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Tracheostomy

Abbas E. Abbas

HISTORY

Since early civilization, making a sharp cut into the easily palpable cervical trachea has been known as a quick method to either cut off or deliver air to the lungs. Indeed, a form of tracheotomy was first depicted on Egyptian hieroglyphs dating back to 3600 BC and was later described by the Greek Homerus of Byzantium and Hippocrates. The first anatomically correct description of the tracheostomy operation for treatment of asphyxiation was by Ibn Zuhr in the twelfth century, and the first recorded successful tracheostomy was by Antonio Musa Brassavola (1490-1554), who treated a patient suffering from a peritonsillar abscess by tracheotomy. However, it remained an operation with a high mortality rate, and there are only few cases reported before the 1800s. With the beginning of the nineteenth century, several surgeons began using this technique for both emergent and elective reasons. In 1852, Armand Trousseau reported a series of 169 tracheotomies, and after that, the indications for this procedure rapidly expanded to include the treatment of diphtheria, croup, and poliomyelitis, in addition to using it as an adjunct for tracheal intubation and administration of inhalational anesthesia.

The currently used technique for open tracheostomy was accurately described in 1909 by the American surgeon Chevalier Jackson (1865-1958), who emphasized the importance of postoperative care to reduce morbidity and mortality. More recently, percutaneous approaches based on the Seldinger technique have also become popular. These were first described by Sheldon and Pudenz in 1957. In 1985, Ciaglia described the technique of serial dilatations using a set of seven progressively larger sized dilators in order to establish the stoma for the tracheostomy tube. In 1989, Griggs et al. described a single-step dilator technique and, in 1997, Fantoni et al. described the retrograde percutaneous translaryngeal tracheostomy. Other techniques have since been described and each has its proponents and opponents.

SURGICAL ANATOMY

Understanding the surface anatomy of the trachea, shown in Figure 6.1, is essential when performing tracheostomy. In the neck, it is a superficial structure, allowing easy palpation of the superior thyroid notch, cricoid cartilage, tracheal rings, and suprasternal notch. Also palpable are the innominate artery; the carotid artery; and, when present, a goiter. The adult trachea measures 10-13 cm, and its upper half lies above the suprasternal notch. However, in obese or kyphotic patients, most of the trachea may reside in the chest, making the cervical exposure of the trachea more difficult.

It is a D-shaped structure with anterior cartilaginous arch like incomplete rings and a posterior flat membranous wall. In the neck, the trachea lies posterior to the strap muscles (the sternohyoid and sternothyroid muscles) and is crossed by the thyroid isthmus at the level of the second to fourth tracheal rings. It is shrouded by the pretracheal fascia, in which the inferior thyroid veins and sometimes a midline thyroid ima artery course. Inferior to the thoracic inlet, it dives posteriorly into the mediastinum, posterior to the thymus gland, innominate vein, and innominate artery. The esophagus is intimately adjacent to the membranous wall along its entire course.

The blood supply to the cervical trachea is segmental and is derived from branches of the inferior thyroid artery that form a longitudinal plexus running laterally alongside the cartilaginous-membranous junction. Also laterally, the recurrent laryngeal nerves run in the tracheoesophageal groove. It is therefore important to avoid any lateral dissection of the trachea during this procedure.

INDICATIONS FOR TRACHEOSTOMY

In general, the indication for tracheostomy is an obstructed proximal airway, an inability to safely maintain a patent airway, or the need for long-term positive-pressure ventilation. These indications range from the elective to the emergent. Although a cricothyroidotomy is more commonly performed in an emergent setting due to it being a simpler and faster procedure, this should always be converted to a tracheostomy within 24 hours if a surgical airway is still necessary. Whenever the situation allows, a tracheostomy should be the primary surgical airway in order to avoid the potential complications of cricothyroidotomy, specifically glottic and subglottic stenosis, which are more common when a cricothyroidotomy stoma is maintained longer than 48 hours.

Common indications include:

• Prolonged ventilatory support. It is recommended to perform tracheostomy if a patient continues to require mechanical ventilation beyond 7 days in order to avoid the high incidence of tracheal strictures associated with prolonged endotracheal intubation. (Clinical judgment comes into play in deciding the optimal time to perform tracheostomy in a patient requiring prolonged mechanical ventilation. Almost two-thirds of tracheostomies are currently performed for this indication.)
  
• Glottic or subglottic obstruction, either acquired or congenital.
  
• The need for pulmonary toilet in situations with excessive bronchial secretions or in cases of vocal cord paralysis.
  
• Patients with maxillofacial trauma, at risk for upper airway obstruction, may require a temporary tracheostomy until the airway is stabilized.
  
• As an adjunct to other surgical procedures on the upper aerodigestive tract, which have the potential to produce proximal airway edema and obstruction.
  
• Hypoventilation syndromes such as spinal cord injuries, phrenic nerve paralysis, and neuromuscular disorders affecting the diaphragm and chest wall.
  
• Smoke inhalation injury and airway burns.

Contraindications to tracheostomy include any medical condition contraindicating surgery such as uncontrolled coagulopathy or hemodynamic instability. Patients who require high levels of inspired oxygen, significant positive end-expiratory pressure or have high peak airway pressures may not tolerate a procedure possibly associated with a period of apnea until establishing an airway. Such patients should be stabilized and optimized before an elective tracheostomy.

The indications for percutaneous tracheostomy are the same as those already listed. However, relative contraindications to the percutaneous technique include emergent situations and being a member of the pediatric population.

PROCEDURE

There are two surgical options for creation of a tracheostomy: open and percutaneous. The decision on which one to use depends on several factors including surgeon preference.

Open technique (see Figures 6.2 through 6.6)

LOCATION FOR THE PROCEDURE

The procedure is typically performed in the operating theater.

POSITION

The ideal position is supine with the neck hyperextended, which is achieved by placing the patient on a shoulder roll. This maximizes delivery of the proximal trachea into the neck and allows excellent exposure of the tracheal cartilages.

THE TUBE (SEE FIGURE 6.7)

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