V 20TH ANNIVERSARY
1 January 1999
CE Refereed Peer Review
FOCAL POINT
★The likelihood of such
complications as luminal
stenosis, stomal stenosis, or
occlusion occurring after
tracheostomy can be minimized
by using proper surgical
technique and following correct
postoperative management.
KEY FACTS
■ Cuffed tracheostomy tubes are
only to be used for patients that
require mechanical ventilation.
■ The type of tracheal incision is
not a factor in the development
of luminal stenosis.
■ The transverse flap technique
is simple and allows easy
removal and replacement of a
tracheostomy tube.
■ Animals with permanent
tracheostomies must avoid
contact with dust, dirt, smoke,
and water-related activities.
■ Laryngeal aspiration of food,
water, or saliva has not been
reported as a problem in animals.
Vol. 21, No.
Tracheostomy
Techniques and
Management
Animal Specialty Group, Inc. Auburn University
Patricia Colley, DVM Ralph Henderson, DVM, MS
Michael Huber, DVM, MS
ABSTRACT: Tracheostomy is an important tool for managing critically ill patients or patients
with upper airway obstructions. Surgical techniques for temporary tracheostomy include
transverse flap; transverse (horizontal), vertical, and inverted ventral wall flaps; and percuta-
neous (Seldinger) procedures. Serious complications can be prevented if practitioners apply
their knowledge of tracheal anatomy, physiology, and wound healing and follow proper surgi-
cal technique and postoperative management procedures. Potential complications associated
with permanent tracheostomy include skinfold occlusion and stomal stenosis.
C
ommon emergency situations can arise when a patient’s airway quickly
becomes compromised or a critically ill patient requires long-term venti-
latory support or even permanent bypass of the upper airways. In these
situations, surgical access to the trachea (tracheostomy) and proper placement of
a tracheostomy tube are essential. Life-threatening complications can, however,
develop after the presenting problem has been resolved. This article reviews the
indications and techniques for temporary and permanent tracheostomy, tra-
cheostomy tube maintenance, and potential complications.
INDICATIONS
A temporary tracheostomy may be of short duration (6 or fewer hours) or in-
termediate duration (days to weeks). Short-duration tracheostomy is usually
used during anesthesia for surgery of the oropharynx, especially if fracture repair
requires restoration of correct dental occlusion. Intermediate-duration tra-
cheostomy is usually used to manage upper airway obstruction, injury, or tra-
cheal disruption.1–4 Tracheal obstruction may be secondary to stenosis, trauma,
or neoplastic disease.1 Torsion, vascular anomalies, and peritracheal abscesses are
causes of tracheal stenosis.1 In addition, trauma from luminal foreign bodies,
wounds, and previous surgery may result in second-intention healing and steno-
sis. Laryngotracheal neoplasms are uncommon but may cause progressive ob-
struction of the airways during growth. The more common laryngotracheal neo-
plasms include mast cell tumor, oncocytoma, adenocarcinoma, chondrosarcoma,
embryonic rhabdomyosarcoma, leiomyoma, lymphoma, osteochondroma, plas-
macytoma, polyps, and squamous cell carcinoma.5,6 Temporary tracheostomy
Compendium January 1999 20TH ANNIVERSARY
can be used to circumvent the upper airways while
awaiting remission of obstruction during radiation
therapy or during long-term ventilatory support of crit-
ically ill patients.
Indications for a permanent tracheostomy include la-
ryngeal paralysis or collapse, radiation therapy of the
upper airways or oropharynx, laryngotracheal resec-
tions, staged laryngeal reconstruction, nasal neoplasia,
or severe secretory respiratory disease.7,8 Permanent tra-
cheostomy can be either lifelong or surgically closed af-
ter resolution of the primary disease.
NORMAL TRACHEAL ANATOMY
The trachea is a semirigid, flexible air conduit that
extends from the cricoid cartilage to the tracheal carina,
where it divides to form the mainstem bronchi.9–12 The
tracheal lumen is maintained by 35 to 45 C-shaped
hyaline cartilage rings (the actual number varies by
species, breed, and individual).12,13 The width of the av-
erage canine cartilage is 4 mm at its thickest point ven-
trally and tapers dorsally. The first tracheal ring, which
is complete in dogs, resembles and is partially covered
by the cricoid cartilage.13 The remaining rings are unit-
ed longitudinally by interspersed 1-mm-wide fibroelas-
tic annular ligaments.9,12
The tracheal rings are joined dorsally by the smooth
transverse fibers of the tracheal muscle and, together
with the mucosa, submucosa, and adventitia, form the
dorsal tracheal membrane.9,10 The cervical trachea is
bounded dorsally by the esophagus (cranially) and the
longus colli muscles (caudally) and ventrally by the ster-
nohyoid muscles (cranially) and sternocephalic and ster-
nothyroid muscles (caudally).12,13 The trachea is bound-
ed laterally on both sides by large neurovascular bundles
that contain the vagosympathetic trunk, common
carotid artery, internal jugular vein, and recurrent laryn-
geal nerve (which lies outside the common sheath on
the left).12 The cervical portion of the trachea ends at the
cranial mediastinum and becomes the thoracic trachea.
The tracheal mucosa is composed of pseudostratified
ciliated columnar epithelium, which contains basal, cil-
iated columnar, goblet, and nonciliated columnar
cells.1,10,12,14 Most of the epithelium contains a ratio of
approximately five ciliated cells per goblet cell.1,10 The
submucosa contains elastic fibers, fat cells, and seromu-
cinous tubular glands,10 the latter of which can secrete
as much mucus as 40 goblet cells.1 The hyaline cartilage
rings, annular ligaments, and tracheal muscle form the
musculocartilaginous layer, whereas the adventitia is a
loosely enclosing sleeve of fascia that blends the muscu-
locartilaginous layer to surrounding connective tissue.1
The trachea is supplied by branches of the cranial
thyroid, caudal thyroid, and bronchoesophageal arter-
TRACHEAL RINGS ■ CHANGES IN TRACHEAL DIAMETER ■ INCREASED MUCUS PRODUCTION
Small Animal/Exotics
ies. The cranial and caudal thyroid arteries anastomose
in the lateral pedicles and have branches that segmen-
tally supply the ventral and lateral aspects of the tra-
chea.1 The dorsal tracheal membrane is supplied by
branches of the bronchoesophageal arteries.1 After the
arterial branches have penetrated the annular ligaments,
they arborize in the submucosa and communicate with
a dense capillary net beneath the epithelium.13,15 Venous
drainage occurs through the thyroid and internal jugu-
lar and bronchoesophageal veins.16 Lymphatic drainage
continues to the deep cervical, cranial mediastinal, me-
dial retropharyngeal, and tracheobronchial lymph
nodes.1,17
The trachea is innervated by the sympathetic system
via the sympathetic nerve trunk and the parasympa-
thetic system via the recurrent laryngeal nerve.12,13 Sym-
pathetic stimulation inhibits tracheal muscle contrac-
tion and glandular secretions, whereas parasympathetic
stimulation has an opposing action.10
NORMAL TRACHEAL PHYSIOLOGY
The primary purposes of the trachea are conduction
of air to and from the lower airways and removal of
particulate material from the bronchial tree.11 Patent
flexibility is achieved during normal cervical move-
ments by joining rigid cartilage rings with flexible an-
nular ligaments.1,11 Although tracheal diameter changes
slightly during normal respiration, the diameter of the
lumen decreases by 50% during coughing.10 This dra-
matic reduction results from tracheal muscle contrac-
tion, which reduces dead space, increases the velocity of
air, and is believed to aid in mucosal expulsion during
the cough reflex.13
Inhaled particulate material and excessive bronchial
secretions are cleared from the respiratory tract by the
mucociliary escalator (a continuous layer of mucus pro-
duced by the goblet cells and seromucinous glands) and
propelled toward the larynx by the ciliated epithelial
cells at approximately 12.6 mm/min.1,10,11 The flow of
mucus is most rapid in cats and younger dogs and is ac-
celerated when warm, dry air is inspired.2
TRACHEAL WOUND HEALING
Tracheal mucosa responds to irritation by increasing
the production of mucus.10 Trauma to only the tracheal
mucosa heals by migration, mitosis, and differentiation,
which lead to complete epithelial regeneration.1,18 As
early as 2 hours after injury, marginal epithelial cells
lose their cilia, flatten, and begin migrating across the
injury. These migrating epithelial cells, guided by the
underlying elastic lamina, secrete enzymes that dissolve
the fibrinous clot covering the denuded mucosa. Unlike
in the epidermis, migration is limited to the marginal
Small Animal/Exotics 20TH ANNIVERSARY Compendium January 1999

ciliated columnar cells. Mi- smallest Shiley® double-lu-

tosis within the basal and
columnar epithelia begins
after cell migration; thus,
the defect is covered with
transitional epithelium
within 48 to 72 hours. Dif-
ferentiation to ciliated or
goblet cells begins within 96
hours. Development of cilia
or differentiation to goblet
cells concludes mucosal re-
generation.
Linear full-thickness in- ria for the ideal tracheostomy tube. (Right) Shiley tracheosto- in patients requiring mech-
men tracheostomy tubea has
a 5-mm inner diameter and
a 9.4-mm outer diameter.
The smallest Shiley® single-
lumen tubea has a 3-mm in-
ner diameter and 4.5-mm
outer diameter.
Noncuffed tubes are used
in patients that require a by-
pass of the upper airways,
whereas cuffed trache-
Figure 1—The Shiley® tracheostomy tube (left) meets the crite-
ostomy tubes are only used
®

my tube with obturator (Mallinckrodt Medical TPI, Inc.).

juries heal similarly if the
tracheal mucosa remains in
apposition; however, loss of mucosa leads to gaps being
filled by granulation tissue, followed by wound con-
traction and epithelialization (also known as second-in-
tention healing).3,10,19 Wound contraction results in a
certain degree of circular cicatrization. Therefore, heal-
ing by second intention usually results in smaller lumi-
nal diameters.
Resection and anastomosis procedures and tra-
cheostomy invariably result in a degree of stenosis. Fac-
tors promoting tracheal stenosis include excessive ten-
sion at the surgical site, poor anastomotic apposition,
formation of granulation tissue, and infection.1,19–21 The
tension exerted on an anastomotic suture line depends
on the amount of trachea resected and the relative elas-
ticity of the trachea.1,19 The maximum tension before
tracheal disruption has been reported to be 1.7 kg for
puppies and 1.0 kg for adult dogs.22 Healing has been
associated with less inflammation and scar tissue if tra-
cheal cartilages are not compromised.23–25 Based on the
degree of luminal stenosis, many authors have conclud-
ed that the type of tracheal incision (transverse flap,
horizontal, or vertical) is not important in the develop-
ment of stenosis.24–27
TRACHEOSTOMY TUBES
Selection and Placement
Proper selection and placement of tracheostomy
tubes can affect the success of the procedure. Veterinar-
ians can select from a variety of sizes available as single-
or double-lumen and cuffed or noncuffed tubes.
Single-lumen tubes must be removed and reinserted
each time cleaning is required; double-lumen tubes are
easier to manage because the outer cannula remains in
place and the inner cannula can be removed, cleaned,
and replaced. Mucus can, however, still accumulate just
distal to the inner cannula. Small tracheas cannot ac-
commodate double-lumen tubes. For example, the
anical ventilation. A trache-
ostomy tube with a high-
volume, low-pressure cuff can minimize damage to the
tracheal mucosa and cartilage.
The ideal tracheostomy tube should measure no larg-
er than one half the diameter of the tracheal lumen, ex-
tend approximately six to seven tracheal rings, and be
made of an autoclavable material (e.g., silicone, silver,
or nylon) that is nonirritating to the trachea or be dis-
posable.4,28 The Shiley® tracheostomy tubea meets all of
these requirements and is available in various sizes (Fig-
ure 1) as either single lumen (or cannula) or double lu-
men and cuffed or noncuffed.
Proper cuff inflation is very important to minimize
pressure necrosis and subsequent tracheal stenosis. Prop-
er inflation controls the amount of air in the cuff to al-
low optimum sealing of the airway.29 Such control, called
minimal occluding volume, is achieved in patients re-
ceiving positive-pressure ventilation by gradually releas-
ing small increments of air from the cuff (0.25 to 0.5 ml)
until a small leak can be auscultated at the peak inspira-
tory pressure. This point represents the minimal occlud-
ing volume, and cuff pressure should not be altered un-
less problems develop with positive-pressure ventilation
and airway pressure cannot be maintained.29 After the
tracheostomy tube has been positioned, it should be se-
cured by tying umbilical tape around the patient’s neck.
Monitoring and Care
Tracheostomy tubes require intensive care and moni-
toring to maintain patency and prevent life-threatening
complications (e.g., tube dislodgment or occlusion
from blood and mucus). In some patients, the tube
must be suctioned every 15 minutes during the imme-
diate postoperative period whereas in others the tube
can be checked every 4 to 6 hours. Maintenance in-
volves removing and cleaning the tube or inner cannu-
la, suctioning the trachea, maintaining proper humidity
aMallinckrodt Medical TPI, Inc., Irvine, California.

TRACHEAL STENOSIS ■ TYPES OF TUBES ■ CUFF INFLATION ■ INTENSIVE CARE

Compendium January 1999 20TH ANNIVERSARY
in the patient’s airways, and cleaning the stoma.
Patients should undergo preoxygenation for at least 2
minutes before the procedure begins because tracheal
suctioning can cause hypoxemia, which can lead to myo-
cardial hypoxemia and premature ventricular contrac-
tions. In addition, because vagal stimulation from tra-
cheal irritation can cause bradycardia, patients should
have electrocardiographic monitoring during suction-
ing. Vagal stimulation can also cause gagging or vomit-
ing; therefore, the trachea should not be suctioned im-
mediately after a patient has eaten. Cats may require
more frequent monitoring of the tube because they re-
portedly have more problems with the formation of
thick mucus.
During suctioning, the inner cannula of the tra-
cheostomy tube or the entire single-lumen tube should
be removed and soaked in 2% chlorhexidine solution
and after suctioning, rinsed with sterile saline before
being replaced. Using aseptic technique, a small, sterile
suction catheter should be gently inserted through the
outer cannula. Suctioning should not begin until the
catheter is properly positioned within the tracheal lu-
men and should continue for no longer than 10 to 12
seconds. The catheter should then be rotated and with-
drawn and oxygen immediately supplied to the patient.
The procedure can be repeated if necessary but should
never be continued in patients that show excessive dis-
comfort or respiratory or cardiac changes.
A low-friction catheter made from soft pliable tubing
(e.g., suction catheter or red rubber catheter) should be
used. All catheters are measured as 6, 8, 10, 12, 14, 16,
or 18 Fr, which correspond to 2.0, 2.7, 3.3, 4.0, 4.7,
5.3, or 6.0 mm, respectively.
The airways can be humidified by instilling sterile
saline (0.2 ml/kg) into the tracheostomy tube every
hour or by nebulization. Periodic forceful bilateral com-
pression of the chest (coupage) is beneficial in clear-
ing the lower airways of patients with excessive bron-
chial secretions.
The bandage should be changed at least once a day
and the site inspected for signs of infection. The area
around the tube should be cleaned with a dilute solu-
tion of povidone–iodine or chlorhexidine and the ban-
dage (soft roll gauze) replaced to minimize tube move-
ment.
Removal
The tracheostomy tube should be removed as soon as
a normal airway has been established or when ventilation
therapy is no longer required.30 Whether the patient can
ventilate adequately without the tube can be determined
by deflating the cuff (if present), occluding the tube to
allow airflow to resume its normal passage, and monitor-
TUBE CARE ■ DAMAGE TO TRACHEAL MUCOSA ■ OCCLUSION
Small Animal/Exotics
ing ventilation.4 If air cannot flow around the tube and
occlusion causes respiratory distress, a smaller tube
should be inserted and the patient monitored. The tube
can then be removed when the patient is breathing nor-
mally with the occluded tube. The tracheostomy site
should be allowed to heal by second intention and exu-
date cleaned from the site during healing.4
Associated Complications
Complications involving tracheostomy tubes include
partial or complete obstruction, gagging and vomiting
during suctioning, subcutaneous emphysema, and tra-
cheal infection and necrosis.31 Acute complications also
include hemorrhage, damage to peritracheal neurovas-
cular structures, subcutaneous emphysema, pneumo-
thorax, and pneumomediastinum.11,26,30 Tracheal irritation
caused by the tube can lead to the formation of tracheo-
esophageal fistulas in the dorsal tracheal membrane
and/or vascular erosions and hemorrhages.32
Luminal stenosis can cause a 5% to 75% reduction
of the tracheal cross-sectional area. The tracheal mu-
cosa is extremely sensitive to injury; mucosal erosions
leading to ulceration and stricture can result after only
a few hours if the endotracheal tube cuff is over-
inflated.33 Circumferential stenosis results from damage
to the tracheal mucosa caused by inserting a trache-
ostomy tube that is too large or overinflating the cuff.
Stenosis can also result from excessive tube movement
within the tracheal lumen, which allows the tip of the
tube to damage the tracheal mucosa or cartilage rings at
the stoma. Several studies have shown that the type of
tracheal incision plays a minor role in the development
of luminal stenosis.24,26,27,34 The major factors contribut-
ing to luminal stenosis are the number of cartilage rings
damaged or removed, amount of tube motion, length
of time the tracheostomy tube was in place, and exces-
sive cuff pressure.25,33,35 Tracheal resection and/or anas-
tomosis is indicated to correct severe luminal stenosis.
TEMPORARY TRACHEOSTOMY
Temporary tracheostomy procedures involve the
transverse flap34,36; transverse (horizontal),10,11,30,37,38 ver-
tical,10,11,26,38 and inverted ventral wall flap26,38; and per-
cutaneous (Seldinger)38 techniques. The lack of a per-
manent stoma with these techniques necessitates the
use of a tracheostomy tube to maintain airway patency.
The tracheostomy tube itself acts as a foreign body and
causes inflammatory edema, increased mucus produc-
tion, and decreased ciliary movement—all of which can
lead to postoperative complications.10,12,13,32,37 In addi-
tion, partial or complete occlusion and dislodgment of
the tracheostomy tube are common life-threatening
complications.30
Small Animal/Exotics 20TH ANNIVERSARY Compendium January 1999

Transverse Flap When the tracheostomy

Advantages of the trans- tube is no longer required,
verse flap tracheostomy the transverse flap should be
include easy removal and re- secured to its normal posi-
placement of the trache- tion on the trachea using a
ostomy tube by a single in- single interrupted suture.
dividual. In addition, the The remaining wound should
procedure is technically sim- be allowed to heal by second
ple34,36 (Figure 2). intention.
The trachea should be ap- Although the original re-
proached through a 10-cm port 34 describes relocating
ventral cervical midline inci- the trachea to a more super-
sion that begins at the A ficial plane by opposing the
cricoid cartilage and extends sternohyoid muscles dorsal
caudally.34 The sternohyoid to the trachea, we did not
muscles should be retracted find this step necessary ex-
laterally to expose the tra- cept in patients with a deep
chea. After the recurrent la- trachea or excessive cervical
ryngeal nerves have been lo- B skinfolds (e.g., bulldogs).
cated, the trachea should be
isolated from the sternohy- Figure 2—The transverse flap technique involves (A) tracheal Transverse (Horizontal)
oid muscles and the esopha- incision and placement of a flap handle suture and (B) place- The transverse tracheos-
ment of a tracheostomy tube. (Inset) Suture placement in the
gus without damaging these sternohyoid muscle dorsal to the trachea. tomy consists of an incision
nerves. The sternohyoid through the annular liga-
muscles should then be reap- ment between either the
posed dorsal to the trachea third and fourth or the
at the level of the second fourth and fifth tracheal
through seventh tracheal rings 4 (Figure 3). The ap-
rings in order to deviate the proach should be made
trachea ventrally. through a ventral midline
The transverse flap can be incision that starts from the
made by incising the fifth cricoid cartilage and extends
and sixth tracheal rings lon- caudally 4 to 6 cm. 7 The
gitudinally 30 degrees to the sternohyoid muscles should
right of midline and then in- be retracted laterally to ex-
cising transversely through pose the trachea and an in-
the annular ligaments be- cision made through the an-
tween the fourth and fifth nular ligament parallel to
and the sixth and seventh and between the third and
tracheal rings. The subcuta- fourth or the fourth and
neous tissue and skin should fifth tracheal rings. The in-
be partially closed cranial cision should not extend
and caudal to the site, allow- more than half the circum-
ing at least one tracheal ring ference of the trachea.7 An
caudal and cranial to the ellipse of cartilage can be
Figure 3—A completed transverse (horizontal) tracheostomy.
flap to remain visible. excised from each tracheal
(Inset) Location of the tracheal incision.
A nonabsorbable mattress cartilage adjacent to the in-
suture should be placed cision to aid in tube place-
through the flap and should engage the skin, subcutis, ment and minimize tracheal irritation.39
cartilage, and tracheal mucosa two thirds from the base A nylon or polypropylene suture can be placed
of the flap. The suture should be loosely tied, leaving around the cartilage ring immediately cranial and cau-
the ends long enough to move the flap when the tra- dal to the incision and the ends cut long. The suture
cheostomy tube is being removed or replaced. can be used to open the tracheal incision when placing

SIMPLE, EASY TRACHEOSTOMY ■ SURGICAL APPROACHES ■ SUTURE PLACEMENT

Compendium January 1999 20TH ANNIVERSARY Small Animal/Exotics

or removing the tube. The second intention and found

sternohyoid muscles, subcu- no significant difference.
taneous tissue, and skin Anesthesia is not required if
should be reapposed after the flap is allowed to heal by
tube placement. second intention and there-
After the tracheostomy fore is ideal for patients that
tube has been removed, the cannot tolerate additional
tracheal incision should be anesthesia.
allowed to heal by second
intention. Percutaneous Tube
Percutaneous tube trache-
Vertical ostomy (also known as the
The vertical tracheostomy Seldinger technique) is cur-
approach is similar to that rently used in human medi-
for the transverse tracheosto- cine for critically ill and venti-
my except vertical tra- lator-dependent patients.
cheostomy involves a long- The technique is also used
axis ventral midline incision to access the airways during
through the third to fifth pediatric emergencies.40 Al-
tracheal rings (Figure 4). though it is not widely used
Figure 4—A completed vertical tracheostomy. (Inset) Loca-
This technique has not been tion of the tracheal incision. in veterinary medicine, per-
advocated because the tra- cutaneous tube tracheosto-
cheostomy tube can exert my may be useful when
pressure on the everted rings, resulting in mucosal rapid access to the trachea is necessary.
necrosis.2 Lidocaine should be injected into the skin over the
site and the cricoid cartilage stabilized. After the annu-
Inverted Ventral Wall Flap lar ligament between the second and third tracheal car-
The inverted ventral wall flap can be either a U or V tilage rings has been located, a saline-filled syringe with
shape and begins at the distal aspect of the fourth tra- a 14-gauge needle can be used to locate the tracheal lu-
cheal ring and then extends cranially through the annu- men (bubbles are aspirated when the needle is within
lar ligament between the second and the lumen). The needle can serve as a
third tracheal rings (Figure 5). After guide for making a 1-cm incision
the tube has been placed, the flap along the lateral side of the needle on
should be reflected outward and at- the ventral midline; a closed curved
tached to the sternohyoid muscles hemostat should be placed through
using either nylon or polypropylene the incision and into the lumen. 2
sutures. The sternohyoid muscles, The hemostat should be opened to
subcutaneous tissue, and skin should spread the incision and should allow
then be reapposed. for tracheostomy tube insertion.
When the tracheostomy tube can
be removed, the trachea can either be PERMANENT TRACHEOSTOMY
resutured or allowed to heal by sec- A permanent tracheal stoma can
ond intention. If the flap is to be re- be created in the ventral tracheal wall
sutured to its original position in the by suturing the tracheal mucosa to
trachea, sharp dissection is used to the skin. The tracheostomy can be
free the flap from surrounding tis- either lifelong or surgically closed af-
sue.38 The flap can also be freed by ter the primary disease has resolved.
blunt dissection and returned to its
normal position in the trachea with- Technique
out using sutures. Lulenski and Bat- Using the technique described by
sakis 38 evaluated luminal stenosis Hedlund,7,41 the trachea should be
when the flap was resutured and Figure 5—A completed inverted ventral approached through an 8- to 10-cm
wall flap tracheostomy.
when the flap was allowed to heal by ventral cervical midline incision by

MUCOSAL NECROSIS ■ SELDINGER TECHNIQUE ■ PERMANENT STOMA

Small Animal/Exotics 20TH ANNIVERSARY Compendium January 1999

starting at the cricoid carti- includes the application of

lage and extending the inci- A B petrolatum ointment around
sion caudally (Figure 6). the stoma to prevent the
The trachea should be iso- mucus from adhering to the
lated from the sternohyoid skin and obstructing the
muscles and the recurrent stoma.4,8 The cleaning inter-
laryngeal nerves and esopha- val gradually increases to
gus protected. The sterno- about once a day after the
hyoid muscles should then first month. Owners also
be reapposed dorsal to the need to clip the hair around
trachea using several hori- the stoma once or twice a
zontal mattress sutures, mov- month to prevent matting.4
ing the trachea to a more su-
perficial plane, and reducing Complications
the tension on the mucosa– Skinfold occlusion of the
skin anastomosis. tracheostoma is the most
Starting at the second or common long-term compli-
third tracheal ring, a rectan- cation after permanent tra-
gular segment of ventral tra- cheostomy.8 This complica-
cheal wall that measures 3 or tion occurs in animals with
4 tracheal rings in length and excessive skinfolds or sub-
one third of the tracheal di- cutaneous fat that occlude
ameter in width should be the tracheostoma. Occlu-
excised. 7,41 It is important sion can also occur when the
that the tracheal mucosa is C D neck is flexed. Tracheosto-
not penetrated. A similar seg- mies created more distally
ment of skin on each side of Figure 6—Permanent tracheostomy involves (A) a tracheal in- along the trachea have an
the tracheal defect can then cision, (B) incision in the tracheal mucosa, and (C) place- increased frequency of skin-
be excised. If the animal has ment of a suture to achieve mucosa–skin apposition. (D) A fold occlusion. 8 To mini-
loose skin or abundant sub- completed tracheostoma. mize skinfold occlusion, ad-
cutaneous fat, larger amounts ditional skin can be incised
of skin should be excised. before the skin–peritracheal
Closure begins by apposing the skin to the peritra- fascia closure during the initial procedure. Skinfold oc-
cheal fascia laterally and annular ligaments cranially clusion can also be resolved by excising elliptic-shaped
and caudally using interrupted intradermal sutures. An pieces of skin on the right, left, and cranial aspect of
I- or H-shaped incision should be made in the tracheal the tracheostoma as needed.8 A tracheostomy tube can
mucosa and the edges sutured directly to the skin. The be inserted to provide temporary relief from the ob-
remaining incision cranial and caudal to the stoma can struction.
be closed routinely. Another serious complication is obstruction of the
tracheostoma by mucous secretions, especially during
Care the postoperative period. The owner should be advised
The stoma should be inspected every 1 to 3 hours for that the animal must remain indoors in a clean envi-
accumulation of mucus during the postoperative period ronment and not be subjected to dust, dirt, cigarette
and cleaned when mucus begins to occlude the tra- smoke, or burning wood. These environmental hazards
cheostoma or causes increased respiratory effort.8 This can cause increased tracheobronchial secretions that can
interval gradually increases from every 4 to 6 hours up result in stomal obstruction.8
to every 12 hours or as necessary as healing continues As the tracheostomy site heals, some degree of stomal
to progress.8 stenosis (up to 30%) is normal. Excessive or progressive
Owners must inspect the tracheostoma on a regular stenosis can result in hypoventilation. The degree of
basis (every 4 to 6 hours during the first week) and stenosis can be minimized by using proper surgical
carefully remove any mucous secretions using a clean technique with minimal manipulation of the tracheal
moistened cottonball, swab, or gauze without disrupt- mucosa and by achieving precise mucosa–skin apposi-
ing the suture line.4 Good tracheostoma hygiene also tion.4 Complete stenosis can occur if the stoma is too

MUCOSAL–SKIN ANASTOMOSIS ■ MUCUS ACCUMULATION ■ SKINFOLD OCCLUSION

Compendium January 1999 20TH ANNIVERSARY
small (only two to three cartilage rings long); tracheal
collapse can occur if the stoma is too wide (more than
one third the tracheal circumference) or too long (more
than four cartilage rings).4 Preventing wound infection
or self-trauma is also important in reducing tra-
cheostomal stenosis and may require the use of hobbles
or paw bandages.42 Preexisting problems, such as tra-
cheal collapse or tracheomalacia, must be identified be-
fore permanent tracheostomy and corrected with an ex-
ternal ring prosthesis at the time of surgery.4
Excessive stomal stenosis requires surgical excision of
the scar tissue and possibly enlargement of the original
stoma without exceeding four rings in length and 30%
of the circumference of the trachea. All cartilage should
be covered by complete mucosal–skin apposition.42
Because cats may be more prone to develop thick
mucus in the trachea, their postoperative recovery
should be carefully monitored. They may also require
more frequent cleaning of the stoma. After the stoma
has healed, cats may experience problems with hair
growing into the stoma; owners should be advised to
keep the hair around the stoma clipped short.
Laryngeal aspiration of food, water, or saliva has not
been reported as a problem in animals. In one study,
73% of owners reported that their pets learned to
forcefully expel mucus through the tracheostoma.8 Pul-
monary infections also are not a problem if the lower
respiratory tract is not compromised.4 Aspiration pneu-
monia or drowning can occur during bathing. In addi-
tion, owners should be advised that animals with a per-
manent tracheostomy should never be allowed to swim.
CONCLUSION
Tracheostomy is an important part of surgical man-
agement for patients with upper airway disease or ob-
struction. Proper tube selection, cuff pressure, and
postoperative management can help minimize the
risks of life-threatening complications and stenosis de-
veloping after a temporary tracheostomy. Permanent
tracheostomy can provide relief from upper airway
distress and allow patients to live a near-normal
lifestyle. The basic principles of proper tissue han-
dling, wound care, and management result in mini-
mal postoperative problems.
About the Authors
When this article was accepted for publication, Dr. Colley
was affiliated with the Animal Specialty Group, Inc., Los
Angeles, California; she is currently affiliated with New-
port Harbor Animal Hospital in Costa Mesa, California. Dr.
Huber, who is affiliated with the Animal Specialty Group,
Inc. in Los Angeles, is a Diplomate of the American Col-
Small Animal/Exotics
lege of Veterinary Surgeons. Dr. Henderson is affiliated
with the Department of Small Animal Surgery, College of
Veterinary Medicine, Auburn University, Alabama; he is a
Diplomate of the American College of Veterinary Sur-
geons and the American College of Veterinary Internal
Medicine (Oncology).
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