Tracheostomy is derived from the Latin words “trachea arteria” and “ostium,” which means “creating an opening in the trachea.” The earliest documentation of tracheostomy is a description of the healing of a throat incision in the Rig Veda. Hippocrates described intubation of the trachea to support ventilation. Tracheostomy to resolve upper airway obstruction was first mentioned in hieroglyphics by Imhotep. The first documented case of a successful tracheostomy was performed in a patient with tonsillar obstruction by Antonio Brassavola in 1546. In 1620, Nicolas Habicot successfully resuscitated a boy who was initially pronounced dead after sustaining a stab wound to the neck, following an emergent tracheostomy and release of a tracheal blood clot. In 1833, Trousseau saved more than 200 patients with diphtheria by performing a tracheostomy.
Tracheostomy techniques available today are surgical tracheostomy (ST) and percutaneous dilational tracheostomy (PDT).
ST is usually performed in the operating room under general anesthesia and entails surgical dissection of the neck tissue to create a stoma. Conversely, in PDT, a needle is placed percutaneously and then, using a modified Seldinger technique, a stoma is created by dilation.
PDT has a smaller incision size, shorter procedural duration, less postoperative bleeding, and faster healing time compared to ST. Several meta-analyses and randomized controlled trials (RCTs) comparing ST and PDT have also confirmed that PDT is associated with significantly shorter operative time, lower cost, lower incidence of perioperative bleeding, shorter sedation time, accelerated wound healing, and lower risk of stoma infections. However, there is no difference in mortality between ST and PDT.
In this chapter, we will primarily focus on PDT in the intensive care unit (ICU) setting.
Surgical Tracheostomy Technique
ST is ideally performed in the operating room under general anesthesia, although ST may be performed at the bedside. Landmarks should be identified preoperatively, including the thyroid cartilage, cricoid cartilage, and sternal notch. Local anesthetic with 1% lidocaine with epinephrine is infiltrated at the incision site if not performing under general anesthesia. A 2–3-cm long transverse skin incision is made about a centimeter below the cricoid cartilage. The midline raphe is located, and retractors are used on either side of the strap muscles to expose the trachea. The endotracheal tube (ETT) is slightly withdrawn to allow stoma creation. An incision is made in the interspaces between the first and the second tracheal rings and is extended laterally. Stay sutures are placed through the skin, around the tracheal ring, and then back through the skin. Often a Bjork flap is made. The tracheostomy tube (TT) is then placed through the tracheostomy stoma, the cuff inflated, and the ventilator circuit connected. The TT is secured with sutures in the neck and ventilation is then transferred from the ETT to TT.
Types of Percutaneous Dilational Tracheostomy
The first tracheostomy technique described in 1955 required a special needle to enter the trachea and involved a one-stage insertion of the TT using a cutting trocar.
Percutaneous tracheostomy has been modified over the years. The Ciaglia technique, introduced in 1985, is one of the most widely used techniques in North America. In 1990, the Griggs guidewire dilating forceps (GWDF) was developed, where a special forceps is threaded over the guidewire into the trachea, and a tracheal aperture is created by opening the forceps. In 1997, Fantoni and Ripamonti described the translaryngeal method where the dilator and the TT are pulled in a retrograde fashion through the stoma. Another single-dilator technique called the PercuTwist, developed by Frova and Quintel in 2002, utilizes a single dilator, which is advanced over the guidewire into the soft tissue using a clockwise rotation to create a stoma.
Since these latter techniques do not exert pressure over the tracheal wall during dilation, they were thought to minimize the risk of posterior tracheal wall injury.
Indications for PDT are similar to ST ( Box 18.1 ). ST is primarily performed in patients with upper airway obstruction from laryngeal or cervical malignancies or in emergencies. It is also done in patients undergoing neck surgery, total laryngectomy, and in patients with ineffective swallowing or cough mechanisms resulting in an inability to protect their airway.
Prolonged ventilator dependence with failure to wean
Inability to protect airway (stroke, encephalopathy, etc.)
Obstruction of proximal trachea or upper airways
Gross distortion of neck anatomy due to tumor, high innominate artery, thyromegaly
Soft-tissue infection on anterior neck
Medically uncorrected bleeding disorders
High positive end-expiratory pressure (PEEP) of more than 20 cm of water
Major head and neck surgery or trauma
Overwhelming systemic infection
In the medical ICU, tracheostomy is commonly performed in patients requiring prolonged ventilation or for airway protection. Transitioning from oral intubation to tracheostomy helps to minimize sedation requirements, decrease the incidence of lung infections, reduce dead space ventilation, improve respiratory work, and aid in tracheobronchial toileting while protecting the airways.
Although when first introduced there were suggested contraindications related to body habitus, today it is recognized that PDT is a viable alternative to ST and there are no absolute contraindications for PDT as compared to ST.
Relative contraindications ( Box 18.1 ) to PDT include trauma resulting in an unstable cervical spine, uncontrollable coagulopathy, or prior neck surgery. In addition, PDT can be performed with caution in patients with difficult anatomy (enlarged thyroid gland, local malignancy, short neck, tracheal deviation, previous tracheostomy), high ventilator support (F io 2 >70% or positive end-expiratory pressure [PEEP] >10 cm H 2 O), and radiation therapy to the cervical region within the previous 4 weeks. Other contraindications include infection at the insertion site or palpable but obscured neck anatomy. Recent data suggest that PDT is largely dependent on operator experience and can be safely performed in patients with relative contraindications.
PDT has been performed in patients with an average Pa o 2 /F io 2 of 130 and an average PEEP of 17 cm H 2 O without any significant deterioration in oxygen saturation. PDT has also been done in patients with acute respiratory distress syndrome (ARDS) on high-frequency oscillatory ventilation without any significant hemodynamic or respiratory compromise.
ST is often preferred over PDT in patients with a body mass index (BMI) >30 kg/m 2 , in neck trauma, and in head and neck malignancy. However, PDT can be safely performed in the obese population. A retrospective study found no significant difference between PDT and ST in malpositioning of TT, loss of airway, or bleeding in patients with BMI >35 kg/m 2 . Another prospective study comparing PDT in ICU patients with BMI ≥30 kg/m 2 versus lower BMI revealed significantly higher major complication rates (12% vs. 2%, P < 0.04) in obese patients. The creation of a false passage due to the increased distance from skin to trachea was a major complication in morbidly obese patients. The risk of complications can be minimized with proper evaluation, appropriate patient selection, operator experience, and concurrent bronchoscopic visualization to avoid unrecognized false passages.
Timing of Tracheostomy
In general the consensus for appropriate time to perform tracheostomy is around 10–20 days after intubation. Early tracheostomy (within 7 days after intubation) in critically ill patients is associated with a reduction in weaning time, complications, and morbidity and mortality.
Early tracheostomy, performed within 4–7 days of admission, is associated with a significant increase in ventilator-free days (VFD). A systematic review of RCTs comparing outcomes of early versus late tracheostomy confirmed more VFD, shorter ICU stays, a shorter duration of sedation, and reduced long-term mortality in patients with early tracheostomy. However, although early tracheostomy reduced hospital length of stay and cost, it did not affect in-hospital mortality.
Tracheostomy Tubes and Types
The main components of the TT are an outer cannula, the flange, and an inner cannula ( Fig. 18.1 ).
The curved outer cannula ( Fig. 18.1a,b ) is attached to the flange and has a cuff attached to the distal end to provide a seal within the trachea for ventilation.
The flange is attached to the proximal end or is a part of the TT, which is used to secure the TT on the neck with a tracheostomy tie or suture. The flange is commonly labeled with the tube size, type, and length.
The inner cannula ( Fig. 18.1c ) snugly fits inside the outer cannula and often has a 15-mm adapter for connecting to the ventilator circuit. The inner cannula can be reusable or disposable. Reusable inner cannulas need to be cleaned at least twice a day. Some TTs do not have the provision of an inner cannula and the inner aspect is specially coated with water-repellent material to prevent mucus plugging.
The obturator ( Fig. 18.1d ) is a firm guide with a rounded tip designed to be placed inside the outer cannula of the TT for easy placement through a matured stoma during tracheostomy tube replacement.
Patients on a ventilator or those with risk of aspiration usually require a cuffed TT. The cuff is connected to a pilot balloon ( Fig. 18.1b ) that provides information on the cuff inflation. When patients are weaned off mechanical ventilation, they can be transitioned to a cuffless TT in preparation for decannulation. Cuff pressures should be checked periodically to avoid ischemic injury of the tracheal mucosa.
The TTs come in different sizes and shapes depending on the length, curvature, thickness, and a detailed discussion is beyond the scope of this chapter.
A modified TT is available for placement with the PDT technique ( Fig. 18.2b ), which has a tapering distal end to make it easier to insert through the newly created stoma by dilation.
A longer TT is used in obese patients to accommodate the longer skin to tracheal distance so the distal tip of the TT ( Fig. 18.2a ) remains parallel to the long axis of the trachea. Various commercially available TTs are available that are extra long.
Percutaneous Tracheostomy Kit
The two well-known commercially available kits in the United States that use a single-stage dilator include the Ciaglia Blue Rhino (Cook Medical Inc, Bloomington, IN, USA) and Portex Ultraperc (Smiths Medical, Dublin, OH, USA).
Bronchoscopic guidance is an important adjunct in proper placement of TTs during PDT to avoid posterior wall trauma or puncture, and is especially important in patients with obesity, difficult anatomy, or those with cervical fixation or an unstable cervical spine. A more detailed procedural description is provided later, including how bronchoscopy can be utilized to confirm placement of the guidewire, and to avoid false lumen formation and tracheal injury.
There is conflicting evidence, with some studies failing to demonstrate a benefit for concurrent bronchoscopy, whereas others have found that bronchoscopic visualization during PDT reduces complications. For example, a retrospective analysis of PDT with and without bronchoscopy in the trauma population revealed no significant difference in safety and efficacy with experienced operators. However, over time other studies have shown the benefits of routinely utilizing bronchoscopy when performing PDT. For example, a prospective study reported significantly lower rates of major complications including bleeding, subcutaneous emphysema, or pneumothorax (20% vs. 40%); higher rate of first-time successful needle puncture; and significantly shorter procedural duration with bronchoscopic guidance. On balance, given that false lumens and unrecognized tracheal lacerations are the most significant major complications of PDT, concurrent bronchoscopy during PDT should be considered an essential element of PDT in terms of safety. At present, bronchoscopic guidance is used routinely by almost all interventional pulmonologists.
Ultrasound Guidance During Percutaneous Dilational Tracheostomy
Ultrasound guidance during PDT can assist with localizing anatomic landmarks and to identify the appropriate point of entry by examining the pretracheal area for aberrant vasculature, tracheal rings, neck mass, and the thyroid gland. Real-time ultrasound can be used to follow the needle path during tracheal puncture and to determine the final position of the TT. However, injury to the posterior tracheal wall cannot be assessed with ultrasound due to the inability to visualize the posterior wall. In our practice, we do not routinely use ultrasound guidance.
A randomized prospective study comparing efficacy, safety, and incidence of complications between bronchoscopic guidance and ultrasound guidance revealed no significant differences between the two groups in terms of technical difficulty of the procedure or the number of needle interventions. Interestingly, the risk of hemorrhage was higher and the mean duration of procedure was longer in the bronchoscopy group. A network meta-analysis found that bronchoscopy or ultrasound-guided percutaneous tracheostomy has similar rate of procedure-related complications. Ultrasound guidance may not be an alternative to bronchoscopic guidance, but rather an adjunct to bronchoscopy to potentially improve the safety profile in select cases.
Evaluation of Patient for Tracheostomy
A thorough clinical and anatomic evaluation should be performed before planning a PDT. Review of the clinical history including medication use, previous tracheostomy or neck surgery, bleeding disorders, evaluation of the neck anatomy for palpable cricoid cartilage or tracheal rings, palpable isthmus of the thyroid gland, cricoid to sternal distance, and ability to extend the neck are essential.
Hemodynamically unstable, coagulopathic, and obese patients need careful risk stratification to avoid any complications. Depending on the clinical context, PDT on obese patients can be done safely by a skilled operator. In select patients with mild hemodynamic instability, PDT may be feasible, depending on the alternatives. Coagulopathy should in general be corrected prior to PDT, but if it is mild and cannot be corrected, then with a skilled operator and appropriate surgical backup it may be done if there are no alternatives.
History of sedation tolerance is helpful to plan the procedural sedation. Platelet count and coagulopathy should be reviewed 24 h prior to procedure.
There is a high risk of aerosolization of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) during tracheostomy. Delaying the procedure for 10 days or until the patient is stable and able to tolerate apnea during creation of the stoma and insertion of TT may minimize risk of aerosolization. We perform PDT in COVID-19 (Coronavirus disease 2019) patients in a negative airflow room wearing full personal protective equipment with a powered air-purifying respirator (PAPR).
After a decision for tracheostomy is made, informed consent should be obtained from the patient (if able), durable power of attorney (DPOA), or family for tracheostomy, bronchoscopy, and ultrasound examination (if planned). Risks, benefits, potential complications, and alternative options should be clearly explained to the patient or family.
Anticoagulation or Antiplatelet Therapy Management in Percutaneous Dilational Tracheostomy
There are no specific guidelines on anticoagulation and antiplatelet management in patients undergoing PDT. The incidence of major bleeding requiring blood transfusions directly related to PDT is extremely low. However, general guidelines for perioperative management of antithrombotic therapy can be applied to PDT.
The incidence of major and minor bleeding following PDT, in patients on extracorporeal membrane oxygenation (ECMO) receiving systemic heparinization, was 1.7% and 31.4%, respectively, with a median platelet count of 126, 000/µL and international normalized ratio (INR) 1.1, when heparin infusion was held 1 h before the procedure. Even with coagulation disorders (activated partial thromboplastin time [aPTT] >50 s, prothrombin time [PT] <50%, INR >1.4, or platelet <50, 000/µL) there was mild bleeding without any need for surgical intervention or transfusion. Thus PDT is relatively safe in patients with coagulopathy and severe thrombocytopenia after correction.
We recommend holding the heparin drip at least 3 h prior to the procedure and resuming heparin 3 h postprocedure. Subcutaneous heparin and enoxaparin should be held at least 12 h prior if they are receiving BID dosing. If they are receiving once-a-day therapeutic dosing of enoxaparin, it should be held for 24 h. Dual antiplatelet therapy preferably should be held for 3–5 days. However, in the setting of recent cardiac stenting, PDT can be performed safely on clopidogrel with appropriate informed consent. Direct oral anticoagulation agents (DOAC) and vitamin K antagonists (VKA) should be bridged with unfractionated heparin if possible. DOAC should be held for two to three drug half-lives in cases with low risk of bleeding and four to five drug half-lives in high risk of bleeding. Renal dysfunction is also a key factor and desmopressin (DDAVP) can be used in uremic patients since platelets can be dysfunctional. There is no specific guidance on the use of antiangiogenic agents such as bevacizumab or other oral VEGF (vascular endothelial growth factor) TKI (tyrosine kinase inhibitor) such as sunitinib or cabozantinib during PDT. A French guideline recommends a delay of 2 days between implantation of an intravenous device and the initiation of bevacizumab, a delay of at least 5 weeks between the last dose of bevacizumab and invasive surgery, and a delay of 4 weeks between surgery and the initiation of bevacizumab treatment.
Preparation for Percutaneous Dilational Tracheostomy
Once the decision for bedside PDT is made, the plan should be communicated to the primary team, the nursing staff in the ICU, and the bronchoscopy team. A procedural checklist ( Box 18.2 ) ensures that all necessary supplies, medications, and equipment are available at the bedside. Tube feeding should be held, or patients should be NPO for at least 4–6 h prior to the procedure. Anticoagulation should be managed as described earlier.
Flexible bronchoscope with monitor and other equipment
Fentanyl, midazolam, propofol, dexmedetomidine
Rocuronium or succinylcholine for neuromuscular block
Additional saline available in case of hypotension
Percutaneous tracheostomy kit
Extra-long tracheostomy tube (if deep neck or BMI >35 kg/m 2 )
Face shield and caps
Electrocautery or thermocautery
Split sponge dressing
Lidocaine with epinephrine