Tracheostomy is one of the most commonly performed procedures in surgical practice. An intervention dating back to 1500 bc,^1–3 tracheostomy, until recently, was used solely to relieve acute upper airway obstructions. Polio and the advent of modern ventilators in the twentieth century made tracheostomy largely a routine elective procedure for patients dependent on ventilatory assistance. This chapter describes the techniques and associated risks and benefits of the procedure.

Tracheostomy continues to be indicated for relief of upper airway obstruction, including intermittent obstruction such as those occurring in sleep apnea, although cricothyroidotomy is preferred in the acute emergency situation. More tracheostomies today, however, are performed electively in the critical care setting to facilitate pulmonary toilet and ventilatory support for chronically ventilated patients. Tracheostomy is superior to prolonged translaryngeal intubation in many ways (Table 54-1). Tracheostomy improves patient comfort, leading to decreased requirements for analgesia and thereby facilitating ventilatory weaning. It provides a more secure airway, which, in turn, permits greater patient mobilization because the risk of inadvertent extubation is decreased. It reduces the incidence of vocal cord injury and subglottic stenosis, as well as the rate of sinusitis. Airway resistance is also reduced over the short tracheostomy in comparison with the longer endotracheal tube. Pulmonary toilet and oral hygiene are improved, and it permits the use of fenestrated devices that provide the potential for speech.^4–8 Despite these advantages, considerable debate remains over the ideal timing of tracheostomy. In principle, tracheostomy should be considered for any critically ill, intubated patient in whom extubation is not immediately foreseeable, after the patient has spent a “reasonable” length of time on the ventilator. Defining reasonable forms the basis of the controversy. In the 1960s, a reasonable length of time was considered to be as few as 3 or 4 days because of the high rate of complications associated with the use of rigid, low-volume, high-pressure endotracheal cuffs during prolonged translaryngeal intubation. After the introduction of high-volume low-pressure endotracheal cuffs in the 1970s, complication rates decreased, and it became reasonable to keep patients with endotracheal intubation for longer periods. Translaryngeal or endotracheal intubation now may be appropriate for periods up to 3 weeks, particularly if the patient objects to a tracheostomy or if there are contraindications or other risks.^4-6,9–12

Although tracheostomy is a safe procedure, it is neither benign nor without risk. Morbidity for tracheostomy ranges from 4% to 10%, whereas mortality is less than 1%.^4–6 Complications include infection at the stoma site, stomal hemorrhage, granuloma formation that can lead to obstruction, tracheal ring rupture, tracheoinnominate fistula, tracheoesophageal fistula, tracheal stenosis, tracheomalacia, and swallowing dysfunction that may be permanent even after decannulation^{4,5,7–9,13,14} (see Table 54-1). Recent outcome studies that compare early versus late tracheostomy in the setting of trauma or medical illness are inconclusive and often flawed with multiple internal design errors.^{4–6,10,12,15} The optimal time for tracheostomy must account for numerous factors, including the likelihood of extubation, the chance of multiple reintubations, the probability of complications secondary to laryngeal intubation, and the wishes of both the patient and the family. Although no strict timelines exist, current practice recommends tracheostomy in any patient who has been intubated for more than 1 week and is not likely to be extubated within the next week or for patients in whom tracheostomy would improve pulmonary toilet and decrease sedation requirements, thereby facilitating ventilatory weaning.^4–10,13

Relative contraindications to tracheostomy include poor oxygenation that requires high levels of positive end-expiratory pressure and ventilatory support that prohibits safe transport or prevents the patient from safely tolerating apnea during exchange of the endotracheal tube for the tracheostomy appliance. Other relative contraindications include bleeding disorders, anatomic restrictions such as body habitus, “high” passage of the innominate artery at the level of the suprasternal notch, or high vasopressor requirements that prevent adequate sedation during the procedure secondary to hypotension.

The selection of tracheostomy appliance is based on a thorough knowledge of the specific features of each device in relation to the patient’s needs. Pertinent features include inner and outer diameters, length (of both proximal and distal portions of the device), angle, and presence or absence of an inner cannula or fenestrations. The size of the tracheostomy appliance should be large enough to provide adequate bronchoscopic pulmonary toilet if this is a consideration, bearing in mind that larger cannulas lead to higher rates of tracheal stenosis and smaller cannulas are associated with increased airway resistance.^5,6 A 7- or 8-mm diameter (inner circumference) tube typically is used because it is the smallest diameter that will allow for adequate pulmonary toilet. Appliance length usually is fixed but adjustable. Adjustable alternative-length devices are available for patients with anatomic features that do not accommodate standard-length devices. For example, the cannula may be too short, such that it abuts the posterior tracheal membrane, or it may be too long, such that it abuts the carina, leading to partial airway obstruction. The optimal length should place the end of the tracheal cannula 3 to 4 cm above the carina. The high-volume low-pressure cuff is currently preferred because it leads to fewer airway complications while providing substantial airway resistance to airflow around the cuff. When the tracheostomy is still required after the cuff is no longer needed for ventilatory support, the tracheostomy appliance should be replaced with a cuffless or fenestrated variety. If there is sufficient airflow around the deflated cuff, patients with intermittent ventilatory requirements can be fitted with a one-way Passey–Muir valve to permit speech when the patient is not being ventilated. Extreme caution is required, however, because the Passey–Muir valve increases the airway resistance. Failure to deflate the cuff before attaching the one-way valve can result in respiratory failure and death of the patient. Fenestrated appliances decrease airway resistance by permitting airflow through the fenestrations, which, in turn, allows the patient to speak when the tracheostomy is capped and the fenestrations are open. However, a closed inner cannula and inflated balloon must be present to mechanically ventilate these patients, and the fenestrations can make suctioning more difficult and increase granulation tissue in the airway in some instances. Inner cannulas decrease the risk of tracheal occlusion secondary to the accumulation of secretions within the outer cannula. For this reason, inner cannulas are preferred for permanent or long-term tracheostomies. Another option includes placement of a tracheal T-tube through the tracheotomy opening for those who require stenting of upper airway obstruction, either temporary or permanent. Selecting the appropriate appliance requires careful consideration on a case-by-case basis. When patients have recovered sufficiently and no longer need a tracheostomy, the appliance is either removed completely or replaced with a smaller, noncuffed variety for pulmonary toilet. The stoma is covered, and the patient is instructed to hold the stoma closed during coughing. With time, most tracheostomies close spontaneously, although there occasionally can be excessive granulation tissue around the stoma site requiring surgical debridement and closure in the OR.

Surgical Tracheostomy

Surgical tracheostomy usually is performed under general anesthesia in the OR. The key steps are outlined in Table 54-2. The patient is placed in the supine position with the neck extended. Neck extension is facilitated by placing a towel roll under the patient’s shoulders. Neck extension facilitates tracheostomy by elevating the trachea out of the thorax into the operative field. Care must be taken to avoid hyperextending the neck. In younger patients, overelevating the trachea creates the possibility of placing the tracheostomy too low in the trachea. Trauma victims and elderly patients are also particularly vulnerable to hyperextension injuries. Neck extension should not be performed in patients with a history of known or suspected cervical spine injury, and it may not be possible in patients with severe kyphosis, arthritis, or spinal fusion. In these patients, tracheal exposure can be aided by using a tracheal hook or by dividing the thyroid isthmus.