DEFINITIONS
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Tracheotomy refers to a procedure that creates an opening in the trachea.
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Tracheostomy refers to the opening created by tracheotomy and to the artificial airways inserted into the opening.
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An open surgical tracheotomy entails surgical dissection of pretracheal tissue with incision of the trachea to create an opening by varying techniques that include the removal or incision of anterior tracheal rings and the creation of a tracheal wall (Björk) flap. The tracheostomy tube is inserted under direct vision.
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Percutaneous tracheotomy refers to differing procedures wherein a tracheostomy tube is inserted by a guidewire Seldinger technique below the first or second tracheal rings using a dilator or a forceps-like device to cut and spread the trachea.
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Cricothyroidotomy allows insertion of an artificial airway through the cricothyroid membrane either by percutaneous or surgical techniques.
INDICATIONS
Tracheotomy is performed in critically ill patients for the following indications:
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Airway control and suctioning for patients with incompetent glottic function or poor clearance of tracheobronchial secretions;
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Functional or mechanical upper airway obstruction;
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Airway access for continuing mechanical ventilation after an initial period of translaryngeal endotracheal intubation.
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Emergency airway access:
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Some centers report high complication rates for emergency surgical tracheotomy in nonintubated patients and prefer cricothyroidotomy. Surgeons with specialized otolaryngologic skills report good outcomes with emergency tracheotomy.
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Emergency percutaneous tracheotomy has use in the emergency setting in experienced hands.
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Selection of a preferred approach for emergency airway access depends on available expertise, team-based training and drilling, and demonstrated outcomes.
SURGICAL VERSUS PERCUTANEOUS TRACHEOTOMY
Surgical tracheotomy is usually performed in the operating room but can be done in an intensive care unit (ICU) if an operating milieu is created (appropriate staff, lighting, sterility, and equipment).
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Advantages of surgical tracheotomy:
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Traditional procedure with long-term experience with techniques and outcomes.
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Low early complication rates for critically ill patients.
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Direct access to deep cervical structures to control bleeding and ensure proper placement of standard or specialized airways for patients with abnormal cervical anatomy.
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Disadvantages of surgical tracheotomy:
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Most performed in the operating room with attendant high hospital-based costs and charges and risks of patient transport.
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Procedure delays because of operating room availability.
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Stoma infection and bleeding.
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Advantages of percutaneous tracheotomy:
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Low early complication rates in the critical care setting when performed by experienced operators.
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Avoids deep neck dissections and provides a tamponading effect of the tracheostomy tube on vascular structures to decrease bleeding.
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Nonsurgeons can perform the procedure to expand available operators, increase access, and avoid operating room (OR) delays to decrease the duration of translaryngeal intubation before tracheotomy.
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Can be performed at the bedside to avoid OR-related risks of patient transport and costs.
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Few contraindications, which allows its wide application for critically ill patients.
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Disadvantages of percutaneous tracheotomy:
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Airway misplacement when performed without broncho-scopy.
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Few long-term outcome studies to define late airway complications.
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Comparative advantages and disadvantages of surgical versus percutaneous tracheotomy:
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Percutaneous tracheotomy has lower costs and delays in scheduling when compared with surgical tracheotomy performed in the operating room. Costs may be similar if surgical tracheotomy is performed at the bedside.
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Large-scale randomized studies do not exist to compare short-term and long-term outcomes between the two procedures. Available studies and meta-analyses vary in their conclusions. Recent critical appraisals suggest:
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Most clinically important complications are comparable between the two procedures.
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The overall mortality rate is similar but may be lower when percutaneous tracheotomy is compared with surgical tracheotomy performed in the operating room.
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Percutaneous tracheotomy has a lower incidence of stoma wound infection.
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Percutaneous tracheotomy has a lower incidence of clinically relevant bleeding.
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Long-term follow-up studies with comparative quality-of-life measures are few but show no differences between procedures.
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Better neck cosmesis with percutaneous tracheotomy after decannulation.
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Conclusions: Although most major outcomes appear similar between the two procedures, percutaneous tracheotomy is becoming the preferred procedure in centers with adequately skilled operators.
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Patient selection for percutaneous tracheotomy:
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Early trials of percutaneous tracheotomy excluded potentially complicated patients and proposed contraindications, such as obesity, thyroid disease, use of positive end-expiratory pressure (PEEP), and bleeding disorders, based on lack of experience with these clinical settings.
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Increased experience with the procedure indicates that few absolute contraindications exist and that only 5% of critically ill patients require an open procedure.
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Absolute contraindications include:
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Active infections over the tracheotomy site;
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Uncontrolled bleeding disorders;
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Unstable cardiopulmonary status (hypotension on pressors or extreme ventilation and oxygenation requirements that worsen with a brief interruption of ventilation or oxygenation);
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Uncontrollable patient movement or agitation.
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Inability to identify tracheolaryngeal structures due to cervical anatomic abnormalities.
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Special considerations:
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Obesity—Some reports note more complications (44% versus 18%) in obese patients, but others report no differences in outcomes.
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Repeated tracheotomy—Retrospective reviews support the safety of percutaneous tracheotomy after previous tracheotomies.
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Bleeding disorders—5% bleeding risk in thrombocytopenic patients with thrombocytopenia transfused with platelets before the procedure.
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Neutropenia—Reported safe.
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Spinal cord injury—Reported safe in trauma patients before cervical spine clearance and in those with stabilized cervical spine injuries.
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Sternotomy—No relationship exists between early tracheotomy and mediastinitis after median sternotomy.
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PEEP—Reported safe in patients with severe hypoxic respiratory failure that requires high levels of PEEP (15–20 cm H 2 O).
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SPECIALIZED TRACHEOSTOMY TUBES
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Obese patients have a deep stoma tract from skin to tracheal lumen and benefit from a long tube (extra-length tubes) with an adjustable or fixed flange ( Fig. 10-1 ). Some extra-length tubes are flexible and wire reinforced.
Figure 10-1
Extra-length tubes for placement in patients with abnormal cervical anatomy, such as obesity. The tubes may be flexible and wire reinforced with an adjustable flange ( left ) or rigid with a long intratracheal length ( right ).
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Dual-cannula tracheostomy tubes have a removable inner cannula that can be removed for cleaning.
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Localized tracheomalacia where tube cuff rests against the tracheal wall benefits from a long tube that places the cuff below the area of tracheal injury or tubes with multiple cuffs.
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Tracheostomy tubes with proximal suction ports allow aspiration of tracheal sections to lower risk of pneumonia; no data exist regarding benefit in contrast to studies with endotracheal tube suction ports.
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After removal of an inner cannula, fenestrated tubes allow breathing through the native upper airway on exhalation to promote speech. Deflation of the cuff allows breathing through the fenestrations and around the tube for patients undergoing spontaneous weaning trials.
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Pneumatic speaking tubes have ports to stream air above the cuff to allow speech.
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Many manufacturers can provide customized tracheostomy tubes to meet specialized needs with a 1-week response to requests.
AIRWAY PLACEMENT TECHNIQUES
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Surgical tracheotomy:
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Extend the neck
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1-cm incision transversely just above the sternal notch
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Blunt dissection in the midline, directly to the trachea. With a normal sized thyroid, nothing needs to be done with the thyroid
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Transverse tracheal incision to excise an 8-mm portion of the fourth tracheal ring.
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Tube size equals two thirds the tracheal diameter at level of stoma.
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Specialized dissections and excision of subcutaneous fat can be performed for obese patients.
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A Björk flap in the anterior tracheal wall can be placed to facilitate tube replacement before the stoma tract matures.
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Percutaneous tracheotomy can be performed by several techniques. Consensus and available studies do not support the superiority of one procedure over another in expert hands.
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Ciaglia Blue-Rhino—Seldinger guidewire insertion of a single progressive dilator, followed by insertion of a tracheostomy tube.
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One can visualize proper insertion of the needle/guidewire and tube in the trachea through bronchoscopy to avoid tube misplacement or perforation either of the posterior tracheal wall or the endotracheal tube.
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Ultrasound can also assist in placement of the needle or guidewire, especially in obese patients, and can aid in evaluation of the surgical site for abnormal vascular anatomy before the procedure.
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The procedure is performed in some centers as a blind technique, whereas others guide tube placement by capnography.
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Postprocedure chest radiographs are not necessary when bronchoscopy guides insertion.
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A Griggs forceps technique inserts a forceps with a groove that allows loading of a guidewire onto the forceps, which is used to dilate the trachea, thread the wire, and insert a tracheostomy tube by a Seldinger technique.
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Frova and Quintel described a single-step dilator that threads a screw-type dilator between tracheal rings.
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Fantoni described translaryngeal tracheotomy that places a tracheostomy tube in a reverse direction from within the airway through the tracheostomy tract. The procedure is commonly performed in Europe.
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TIMING OF TRACHEOTOMY IN PATIENTS ON MECHANICAL VENTILATION
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Expert opinion and limited comparative studies propose multiple potential advantages for tracheotomy as compared with prolonged translaryngeal intubation ( Table 10-1 ) :
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Enhanced patient comfort, mobilization, oral hygiene, and decreased sedative requirements.
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More secure airway, which may improve outcome for difficult-to-reintubate patients, such as those in halo fixation.
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Accelerated transfer from the ICU to intermediate care for ventilator-dependent patients.
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Some but not all studies note decreased airway resistance (inspiratory load) for patients undergoing weaning from ventilators.
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Improved airway suctioning and secretion removal.
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Avoidance of laryngeal injury from prolonged translaryngeal intubation. Nearly 90% of patients with subglottic stenosis have a history of translaryngeal intubation with a mean duration of intubation of 17 days.
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Ability to speak and feed orally.
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Decreased anatomic dead space has been proposed as an advantage, but clinical studies demonstrate no measurable change in dead space after tracheotomy.
TABLE 10-1 ▪
▪COMMONLY CITED BENEFITS OF TRACHEOTOMY
Spares larynx from direct injury
Accelerates ventilator weaning
Does not promote sinusitis
Facilitates nursing care and secretion removal
Enhances patient mobility
Provides secure airway
Facilitates transfer from the intensive care unit
Improves patient comfort
Permits speech
Facilitates oral nutrition
Improves psychological wellbeing
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Limited data exist, however, to determine the relative risks and benefits of tracheotomy as determined by duration of translaryngeal intubation to identify the ideal timing of tracheotomy.
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Studies in specific patient cohorts report conflicting results or no benefit from early tracheotomy for trauma or burn patients. Brain-injured patients may experience fewer complications and earlier weaning with early tracheotomy.
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Important clinical outcomes to establish ideal timing include mortality rate, risk of hospital-acquired pneumonia, duration of mechanical ventilation, and length of ICU stay.
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Mortality rate—Timing of tracheotomy does not appear to affect the mortality rate in general populations of patients. One recent study in medical intensive care patients with APACHE II scores greater than 25 noted a decreased mortality rate with early percutaneous tracheotomy largely due to a decreased risk of ventilator-associated pneumonia.
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Pneumonia—Timing of tracheotomy does not alter the risk of ventilator-associated pneumonia in most studies. One study of critically ill medical patients demonstrated marked decreases in pneumonia rates with early tracheotomy, but the degree of benefit appears unprecedented and requires confirmation by future studies. Other studies have observed an increase in pneumonia rates after tracheotomy.
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A Cochrane meta-analysis reported that the duration of mechanical ventilation may be decreased in patients undergoing early tracheotomy.
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The overall length of ICU stay is decreased by early tracheotomy. This outcome may represent “care shifting,” with transfer of ventilator-dependent patients to non-ICU settings or other facilities, such as long-term acute care centers. This factor may account for the increase in application of tracheotomy observed in some regions.
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It is difficult to draw conclusions regarding impact of early versus late tracheotomy because studies use different definitions of “early” versus “late,” failure to control for other important treatment variables (e.g., glucose control, sedation use, and low tidal volume ventilation), lack of blinding, small study sizes, and other inadequacies in study designs.
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Recommendations: Clinicians should base decisions for timing tracheotomy on multiple factors and individualize the decision by anticipating probable duration of mechanical ventilation and incorporating patient and family viewpoints.
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Some patients may be so critically ill (APACHE II > 25, severe head injuries, severe shock on admission, advanced underlying cardiopulmonary disease with severe trauma or severe complications of major surgery) that early tracheotomy can be performed after initial stabilization.
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Other patients should be evaluated after 5 to 7 days of intubation to anticipate the likely duration of continued ventilation. Patients who appear unlikely to achieve extubation within the next 7 to 10 days (e.g., high ongoing FIO 2 requirements in adult respiratory distress syndrome [ARDS] ) can undergo tracheotomy when stable. Other patients can be continued with translaryngeal intubation with daily assessments for extubation with recurrent consideration for tracheotomy based on subsequent course.
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Avoid “calendar watching” wherein an arbitrary duration limit for translaryngeal intubation determines timing of tracheotomy.
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