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Key Points
■ Although described in numerous historic texts, tracheotomy did not become a routine surgical
procedure until the late nineteenth to early twentieth century.
■ Indications for tracheotomy include relief of airway obstruction, access for head and neck surgery,
pulmonary toilet, and need for prolonged mechanical ventilation.
■ Tracheotomy decreases the risk of laryngeal trauma from translaryngeal intubation, decreases the
need for sedation in ventilated patients, and promotes an earlier return to oral feeding and
communication.
■ Early tracheotomy (days 1 through 4) does not significantly impact morbidity, mortality, the
incidence of ventilator-associated pneumonia, or the length of intensive care unit stay compared
with late tracheotomy (>10 days).
■ Percutaneous dilational tracheotomy is a safe, expedient alternative to open tracheotomy that can
be performed in the intensive care unit.
■ Proper tube selection depends upon the individual patient’s anatomy and ventilatory requirements.
■ Multidisciplinary teams and protocols for tracheostomy care decrease morbidity, promote earlier
decannulation, and improve the quality of life in tracheostomy patients.
95
96 PART II | GENERAL OTOLARYNGOLOGY
for prolonged intubation were randomized to receive trache- the early tracheotomy cohort spent an average of 45% less time
otomy at either 3 days or 7 to 14 days after intubation. Thirty on mechanical ventilation, and the mean ICU stay was short-
patients were assigned to each group, and researchers found ened by 34% in the early tracheotomy group. The incidence
no difference in the primary end point (ICU length of stay) of VAP and overall mortality did not differ significantly.39 A
between the early group (17 days) and the standard group (18 follow-on review of seven randomized control trials that involved
days). The overall use of sedatives and narcotics for the early a total of 1044 patients who required mechanical ventilation
group (42% and 64%, respectively) was significantly lower than showed that patients who received an early tracheotomy (2 to
in the standard group (62% and 75%, respectively). 8 days) did not have reduced short-term mortality (RR 0.86),
long-term mortality (RR 0.84), or decreased incidence of VAP
(RR 0.95). The timing of tracheotomy was not associated with
CARDIOTHORACIC PATIENTS a statistically significant reduction in duration of mechanical
Tracheotomy in patients after cardiac surgery is controversial ventilation or sedation, nor did patients spend less time in the
largely because of concerns for sternal wound infection from ICU or have shorter hospital stays.40
contaminated tracheal secretions and the potential for medias- In an attempt to resolve some of these questions, the Inten-
tinitis. A review of 228 adult patients who had either early tra- sive Care Society of the United Kingdom completed a large,
cheotomy (<10 days) or late tracheotomy (14 to 28 days) during multicenter, prospective randomized trial that involved venti-
recovery from coronary artery bypass or valve surgery did dem- lated patients in 2009. Although the full results of the Trache-
onstrate decreased mortality (21% vs. 40%) and decreased ostomy Management in Critical Care (TracMan) trial had not
length of ICU stay (mean difference, 7.2 days). Interestingly, the yet been published at the time of this printing, initial data were
rate of sternal wound infection was found to be less in the early presented at the Twenty-Ninth International Symposium of
tracheotomy group (6% vs. 20%), which raises the question as Intensive Care and Emergency Medicine. In this study, 909
to the real risk of infection in this population.34 patients were identified who were expected to require intu-
Attempts to resolve the wound-infection question have been bation for more than 7 days. Patients were randomized to tra-
fraught with conflicting data. A 2008 study from the United cheotomy early (day 1 to 4) or late (>10 days). This trial
Kingdom looked at 7002 consecutive cardiothoracic surgery demonstrated no significant difference in the length of ICU
patients, and 1.4% of the patients ultimately had a percutane- stay, length of hospitalization, or incidence of pneumonia. The
ous tracheostomy for respiratory failure. The incidences of only significant difference identified between groups was a
deep (9% vs. 0.7%) and superficial sternal infections (31% vs. reduction of sedation requirement by 2.6 days in the early
6.5%) were found to be significantly higher among tracheos- tracheotomy cohort.41
tomy patients. Ultimately, percutaneous tracheostomy was iden-
tified as an independent predictor for deep sternal wound
infection.35
OPEN TRACHEOTOMY
A retrospective analysis of 5095 patients from 2009 identi- Strictly speaking, tracheotomy is the creation of an opening in
fied 57 patients who required tracheotomy after cardiac surgery, the anterior tracheal wall. Tracheostomy, on the other hand, is
none of whom developed mediastinitis. Ten patients did the formalization of a permanent stoma by suturing the edges
develop sternal infection, but the bacteria isolated from these of the trachea to the skin. Over the years, these terms have
infections were different than those isolated from tracheal come to be used synonymously. Whereas open tracheotomy is
secretions. Additionally, no correlation was found between the typically performed in the operating suite, in select patients,
time of tracheotomy and the development of these infections. the procedure can be performed at bedside in the ICU.
The authors concluded that no demonstrable link existed If no contraindication exists, the patient should be posi-
between early tracheostomy after sternotomy and mediastini- tioned with the neck in extension. This elevates the larynx and
tis.36 A similar study reviewed over 2800 cardiothoracic surgery brings up to 50% of the proximal trachea into the neck. Anti-
patients and identified 252 patients who had postoperative biotics should be given preoperatively for prophylaxis against
respiratory failure, and 108 patients ultimately received a tra- skin pathogens. Prior to proceeding, the surgeon should palpate
cheotomy. The incidence of deep sternal wound infection was and identify the hyoid, thyroid, and cricoid cartilage. When
higher in patients with respiratory failure (5.1% vs. 1%), but performing a tracheotomy to establish an urgent airway, or
the rate of infection was similar in the tracheotomy and non- when landmarks are indistinct, a vertical incision is preferred,
tracheotomy subgroups (4.6% vs. 5.6%) of respiratory failure because the surgeon will be less likely to encounter vascular
patients. Tracheostomy was not identified as a predictor of deep structures in the midline. The vertical incision is marked from
sternal wound infection in this study.37 the inferior aspect of the cricoid and extends 2 to 3 cm inferi-
orly. In an elective tracheotomy in a patient with easily palpable
landmarks, the more cosmetically favorable horizontal incision
COMBINED PATIENT POPULATIONS can be used. A 2- to 3-cm horizontal incision should be marked
In 2005, Griffiths and colleagues38 performed a systematic at the approximate level of tracheal ring two, 1 cm below the
review of the literature that looked specifically at early versus cricoid (Fig. 7-1, A). The planned incision is injected with 1%
late tracheotomy in mixed critical care populations. Five studies lidocaine with 1 : 100,000 epinephrine, and then the patient is
were identified in which patients were randomized or “quasi- prepped and draped in a sterile fashion.
randomized.” No significant difference in mortality between Begin by dividing the skin and subcutaneous tissue with a
the two groups could be identified (RR 0.79). Additionally, the No. 15 blade. The superficial layer of the deep cervical fascia
risk of developing VAP was essentially the same between the is then divided vertically, taking care to avoid the anterior
groups. The review, however, did suggest that, in mixed popula- jugular veins and any crossing branches. The strap muscles
tions, patients who received early tracheotomy had a shorter should be divided in the midline raphe and should be reflected
duration of mechanical ventilation (mean, 8.5 days) and spent laterally (see Fig. 7-1, B). The thyroid isthmus can be mobilized
significantly less time in the ICU (mean, 15.3 days). so as to expose the anterior trachea, or it can be divided. If the
Subsequent investigations have supported some of these isthmus is divided, care should be taken to address any bleeding
findings and refuted others. In a retrospective study of 592 from the edges of the gland prior to opening the airway. The
ventilated patients, 128 patients received a tracheotomy before cricoid hook should then be used to secure the airway superi-
7 days, and 464 received a tracheotomy after 7 days. Patients in orly and anteriorly (see Fig. 7-1, C). A Kittner sponge can be
98 PART II | GENERAL OTOLARYNGOLOGY
Median raphe
Incision
A B
C
D
FIGURE 7-1. A, Favorable position of incision below the inferior border of the cricoid. B, The midline raphe of the strap muscles is divided, and the muscles
are reflected laterally. C, The cricoid hook can be used to immobilize and secure the trachea prior to entering the airway. D, The airway is entered between
rings two and three or rings three and four. The inferior ring can be secured with a suture to facilitate easy access, should the patient be accidentally decan-
nulated. (From Cohen JI, Clayman GL, editors: Atlas of head and neck surgery, Philadelphia, 2011, Elsevier.)
used to bluntly clear the remaining pretracheal fascia to allow cricoid hook is removed, and the tube is secured in four quad-
for clear identification of the tracheal rings. rants with suture in addition to tracheotomy ties.
It is imperative that the surgeon communicate with the anes-
thesiologist prior to entering the airway. In the intubated
patient, it is recommended that the cuff of the endotracheal
PERCUTANEOUS TRACHEOTOMY
tube (ETT) be let down temporarily so that it is not perforated The challenges of securing operating room time and the
when entering the airway. The tracheotomy should be created burden of transporting critically ill patients have been the
between the second and third or the third and fourth ring (see impetus behind developing a quick, safe, and reliable alterna-
Fig. 7-1, D). The airway can be entered in any number of ways tive to performing open tracheotomy. Toye and Weinstein43 first
to include vertical, horizontal, or H-shaped incisions. The described percutaneous tracheotomy using the Seldinger tech-
author prefers a horizontal incision between rings two and nique in 1969, but it was not until Ciaglia introduced the dila-
three with the creation of a Bjork flap. This inferiorly based tional percutaneous technique in 1985 that the procedure
tracheal flap was introduced by Bjork42 in 1960 to help prevent began to become more commonplace in the ICU.44
false passage when replacing a dislodged tube. It should be Not surprisingly, the greatest benefits of percutaneous dila-
noted that such flaps often result in semipermanent tracheos- tional tracheotomy (PDT) relate primarily to logistics. In 2005,
tomas that may require surgical closure after decannulation. Liao and colleagues45 reviewed their experience with 368 tra-
Once in the airway, the ETT is pulled back so that the tip of cheotomies, 190 open and 178 percutaneous. The average time
the tube is just above the opening. If necessary, this allows the from consultation to tracheotomy was 7.4 days in the PDT
tube to be quickly advanced to reestablish ventilation. The group compared with 14 days in the open-procedure group.
tracheostomy tube is then advanced through the opening in Per the cost analysis for their institution, PDT saved over $400
the airway, and the tube is connected to the ventilator circuit. per procedure by avoiding the operating room. Additionally,
Once ventilator return and end-tidal CO2 are confirmed, the minimizing the physiologic stress on already critically ill patients
7 | TRACHEOTOMY 99
is essential. A 2007 review of 339 transports of critically ill used (8.3%).51 If the patient does not have significant respira-
patients revealed that unexpected events occurred in nearly tory demands, a laryngeal mask airway can be used to improve
70% of transports. Although most of these were minor events visualization during bronchoscopy.
(tangled lines and loss of oximetry probes), 8.9% of transports Once the patient is positioned with the neck extended,
were associated with a serious event such as severe hypoten- laryngeal landmarks should be palpated, and 1% lidocaine with
sion or increased intracranial pressure.46 The speed with which 1 : 100,000 epinephrine should be used to infiltrate the skin and
a PDT can be performed in experienced hands also helps subcutaneous tissue. A 2-cm incision should be made from the
reduce the amount of time the patient is at risk for additional inferior border of the cricoid toward the sternal notch, and
procedure-related stressors. PDT has been demonstrated to be blunt dissection with a hemostat in a midline sagittal plane
anywhere between 9.847 and 25.748 minutes faster than an open should be used to dissect through the subcutaneous fat. The
surgery. bronchoscope should be advanced through the ETT, and the
tube should be withdrawn to the level of the vocal cords. Once
the trachea can be palpated, a 22-gauge seeker needle on a
GUIDELINES/CONTRAINDICATIONS saline-filled syringe should be passed between the first and
The surgeon should recognize that not all patients are good second or second and third tracheal rings. Placement in the
candidates for PDT. The procedure is contraindicated in chil- trachea should be confirmed with application of negative pres-
dren, because the collapsible, mobile trachea of the pediatric sure on the syringe and aspiration of air. The needle should
airway is difficult to localize and stabilize for safe performance also be visualized with the bronchoscope and should enter
of the percutaneous technique. Additionally, it is challenging between the 10 and 2 o’clock positions on the trachea, with 12
to adequately ventilate the patient and manage the broncho- o’clock at the anterior midline of the trachea. The location of
scope simultaneously through a pediatric ETT.49 tracheal entry is critical to prevent sidewall collapse of the
In adults, few absolute contraindications for PDT exist. Cer- trachea and subsequent stenosis. At this time, the flexible J-wire
tainly, some conditions favor an open technique.50 Midline can be passed through the needle and into the airway. A 14-Fr
neck masses can obscure landmarks and should generally be introducer dilator is used to perform the initial dilation, and
managed with an open surgery. Open tracheotomy is preferred the 12-Fr guiding catheter is then placed over the guidewire.
in the setting of significant coagulation abnormalities because The tract is enlarged with the tapered dilator, and the trache-
of the improved ability to achieve hemostasis, although the ostomy appliance is loaded on the appropriately sized intro-
ability to correct coagulopathy in an ICU setting makes this less ducer and is advanced into the airway over the guidewire/
of an issue. A high level of respiratory support (FiO2 greater guiding catheter unit under bronchoscopic visualization. Once
than 70% and positive end expiratory pressure greater than 10) in place, the guidewire, guiding catheter, and loading dilator
favors an open approach, because the need for bronchoscopy are removed.
during the procedure can make ventilation challenging. Finally,
patients with cervical spine injuries should have an open ALTERNATIVE PERCUTANEOUS
surgery to prevent unintended movement of the neck during
tracheotomy placement.
TECHNIQUES
Obese patients deserve special consideration. Whereas Several modifications have been made to the PDT technique,
obesity is not a strict contraindication to PDT, palpation of although none are currently commercially available in the
laryngotracheal landmarks can be difficult in a thick neck; United States. One technique uses the Griggs (Portex; Hythe,
therefore surgeons should carefully consider their familiarity Kent, UK) guidewire dilating forceps over a guidewire to spread
and comfort with PDT before performing one on an obese through the soft tissue of the anterior neck and into the trachea.
patient. One review identified obesity as an independent risk The tube can then be fed over the guidewire.56
factor for postprocedure complications. Fifteen percent of The Fantoni Translaryngeal Tracheostomy Set (Mallinck-
patients with a body mass index (BMI) greater than 30 kg/m2 rodt; Mirandola, Italy) uses a retrograde method of placing a
experienced complications compared with 8% of patients with tracheotomy. A rigid, cuffed tracheoscope replaces the ETT and
a BMI of less than 30 kg/m2. More specifically, 80% of acciden- is advanced into position under bronchoscopic guidance. The
tal decannulations occurred in patients with a BMI greater than tracheoscope transilluminates the skin and allows passage of a
30 kg/m2.51 This phenomenon, however, is not unique to the guidewire that is pulled out through the mouth. Control of the
PDT technique and may be an indication for an open proce- airway is temporarily relinquished while the guidewire is secured
dure with a Bjork flap or similar technique to mitigate this risk. to a cuffed cannula. The cannula is pulled past the larynx and
through the anterior tracheal wall while applying counterpres-
sure to the neck. The cuffed end of the cannula is directed
TECHNIQUES distally down the trachea. Once in place, the flange can be
The most commonly used technique for PDT was first described applied, and the patient is ventilated through the cannula.57
by Ciaglia and colleagues.52 In this technique, a guidewire is The PercuTwist Kit (Rusch-Teleflex Medical; Kernen,
passed between the first and second or second and third tra- Germany) uses a single-dilator technique.58 A catheter needle
cheal rings. Sequential dilation using graduated dilators is used to pass a J-tipped guidewire into the airway. The PercuT-
(Ciaglia Percutaneous Tracheostomy Introducer Set; Cook wist device, which resembles a large screw, is introduced over
Medical, Inc., Bloomington, IN) over a guidewire creates a the wire. As it is twisted in a clockwise fashion, it engages the
passage through which a tracheostomy tube can be placed. tracheal wall, pulling it anteriorly while dilating the opening
Serial dilation has been replaced by use of a single tapered into the trachea. The device is removed, and a 9.0 tube is place
dilator with a hydrophilic coating (Ciaglia Blue Rhino Percu- with the aid of an insertional dilator.
taneous Tracheostomy Introducer Kit, Cook Medical), which
allows for faster dilation and less instrumentation.53
Although PDT can be performed blindly, it is now generally
TRACHEOSTOMY TUBES
executed with videobronchoscopic assistance.54 This primarily Selection of the proper tube depends on a number of factors
serves to protect the posterior membranous wall of the trachea.55 that include lung mechanics, patient anatomy, and communica-
The overall complication rate is higher when bronchoscopic tion needs.59 Metal tubes made of silver or steel offer the benefit
guidance is not used (16.8%) versus when bronchoscopy is of a low profile but lack a 15-mm connector and cuff and are,
100 PART II | GENERAL OTOLARYNGOLOGY
therefore, not suitable in patients who require mechanical ven- (horizontal) are designed to accommodate the obese neck or
tilation.60 Plastic tubes made of silicone or polyvinyl chloride neck masses that displace the trachea posteriorly. Tubes with
come in a variety of shapes and sizes, with and without cuffs, extra distal length can be used to bypass areas of stenosis or
and most have the ability to be connected to ventilator malacia distal to the stoma. If prefabricated tubes with extra
circuits. length do not meet a patient’s particular needs, flexible adjust-
Tube configurations are defined by the inner diameter (ID), able flange tubes can also be used to customize the length of
outer diameter, length, and curvature of the appliance (Table the tube. Once the ideal length is determined, a custom tube
7-1). In dual-cannula systems, the ID refers to the diameter of can be constructed to fit individual specifications.
the inner cannula. The ID of single-cannula tube systems is Uncuffed tubes are ideal for patients who do not require
determined by the ID of the tube itself. The ID of the tube mechanical ventilation. These tubes can bypass upper airway
determines airflow. If the ID is too small, resistance through obstruction, allow for pulmonary toilet, and accommodate
the tube increases and has an impact on the work of breathing. speech. Cuffed tubes, on the other hand, are designed to facili-
The estimated resistances through size 4, 6, 8, and 10 Shiley tate positive-pressure ventilation. Most cuffs are designed to be
tubes are 11.4, 3.96, 1.75, and 0.69 cm H2O/L/s, respectively.61 high-volume/low-pressure cuffs to help mitigate the risk of
The smallest diameter tube that meets the patient’s needs tracheal stenosis. Tracheal mucosa capillary perfusion pressure
should be selected. is approximately 25 to 30 mm Hg. Cuff pressures above that
It is imperative to select a tube that conforms best to each can result in ischemic necrosis, which leads to stenosis. Low-
patient’s anatomy to avoid complications from obstruction or volume/high-pressure (tight-to-shaft [TTS]) and foam cuffs are
accidental decannulation. Tubes with extra proximal length used less frequently. TTS tubes are ideal for patients who need
only intermittent positive pressure; the low profile of the cuff,
once deflated, allows for easier speech.60 Of note, silicone TTS
tubes should be filled with sterile water during periods that
TABLE 7-1. Common Tracheostomy Tube Sizes require cuff inflation, because air diffuses through the cuff.
ID (mm) OD (mm) Length (mm)
Shiley Disposable Inner Cannula COMPLICATIONS
Size 4 5.0 9.4 62 (cuff)/65 (no cuff) Although a seemingly routine procedure, tracheotomy is not
Size 6 6.4 10.8 74 (cuff)/76 (no cuff) without risk. A 2006 review revealed the overall complication
Size 8 7.6 12.2 79 (cuff)/81 (no cuff)
rate for tracheotomy to be 3.2%. Mortality rate from procedure-
related complications is approximately 0.6%. Complication
Size 10 8.9 13.8 79 (cuff)/81 (no cuff) rates were higher in patients with upper airway infections,
Portex Flex Disposable Inner Cannula obesity, paralysis, and congestive heart failure. Mortality was
Size 6 6.0 8.5 64 also higher in patients with cardiac conditions (>25%) than in
patients with trauma (6% to 11.5%) or pulmonary infection
Size 7 7.0 9.9 70 (5.7%).62
Size 8 8.0 11.3 73 Complications of tracheotomy can be classified as early (<7
Size 9 9.0 12.6 79 days) or late (>7 days; Table 7-2).
Size 10 10.0 14.0 79
Shiley XLT Proximal Extension
INTRAPROCEDUREAL COMPLICATIONS
Size 5 5.0 9.6 20 P, 33 D
Airway Fire
Size 6 6.0 11.0 23 P, 34 D
The initiation and propagation of fire requires three things:
Size 7 7.0 12.3 27 P, 34 D 1) a fuel source, 2) an energy source, and 3) an oxidizing
Size 8 8.0 13.3 30 P, 35 D source. Although surgical fires are rare during tracheotomy, all
Shiley XLT Distal Extension of the essential elements are present, and tracheotomy is the
most common procedure being performed at the time of an
Size 5 5.0 9.6 5.0 P, 48 D
airway fire. The drapes, ETT, and alcohol-based antiseptics are
Size 6 6.0 11.0 8.0 P, 49 D all potential fuel sources. Cautery and oxygen or nitrous oxide
Size 7 7.0 12.3 12 P, 49 D provide the activation energy and oxidizing agents, respec-
tively.63 Care should be taken to keep the concentration of
Size 8 8.0 13.3 15 P, 50 D
inspired oxygen as low as the patient will safely tolerate, ideally
Portex Extra Horizontal Length below 40% when electrosurgical instruments are in use. The
Size 7 7.0 9.7 18 surgeon should discontinue the use of electrosurgical instru-
Size 8 8.0 11.0 22 ments upon entry into the airway to eliminate the risk of fire.
Size 9 9.0 12.4 28 Bleeding
Portex Extra Vertical Length Intraoperatively, most bleeding is secondary to anterior jugular
Size 7 7.0 9.7 41.0 vein injury or from the bleeding edge of the thyroid. This can
usually be easily controlled, but care should be taken with the
Size 8 8.0 11.0 45.0
use of cautery, particularly in the setting of enriched oxygen
Size 9 9.0 12.4 48.0 delivery.
Size 10 10.0 13.8 52.0
Pneumothorax/Pneumomediastinum
Modified from Hess DR: Tracheostomy tubes and related appliances.
Resp Care 2005;50(4):497-518; Adult Tracheostomy, www.covidien.com; Pneumothorax and pneumomediastinum are uncommon after
and Portex Tracheostomy Tubes, www.smiths-medical.com/catalog/ tracheotomy. Potential mechanisms include direct injury to the
portex-tracheostomy-tubes. pleura, dissection of air along the trachea, or rupture of an
D, distal; ID, inner diameter; OD, outer diameter; P, proximal. alveolar bleb.64 The incidence of radiographic pneumothorax
7 | TRACHEOTOMY 101
TABLE 7-2. Reported Range in Adverse Effects in false passage of the tube into the soft tissues of the neck.
Associated with Tracheostomy from Randomized Trials Unrecognized, this can lead to pneumothorax, pneumomedi-
Comparing Percutaneous and Open Surgical Techniques astinum, and respiratory distress. If the tube cannot be success-
fully placed through the tracheotomy, translaryngeal intubation
Incidence (%) should be attempted. Special care should be taken in patients
Complication PDT Open who had PDT, because the tract can be quite tight. If patients
are accidentally decannulated before 7 days, it is recommended
Intraprocedural
that they be intubated from above rather than by an attempt
Paratracheal insertion 0-4 0-4 to replace the percutaneous tube emergently. Once the airway
Posterior wall laceration 0-13 NA is secure, a percutaneous kit can be used to replace the tube in
Early (<7 days)
a controlled fashion.
Bleeding
Minor 10-20 11-80
Major 0-4 0-7 LATE COMPLICATIONS
Pneumothorax <1 0-4 Tracheal Stenosis
Subcutaneous emphysema 0-5 0-11 When cuff pressure exceeds capillary perfusion pressure, the
result is ischemic necrosis and chondritis of the underlying
Airway fire <1 <1
tracheal cartilages. High-volume, low-pressure cuffs have been
Accidental decannulation 0-5 0-15 designed to mitigate this risk. The tip of a poorly positioned
Stoma infection 0-10 11-80 tube can also damage the tracheal mucosa. Such trauma can
Loss of airway 0-8 0-4 potentially lead to tracheal and/or subglottic stenosis. It is
unclear whether PDT or open tracheotomy is more likely to
Late (>7 days) cause stenosis (24% to 58% vs. 7% to 63%, respectively),68,69 but
Tracheal stenosis 7-27 11-63 the incidence of clinically relevant stenosis is low in either case.
Tracheomalacia 0-7 0-8 Stenoses from PDT are unique in that they are characterized
by a corkscrew pattern that is morphologically distinct. This is
Tracheoesophageal fistula <1 <1 thought to be due to disruption and fracture of the tracheal
Tracheoarterial fistula <1 <1 rings.70 Using tapered tracheostomy appliances, proper anterior
Delayed stoma closure 0-39 10-54 location of the tracheotomy and use of the smallest possible
tracheostomy tube are recommended to help reduce this risk.
From Delaney A, Bagshaw SM, Nalos M: Percutaneous dilatational
tracheostomy vs surgical tracheostomy in critically ill patients: a sys- Tracheo-innominate Fistula
tematic review and meta-analysis. Crit Care 2006;10:R55.
PDT, percutaneous dilational tracheotomy. Tracheo-innominate fistula occurs in about 0.7% of patients in
both acute (<2 weeks)71 and chronic (>2 weeks)72 settings. A
sentinel bleeding event often, but not always, precedes massive
hemorrhage. Prompt recognition and treatment of the condi-
in one large study was 4.3%. However, only 3 out of 255 patients tion are required to prevent asphyxiation and exsanguination.
required any sort of intervention, and this decision was made Any patient with severe bleeding should undergo tracheobron-
solely on clinical grounds.65 As such, in the absence of clinical choscopy. In 78% of cases, the event occurs between 3 and 4
findings, routine chest radiography is not indicated after weeks after tracheotomy.73 Risk factors include low placement
tracheotomy. of the tracheostomy, malnutrition, radiation, steroid usage,
and hyperextension of the head. Immediate attention to
establishing an airway with an ETT that bypasses or tamponades
EARLY COMPLICATIONS the fistula is the first priority. Traditionally, definitive treatment
is via median sternotomy with ligation of the innominate
Infection artery.74-76 This emergent surgery, however, carries an approxi-
Tracheotomy site infections occur in approximately 6.6% of mately 50% mortality rate.77 Successful outcomes with endovas-
patients. The incidence has been shown to be less in PDT com- cular treatment have been reported78,79 but carry the concerns
pared with open tracheotomy. Local wound care and antibiotics of placing a stent in a potentially contaminated field.
are usually adequate to resolve the problem.
Tracheoesophageal Fistula
Tube Obstruction Tracheoesophageal fistula occurs in less than 1% of patients
Tracheotomy bypasses the natural warming and humidification who undergo tracheotomy. The risk of fistula formation
provided by the nasal passages. The result is desiccation of the through the party wall is increased when a large-bore nasogas-
tracheal mucosa with decreased mucociliary function.66 As a tric tube is also in place.80 Although stenting to bypass the
result, the tracheostomy tube can become obstructed with fistula is an option,81 Tracheoesophageal fistula is best managed
inspissated secretions. Frequent suctioning and routine chang- by interposition of viable tissue between the membranous
ing of the inner cannula are required initially, but the trachea trachea and the esophagus.82
eventually adapts. Additionally, the tube can be poorly posi-
tioned such that the tip abuts the membranous tracheal wall, Tracheocutaneous Fistula
which often necessitates a different size or style of tube. Of patients who have a tracheotomy tube in place for more
than 4 months, 70% will have a persistent tracheocutaneous
Accidental Decannulation fistula as a result of epithelialization of the tract.83 A history of
Accidental decannulation has been associated with patients radiation exposure or the use of a Bjork flap increases the risk
with altered mental status, increased secretions, and nursing of a persistent tract after decannulation.84 Fistulae should be
shift changes.67 If decannulation occurs prior to the maturation closed because of the risk of aspiration pneumonia, skin irrita-
of the tracheotomy tract, attempts to replace the tube can result tion, and difficulties with voicing.
102 PART II | GENERAL OTOLARYNGOLOGY
TABLE 7-3. Key Statements that Achieved Consensus Regarding Tracheostomy Care
No. Statement Mean
1 The purpose of this consensus statement is to improve care among pediatric and adult patients with a tracheostomy. 8.56
2 Patient and caregiver education should be provided prior to performing an elective tracheostomy. 8.22
3 A communication assessment should begin prior to the procedure when a nonemergent tracheostomy is planned. 7.67
4 All supplies to replace a tracheostomy tube should be at the bedside or within reach. 8.78
5 An initial tracheostomy tube change should normally be performed by an experienced physician with the assistance 8.22
of nursing staff, a respiratory therapist, and a medical assistant, or with the assistance of another physician.
6 In the absence of aspiration, a tracheostomy tube cuff should be deflated when a patient no longer requires 8.22
mechanical ventilation.
7 In children, prior to decannulation, a discussion with family regarding care needs and preparation for 8.67
decannulation should take place.
8 Utilization of a defined tracheostomy-care protocol for the patient and caregiver education prior to discharge will 8.11
improve patient outcomes and decrease complications related to the tracheostomy tube.
9 Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain 8.89
with the patient at all times.
10 All patients and their caregivers should be evaluated prior to discharge to assess competency in tracheostomy care 8.89
procedures.
11 Prior to discharge, patients and their caregivers should be informed of what to do in an emergency situation. 8.89
12 In an emergency, a dislodged, mature tracheostomy should be replaced with a tube of the same size or a smaller 8.44
size or with an endotracheal tube through the tracheal wound.
13 In an emergency, patients with a dislodged tracheostomy that cannot be reinserted should be intubated (when able 8.11
to intubate orally) if the patient is failing to oxygenate or ventilate, or if there is fear that the airway will be lost
without intubation.
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