    1. Intraoperative
      1. Pneumothorax/pneumomediastinum
      2. Hemorrhage
      3. Damage to tracheoesophageal common wall
    2. Early postoperative
      1. Tracheostomy tube displacement or obstruction
      2. Infection
      3. Pulmonary edema
      4. Hemorrhage
    3. Late
      1. Tracheal stenosis
      2. Granulation tissue
      3. Trachea-innominate artery fistula
      4. Tracheomalacia
      5. Tracheoesophageal fistula
      6. Pneumonia
      7. Aspiration
  2. Understand the difference in risk between percutaneous tracheotomy and surgical tracheotomy.
    1. Most studies have shown no significant difference in complication rates and patient factors and surgeon preference/comfort are used to determine the procedure of choice.
References 
  1. Delaney A, Bagshaw SM, Nalos M. Percutaneous dilational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 2006;10(2):R55.
  2. Durbin CG Jr. Early complications of tracheostomy. Respir Care. 2005;50(4):511-515.
  3. Epstein SK. Late complications of tracheostomy. Respir Care. 2005;50(4):542-549.
  4. McCormick B, Manara AR. Mortality from percutaneous dilatational tracheostomy. A report of three cases. Anaesthesia. 2005;60:490-495.
  5. Silvester W, Goldsmith D, Uchino S, et al. Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up. Crit Care Med. 2006; June 13.
  6. Weissler MC, Couch ME. (2006). Tracheotomy and Intubation. Bailey BJ, Johnson  JT. (Eds.), Head & Neck Surgery--Otolaryngology. Philadelphia: Lippincott; 2006. 

Review

Review Questions 
  1. What are the indications for tracheotomy?
  2. What are the special considerations in performing tracheotomy in a pediatric patient?
  3. Describe the surgical options and techniques in performing tracheotomy.
  4. What are the potential complications of tracheotomy?