• Tracheostomy is a surgical airway obtained by incision directly through the anterior wall of the trachea, followed by insertion of a tracheostomy or endotracheal tube (ETT).
• Indications
  • Upper airway obstruction such as head or neck tumor, angioedema, epiglottitis, vocal cord dysfunction, severe sleep apnea.
  • Severe facial or nasal trauma, edema, or subcutaneous emphysema.
  • Pulmonary toilet in patients with poor control over airway secretions or inability to cough, as seen in cerebrovascular disease or muscular disorders.
  • Patients requiring long-term mechanical ventilation (especially if longer than 14 days).
  • "Cannot ventilate, cannot intubate" emergency scenario. Additionally, patients may present with an emergently placed cricothyroidotomy that needs to be converted to a more stable airway.
• Advantages of a tracheostomy tube
  • Improves breathing efficiency by reducing dead space by ~150 mL.
  • Improved comfort (bypasses oropharyngeal and hypopharyngeal gag reflexes).
  • Allows patient to talk and consume food.
  • Decreases the work of breathing
• Disadvantages of a tracheostomy tube
  • Bypasses the upper airway that normally humidifies, warms, and filters air.
  • Increased mucus production in response to dry tracheal and bronchial epithelium can occlude tracheostomy tube.
• Tracheostomy placement techniques
  • Surgical technique (ST) approach. Landmarks commonly identified include the suprasternal notch and the upper borders of the cricoid and thyroid cartilage. Local anesthetic with vasoconstrictor (to decrease bleeding) is infiltrated into the Jackson's triangle (bordered inferiorly by the suprasternal notch, laterally by the sternocleidomastoid muscles on either side, and superiorly by the cricoid cartilage). A midline vertical incision (~2–3 cm) is made from the lower border of the cricoid cartilage to the suprasternal notch (some clinicians perform a 2–3 cm transverse incision over the 2nd tracheal ring) through the skin and subcutaneous tissue. Bleeding vessels are cauterized or ligated to improve visualization and prevent blood from entering the airway. Retractors are used to aid with visualization during subsequent blunt dissection down to the tracheal ring; the thyroid isthmus often requires upward retraction. Entry into the trachea can be performed with a vertical, midline incision between the 2nd and 3rd tracheal rings to allow for insertion of an appropriately sized, lubricated tracheostomy tube. Stay sutures are inserted into the trachea, one on either side of the midline, and sutured to the skin to aid with dissection and recannulation should the tracheostomy tube become dislodged after early placement. The tracheostomy tube is secured to the skin.
  • Percutaneous tracheostomy (PCT) approach. Can be performed at the bedside in the intensive care unit (ICU) or in the operating room by a trained clinician. Benefits of PCT compared to ST are that it is cost-effective, quicker, and easier to learn; it can also be performed at the bedside and can decrease the risk associated with transporting a critically ill patient. Multiple techniques have been described in the literature. The Ciaglia technique is commonly performed; it uses a wire inserted between the 1st and 2nd or 2nd and 3rd tracheal rings as a guide over which sequential dilators are forced through the tracheal wall to create a stoma of appropriate size.

• The patient is positioned supine with the neck extended. Sterile prep is usually performed from the mandible above to the nipples below.
  • A shoulder pad placed under the patient's shoulders can be used to obtain adequate neck extension.
  • A head ring should be used to stabilize the patient's head.
  • Cervical disease or unstable spine may preclude extension and optimal positioning.

• ST approach. A standard 2–3 cm transverse or vertical incision over the 2nd tracheal ring.
• PCT approach. The skin overlying the appropriate tracheal ring is punctured with an IV catheter.

• ST: 15–35 minutes
• PCT: 5–15 minutes

Minimal

Dependent on the underlying condition. Often performed in situations that require extended mechanical ventilation.

• Surgical or PCT kit
• Tracheostomy tube
• Fiberoptic bronchoscopy for guidewire placement in Ciaglia PCT (if desired)

Incidence

One of the most commonly performed ICU procedures. Rates of tracheostomy intervention, however, vary widely in ICUs across the US due to ambiguous evidence-based studies.

Prevalence

Increasing with improved critical care.

• Intraoperative: Hemorrhage, air embolism
• Immediate postoperative: Blocked or displaced tube, pneumothorax, subcutaneous emphysema, pneumonia, tracheal infection.
• Delayed postoperative: Subglottic or tracheal stenosis, tracheocutaneous fistula, tracheal obstruction due to growth of granulation tissue, tracheoarterial fistula causing massive hemorrhage (appear to be more frequent with ST).
• Studies suggest that PCT is associated with a higher incidence of short-term complications when compared to ST. These include tracheal lacerations, tracheoesophageal fistulas, and paratracheal insertion.

Most common causes of death are hemorrhage and displaced tube.

History

• Patients typically present with upper airway obstruction, significant upper airway secretions, or the need for long-term mechanical ventilation.
• for elective tracheostomies, take a full history and discuss previous exposures to anesthesia.
• for emergency tracheostomies or those performed in the ICU, review the patient's history with particular attention to indications of hypoxemia, hypovolemia, hypotension, and acidosis.

Signs/Physical Exam

• Identify potential difficulties with placement such as obesity, short neck, subcutaneous emphysema, and edema
• Airway obstruction: Decreased breath sounds, rapid, shallow, or slowed breathing
• Cerebrovascular disease: Muscle weakness, changes in neurological exam
• Facial or nasal trauma: Bleeding from nose, eyes, mouth, lacerations, periorbital bruising, and edema

Labs/Studies

Hematocrit and coagulation factors: Consider assessment if there is clinical evidence (or suspicion) of a coagulopathy. Platelet count should be at least 50,000/µL. Patients with severe coagulopathies should not undergo a PCT.

None

• A consent form should be signed by a conscious patient for elective tracheostomies.
• Informed consent is excused (implied consent) in emergency situations involving an unconscious patient.

Prophylactic antibiotics for common skin pathogens

• ST is usually performed under general endotracheal anesthesia (in situ or de novo). In tenuous airways (e.g., upper airway obstruction), where maintenance of spontaneous ventilation is mandatory, mild or no sedation may be necessary. Vasoconstrictors are used in both circumstances.
• PCT is usually performed under general endotracheal anesthesia.

Standard ASA monitors

• Patients who require a tracheostomy for long-term mechanical ventilation often have an ETT in situ.
• Patients with upper airway obstruction or otherwise suspected difficult airway may be considered for:
  • Fiberoptic bronchoscopy and ETT placement (awake or asleep). When awake, topical anesthesia, with minimal or no sedation, and supplemental oxygen. Consider using a small ETT if tracheal compression is suspected.
  • Tracheostomy placement without placing an ETT while keeping the patient SV. Minimal or no sedation and supplemental oxygen is administered.
• In the event of a "cannot ventilate, cannot intubate" scenario consider the placement of an LMA, two-handed mask ventilation, supraglottic jet ventilation, or awakening the patient while surgical access is attained.

• Local anesthetic agents and vasoconstrictors are injected at the incisional site and subcutaneous tissue (decreases pain and bleeding via vasoconstrictors)
• If sedation with SV is performed, may be maintained with opioids, propofol, ketamine, or dexmedetomidine. These should be cautiously titrated, if used.
• General anesthesia may be maintained with inhalational or total IV anesthesia. Muscle relaxation is not necessary for surgical exposure
  • Prior to surgical entry into the trachea, the FIO₂ should be decreased, as tolerated, to avoid an airway fire (add air to fresh gas flows). Additionally, tidal volumes and peak inspiratory pressures should be noted for postoperative comparison with the newly placed tracheostomy tube.
  • Surgical entry into the trachea with a scalpel often results in puncture of the ETT cuff; may be avoided by deflation of the cuff and pulling back (not out) the ETT. In the event of a difficult or impossible reintubation, consider the use of a tube exchanger through the ETT to aid with reinsertion, if the tracheostomy becomes difficult.

• Once the tracheostomy tube is in place, the ventilator is connected. End-tidal carbon dioxide, tidal volumes, and peak pressures are confirmed to ensure proper placement.
• With the ventilator attached, the tracheostomy tube is secured with tape or ties.
• The patient is extubated if the tracheostomy tube is placed successfully.