Open Tracheostomy
Sam T. Windham III
John Christopher McAuliffe
DEFINITION
Tracheostomy is a procedure defined as the creation of a communication between the trachea and the skin of the neck anteriorly. In general, this technique is viewed as a definitive airway for the management of the critically ill patient needing prolonged ventilator support.
PATIENT HISTORY AND PHYSICAL FINDINGS
The history from the patient may be limited as compared to standard history and physical exams normally performed on patients during routine evaluations for surgery; however, the history and physical exam should focus to determine (1) the indications for tracheostomy, (2) optimal timing for the performance of the tracheostomy, and (3) which approach will provide the safest tracheostomy for the patient.
With respect to the indication for tracheostomy, the first and foremost indication should be that of the patient with a difficult airway who requires prolonged mechanical ventilator support. In these patients, loss of the airway can have devastating consequences. Pertinent history might include a difficult airway at the time of surgery; prior maxillofacial trauma; presence of severe inflammation or edema in the mandibular, pharyngeal, or base of tongue regions; prior head and neck radiation; or conditions that limit the mobility of the neck (e.g., ankylosing spondylitis, cervical trauma, or fixation). In these patients, early tracheostomy should be considered.
With respect to timing of the tracheostomy, many studies have evaluated this question.
When endotracheal tubes were first created, the tubes were less flexible than modern tubes with low-volume, high-pressure cuffs that resulted in more tracheal trauma than modern tubes. However, tracheal trauma and stenosis still occur with modern endotracheal tubes, and as a result, this leads to one of the indications for timing of the tracheostomy. In order to minimize the risk of tracheal stenosis, most recommend performance of tracheostomy in patients for whom 2 weeks of mechanical ventilation is expected. Pena et al.1 found that 86% of patients requiring laryngotracheal surgery for stenosis had a mean duration of 17 days of mechanical ventilation. So to minimize this risk, tracheostomy is usually recommended for expected duration of 14 days.
Other studies have looked at the timing of tracheostomies based on outcomes for the patients. Most studies evaluating performance of tracheostomies within the first 10 days of intensive care unit (ICU) course suggest statistically significant improvement in days on ventilator, days in the ICU, need for sedation, costs, and total hospital length of stay.2,3,4 In busy hospitals, with increased ICU usage, early tracheostomy should be considered.
With respect to timing of the tracheostomy, an important aspect of the history to evaluate is the disease process that required the need for mechanical ventilator support. In patients with severe brain injury,5 spinal cord injury associated with ineffective cough, severe multiple system organ failure, or in whom multiple-staged operations are planned, early tracheostomy should be considered.
The final aspect to the history and physical exam that should be considered alters whether the patient should undergo percutaneous dilatational tracheostomy versus standard surgical tracheostomy. Certain conditions might warrant open technique over percutaneous tracheostomy.
In the setting of altered patient anatomy, the safer option would favor standard surgical tracheostomy with direct exposure of the trachea.
With respect to morbid obesity, Byhahn et al.6 reported a greater complication rate with percutaneous dilatational tracheostomy over surgical tracheostomy (43% vs. 18%). If an extended length tracheostomy is anticipated to be needed, then surgical tracheostomy may be safer and easier approach.
The final consideration in preprocedural evaluation is the ventilator settings. In this setting, the surgeon must be comfortable either performing nonbronchoscopic percutaneous tracheostomies or choosing an open approach in order to minimize derecruitment.
SURGICAL MANAGEMENT
Preoperative Planning
Prior to taking the patient for open tracheostomy, clotting parameters such as prothrombin time, partial thromboplastin time, and platelet count should be evaluated and optimized.
Cervical spine status should be evaluated in the setting of trauma.
Periprocedural antibiotics should be administered.
Positioning
The patient is positioned supine with arms tucked to the side. Often, a pack is placed behind the shoulders to aid with neck extension (FIG 1).
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