Sunteți pe pagina 1din 11

Tracheotomy 7 

Shannon M. Kraft  |  Joshua S. Schindler

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.

cannulas were devised to help maintain the opening into the


HISTORY OF TRACHEOTOMY airway. One of the first attempts involved a short, straight
The history of tracheotomy is long and storied, its origins rooted cannula designed by Sanctorius in 1590. Unfortunately, this
in legend. The earliest accounts of a procedure resembling tra- tube sat against the common wall between the trachea and
cheotomy are found in Egyptian tablets that date back to 3600 esophagus and was prone to create fistulae.9 A curved metal
bce.1 The Rig Veda (2000 to 1000 bce), a sacred Hindu text, and tube was introduced a few years later by Julius Casserius to over-
the Ebers Papyrus of Egypt (c. 1550 bce) both allude to cutting come this issue,10 although it was never widely utilized.
the neck to access the airway.2,3 In the Greek and Roman era, Despite a growing understanding of respiratory tract
physicians and poets alike recorded accounts of opening the anatomy and physiology, tracheotomy was slow to be recog-
airway. Hippocrates was vehemently opposed to the procedure, nized as a legitimate surgery. Fear and avoidance of the proce-
citing potential risk to the carotid artery.4 The poet Homerus of dure often had dire consequences. One of the most striking
Byzantium regaled the court with stories of Alex­ander the Great, examples of this in American history involves George Washing-
who saved a fellow warrior choking on a bone by opening the ton, who awoke one morning in 1799 with a severe sore throat.
soldier’s airway with his sword.5 Galen reported that the Greek He became increasingly hoarse as the day progressed, and
physician Asclepiades had performed an elective tracheotomy doctors James Craik, Gustavus Brown, and Elisha Dick were
around 100 bce,3 but it was not until 340 ce that a firsthand called to the former president’s Virginia home. Dick, the junior
account of the surgery was recorded. The physician Antyllus of member of the group, suggested that Washington should have
Rome described making an incision at tracheal rings three and a tracheotomy to relieve the obstruction,11 but the elder physi-
four and pulling the cartilage apart with hooks to allow a patient cians disagreed with his assessment and treated Washington for
to breathe more easily.3 The outcome of this and many of the “inflammatory quinsy” in accordance with the practice of the
other surgical adventures, however, remains a mystery. era—blood letting. The president’s airway obstructed, and he
For much of the next 1500 years, tracheotomy was frowned died shortly thereafter from anemia of acute blood loss and
upon as a “semi-slaughter and a scandal of surgery.”6 The proce- what we now believe to be epiglottitis.12,13
dure was largely abandoned except in the most extreme circum- Attitudes toward tracheotomy began to change in the mid-
stances. As the Dark Ages gave way to the Renaissance, anatomists nineteenth century, when outbreaks of diphtheria in Europe
and physicians revived interest in the potential benefits of tra- resulted in numerous deaths as a result of airway obstruction.
cheotomy. In 1543, Andreas Vesalius, best known for his work De French surgeons Pierre Bretonneau and Armand Trousseau
Humani Corporis Fabrica, placed a reed into the trachea of a pig advocated for a more aggressive use of tracheotomy for airway
and demonstrated lung ventilation by blowing into it intermit- management. Trousseau14 published his experience in 1869,
tently.7 Antonio Musa Brassavola is credited with providing the noting that he had “performed the operation in more than 200
first documented successful tracheotomy; he performed the cases of diphtheria, and…had the satisfaction of knowing one-
procedure on a patient in 1546 to relieve airway obstruction fourth of these operations were successful.”
resulting from a peritonsillar abscess.8 The patient reportedly As surgeons became more confident in the procedure, they
made a full recovery. In the years that followed, trocars and began to realize potential indications for tracheotomy beyond

95
96 PART II  |  GENERAL OTOLARYNGOLOGY

management of acute airway obstruction. Friedrich Trendelen-


Box 7-1.  INDICATIONS FOR TRACHEOTOMY
burg presented a paper in 1871, in which he described using
tracheotomy to provide general anesthesia.15 In the years that Prolonged mechanical ventilation
followed, and prior to the advent of orotracheal intubation, • Respiratory disease
elective tracheotomy was used to provide airway control during • Neuromuscular disease
some surgical procedures. Chevalier Jackson’s16 work in Phila- • Depressed mental status (inability to protect airway)
Pulmonary toilet
delphia helped to standardize techniques for performing tra-
Surgical access
cheotomy and establish protocols for the care of these patients. • Head and neck cancer reconstruction
He warned against the potential pitfalls of the “high tracheot- • Extensive maxillofacial fractures
omy” (cricothyrotomy) and the associated risk of laryngotra- Airway obstruction
cheal stenosis. Jackson17 also designed a double-lumen metal • Epiglottitis/supraglottitis
tube of an anatomically appropriate length and curvature, even • Tumor
going so far as to create tubes with longer shafts that allowed • Bilateral vocal cord paralysis
tracheal obstructions to be bypassed. • Angioedema
The development of vaccines, antitoxins, and antibiotics in • Foreign body
• Blunt/penetrating neck trauma
the late nineteenth and early twentieth centuries led to
• Obstructive sleep apnea
improved medical management of many of the upper airway
infections that previously necessitated tracheotomy. In 1921,
Rowbotham and Magill18 published their work on endotracheal
intubation based on their experience with patients who sus- laryngeal stenosis. Repairing glottic level stenosis is not only
tained facial injuries during World War I. Intubation soon challenging, it comes at the risk of disrupting the swallow and/
became the preferred method for administering anesthetic or voice. By virtue of bypassing the larynx, tracheotomy results
during surgical procedures, replacing ether or chloroform in reduced laryngeal damage from local trauma to the posterior
administered by a mask,19 and tracheotomy was reserved for commissure and reduces the risk of laryngeal stenosis.28 For the
those patients who could not be intubated transorally or patient who requires long-term ventilation, another potential
transnasally. advantage of tracheotomy includes a decreased need for seda-
In the first half of the twentieth century, recurrent outbreaks tion. Anecdotally, patients report that having a tracheostomy is
of poliomyelitis in the United States resulted in the paralysis of more comfortable than translaryngeal intubation, which likely
tens of thousands of patients.20 The polio epidemic shaped the accounts for this phenomenon.29 Other advantages of trache-
evolution of tracheotomy in two ways. In those most severely otomy include the potential for early return to oral nutrition
affected by the disease, airway protection and secretion man- and communication, both of which are impeded by translaryn-
agement was compromised by pharyngeal weakness. Although geal intubation.
many of these patients could be treated with postural drainage, As to the timing of tracheotomy, great interest has been
tracheotomy was occasionally necessary for pulmonary toilet.21 shown in early transition to tracheotomy as a means to reduce
In addition to pharyngeal weakness, many patients suffered the incidence of ventilator-associated pneumonia (VAP), the
from respiratory failure as a result of paralysis of the diaphragm duration of mechanical ventilation, and the length of stay in
or disruption of medullary respiratory centers. A negative- the ICU.30 Initial guidelines regarding the timing of tracheot-
pressure ventilator, colloquially referred to as the “iron lung,” omy were quite broad. In 1989, the American College of Chest
was the primary means of assisting ventilation early on in the Physicians released a consensus statement in which translaryn-
epidemic. In the 1950s, positive-pressure ventilation machines geal intubation was recommended if fewer than 10 days of
were developed from technology devised for World War II ventilation were anticipated. If the need for mechanical ventila-
pilots.12 The combination of tracheotomy with positive-pressure tion was expected to exceed 21 days, tracheotomy was recom-
ventilation facilitated long-term ventilation in patients with mended.31 A number of studies have followed in an attempt to
bulbar polio,22 which reduced mortality in the acute phase from provide evidence to support the appropriate timing of trache-
approximately 90% to 25% by some accounts.23 otomy in different subsets of patients.
Tracheotomy continues to be a useful tool in the manage-
ment of acute airway obstruction, for the administration of
general anesthesia in select head and neck oncologic and oro-
TRAUMA PATIENTS
maxillofacial surgeries, and for pulmonary toilet (Box 7-1). In a recent meta-analysis, Dunham and colleagues queried
However, advances in critical care in the last half of the twen- databases for the Eastern and American Associations for the
tieth century have made prolonged mechanical ventilation  Surgery of Trauma and Medline, searching for studies that
the leading indication for tracheotomy in the current era.8,24,25 compared early tracheotomy (3 to 8 days) to late tracheotomy
Almost two thirds of tracheostomies are performed on intubated (>7 days). No survival benefit to performing early tracheotomy
patients in the intensive care unit (ICU),25,26 and tracheotomy is was demonstrated. The incidence of developing VAP was the
currently one of the most commonly performed operations in same between groups (relative risk [RR] 1.00, 95% confidence
the critically ill patient.27 interval). The number of days spent on mechanical ventila-
tion and the length of ICU stay was similar between groups,
although a trend was noted toward decreased ICU time and
ADVANTAGES AND TIMING decreased ventilator requirements in patients with severe brain
injuries.32
OF TRACHEOTOMY
Except in the case of impending airway obstruction, tracheot-
omy is generally performed on an elective basis. As such, con-
STROKE PATIENTS
sideration should be given to the potential advantages of The Stroke-Related Early Tracheostomy Versus Prolonged
tracheotomy over continued orotracheal intubation as well as Orotracheal Intubation in Neurocritical Care Trial (SET-
to the appropriate timing of the procedure. Evidence of laryn- POINT)33 was a prospective trial in which neurosurgical ICU
geal edema, granuloma formation, and ulceration can be seen patients who suffered from intracerebral hemorrhage, sub-
within days of intubation. Left unchecked, this can progress to arachnoid hemorrhage, or ischemic stroke with expectations
7  |  TRACHEOTOMY 97

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

patient is an appropriate candidate for a speaking valve. A


TRACHEOSTOMY CARE speaking valve should not be used unless the cuff has been
The use of multidisciplinary teams and protocols for tracheos- deflated.
tomy care can decrease morbidity, result in earlier decannula- Prior to discharge, patients and caregivers should be assessed
tion, and generally improve the quality of life of tracheostomy for competency in care for the tracheostomy and emergency
patients. 85-88 Despite being a commonly performed procedure, procedures. Caregivers should be able to identify signs of respi-
however, a paucity of peer-reviewed literature exists regard- ratory distress, and both patients and care providers should be
ing tracheostomy care. In 2011, the American Academy of able to demonstrate suctioning and cleaning of the tube, tra-
Otolaryngology–Head and Neck Surgery convened a panel of cheostomy change, and the use of all home equipment. Patients
experts for the purpose of reviewing the available literature and should be provided contact information for health care provid-
developing a consensus statement.89 The goal was to reduce vari- ers and equipment supply companies. Finally, a written instruc-
ances in practice patterns, provide recommendation for stan- tion manual should be provided prior to discharge.
dardization of care, and help reduce complications (Table 7-3).
Whenever possible, the patient and the patient’s caregivers
should be provided education regarding tracheotomy prior to
DECANNULATION
surgery.90 The panel felt that adult patients with favorable For many patients, the need for a tracheotomy is temporary.
anatomy who had had an open tracheostomy could have the When the underlying medical condition has been resolved, the
first tracheostomy tube change by physicians between days 3 patient may be evaluated for decannulation. Fiberoptic endos-
and 5, if the patient had an open tracheotomy, but that percu- copy is helpful to confirm that the glottis and subglottis are
taneous tracheostomy appliances should not be removed or adequately patent. If the patient possesses an adequate level of
changed until day 10 because of the increased risk for false alertness to protect the airway and does not require intubation
passage.90,91 Patients should have ready access to a suction for any additional procedures, an uncuffed tube is placed in
machine in the immediate postoperative period, and as soon the stoma, and the tracheostomy appliance is capped. The
as they are physically able, they should be instructed on how  patient should be able to breathe comfortably and should dem-
to clear the tube in the event of blockage with secretions.  onstrate the ability to manage and clear secretions. Addition-
With the exception of patients who have had recent free-flap ally, the patient should be able to demonstrate the ability to
reconstruction, tracheostomy ties should be used to reduce  remove the cap should difficulty in breathing develop.
the risk of accidental decannulation. Humidification should  The length of the capping trial is patient dependent and
be used for all ventilated patients and in the immediate post- can range from overnight to several weeks. Provided the patient
operative period for patients who do not require mechanical can meet criteria and can tolerate an appropriately long capping
ventilation. trial, the tube can be removed. The site should be covered with
For patients who require mechanical ventilation, the panel gauze, and pressure should be applied to the wound during
recommended that intracuff pressure be monitored and that speech and coughing to reduce airflow through the tract. The
cuffs should be maintained at the lowest pressure that allows patient should continue to observe water precautions until the
for adequate ventilation. Early involvement of the speech- tract is completely closed.89 If the tract does not close spontane-
language pathologist is encouraged to determine whether the ously, it can be closed under local or general anesthesia.

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.
From Mitchell RB, Hussey HM, Setzen G, et al: Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg 2013;148(1):6-20.
7  |  TRACHEOTOMY 103

For a complete list of references, see expertconsult.com.  McClelland RMA: Tracheotomy: its management and alternatives. Proc
R Soc Med 65:401–404, 1972.
Mitchell RB, Hussey HM, Setzen G, et al: Clinical consensus statement:
SUGGESTED READINGS tracheostomy care. Otolaryngol Head Neck Surg 148(1):6–20, 2013.
Das P, Zhu H, Shah RK, et al: Tracheotomy-related catastrophic events: Pratt LW, Ferlito A, Rinaldo A: Tracheotomy: historical review. Laryn-
results of a national survey. Laryngoscope 122:30–37, 2012. goscope 118:1597–1606, 2008.
Durbin CG Jr: Tracheostomy: why, when and how? Respir Care 55:1056– Szmuk P, Ezri T, Evron S, et al: A brief history of tracheostomy and
1068, 2010. tracheal intubation, from the Bronze Age to the Space Age. Intensive
Jackson C: Tracheotomy. Laryngoscope 19:285–290, 1909. Care Med 34:222–228, 2008.
7  |  TRACHEOTOMY 103.e1

32. Dunham CM, Ransom KJ: Assessment of early tracheostomy in


REFERENCES trauma patients: a systematic review and meta-analysis. Am Surg
1. Pahor AL: Ear, Nose and Throat in Ancient Egypt. J Laryngol Otol 72(3):276–281, 2006.
106(8):677–687, 2007. 33. Bosel J, Schiller P, Hacke W, et al: Benefits of early tracheostomy
2. McClelland RM: Tracheotomy: its management and alternatives. in ventilated stroke patients? Current evidence and study protocol
Proc R Soc Med 65:401–404, 1972. of the randomized pilot trial SETPOINT (Stroke-related Early Tra-
3. Frost EA: Tracing the tracheotomy. Ann Otol Rhinol Laryngol 85: cheostomy vs Prolonged Orotracheal Intubation in Neurocritical
618–624, 1976. Care Trial). Int J Stroke 7(2):173–182, 2012.
4. Jones WHS: Hippocrates in English. The Classical Review 2(2):88– 34. Devarajan J, Vydyanathan A, Xu M, et al: Early tracheostomy is
89, 2009. associated with improved outcomes in patients who require pro-
5. Gordon BL: The romance of medicine: the story of the evolution of medi- longed mechanical ventilation after cardiac surgery. J Am Coll Surg
cine from occult practices and primitive times, Philadelphia, 1947, FA 214(6):1008–1016, 2012.
Davis, p 461. 35. Ngaage DL, Cale AR, Griffin S, et al: Is post-sternotomy percutane-
6. Watkinson JJ, Gaz MN, Wilson JA: Tracheostomy. In Watkinson JC, ous dilatational tracheostomy a predictor for sternal wound 
Gaze MN, Wilson JS, editor: Stell and Maran’s head and neck infections? Eur J Cardiothorac Surg 33(6):1076–1079; discussion 1080–
surgery, ed 4, Oxford, UK, 2000, Butterworth Heinemann, 1081, 2008.
pp 153–168. 36. Gaudino M, Losasso G, Anselmi A, et al: Is early tracheostomy a
7. Gillespie NA: The history of endotracheal anesthesia. In Gillespie risk factor for mediastinitis after median sternotomy? J Card Surg
NA, editor: Endotracheal anesthesia, ed 2, Madison, 1946, University 24(6):632–636, 2009.
of Wisconsin Press, pp 67–84. 37. Rahmanian PB, Adams DH, Castillo JG, et al: Tracheostomy is not
8. Colice GL: Historical background. In Tobin MJ, editor: Principles a risk factor for deep sternal wound infection after cardiac surgery.
and practice of mechanical ventilation, New York, 1994, McGraw-Hill, Ann Thorac Surg 84(6):1984–1991, 2007.
pp 1–37. 38. Griffiths J, Barber VS, Morgan L, et al: Systematic review and meta-
9. Pierson DJ: Tracheostomy from A to Z: historical context and analysis of studies of the timing of tracheostomy in adult patients
current challenges. Respir Care 50:473–475, 2005. undergoing artificial ventilation. BMJ 330(7502):1243, 2005.
10. Pratt LW, Ferlito A, Rinaldo A: Tracheotomy: Historical Review. 39. Tong CC, Kleinberger AJ, Paolino J, et al: Tracheotomy timing and
Laryngoscope 118:1597–1606, 2008. outcomes in the critically ill. Otolaryngol Head Neck Surg 147(1):44–
11. Witt CB, Jr: The health and controversial death of George Wash- 51, 2012.
ington. Ear Nose Throat J 80(2):102–105, 2001. 40. Wang F, Wu Y, Bo L, et al: The timing of tracheotomy in critically
12. Sittig SE, Prignitz JE: Tracheotomy: evolution of an airway. AARC ill patients undergoing mechanical ventilation. Chest 140(6):1456–
Times 48–51, 2001. 1465, 2011.
13. Scheidemandel HH: Did George Washington die of quinsy? Arch 41. TRACMAN study. http://pslgroup.com/dg/2361ee.htm.
Otolaryngol 102(9):519–521, 1976. 42. Björk VO: Partial resection of the only remaining lung with the 
14. Trousseau A: Lectures on Clinical Medicine, vol 2, Cormack JR (trans) aid of respirator treatment. J Thorac Cardiovasc Surg 29:179–188,
London, 1869, The New Sydenham Society, p 598. 1960.
15. Mushin WW, Rendell-Baker L: Thoracic anesthesia past and present, 43. Toye FJ, Weinstein JD: A percutanenous tracheostomy device.
Springfield, Ill, 1953, Charles C. Thomas, p 44. Surgery 65:384–389, 1969.
16. Jackson CL: Tracheotomy. Laryngoscope 19:285–290, 1909. 44. Arabi Y, Haddad S, Shirawi N, et al: Early tracheostomy in intensive
17. Jackson CL: High tracheotomy and other errors: the chief  care trauma patients improves resource utilization: a cohort study
causes of chronic laryngeal stenosis. Surg Gynecol Obstet 32:292, and literature review. Crit Care 8:R347–R352, 2004.
1923. 45. Liao L, Myers J, Johnston J, et al: Percutaneous tracheostomy: one
18. Rowbotham ES, Magill I: Anaesthesia in the plastic surgery of the center’s experience with a new modality. Am J Surg 190:923–926,
face and jaws. Proc R Soc Med 14:17–27, 1921. 2005.
19. Pratt LW, Moore VJ, Marshall PJ, et al: Should T and A’s be intu- 46. Papson JP, Russell KL, Taylor DM: Unexpected events during the
bated? Laryngoscope 78:1398–1409, 1968. intrahospital transport of critically ill patients. Acad Emerg Med
20. Trevelyan B, Smallman-Raynor M, Cliff A: The Spatial Dynamics of 14(6):574–577, 2007.
Poliomyelitis in the United States: From Epidemic Emergence to 47. Freeman BD, Isabella K, Lin N, et al: A meta-analysis of prospective
Vaccine-Induced Retreat, 1910–1971. Ann Assoc Am Geogr 95(2): trials comparing percutaneous and surgical tracheostomy in criti-
269–293, 2005. cally ill patients. Chest 118:1412–1418, 2000.
21. Wilson JL: Acute Anterior Poliomyelitis. N Engl J Med 206:887–893, 48. Friedman Y, Fildes J, Mizock B, et al: Comparison of Percutaneous
1932. and Surgical Tracheostomies. Chest 110(2):480–485, 1996.
22. Andersen EW, Ibsen B: The anaesthetic management of patients 49. Moe KS, Stoeckli SF, Schmid S, et al: Percutaneous tracheostomy:
with poliomyelitis and respiratory paralysis. Br Med J 1:786–788, a comprehensive evaluation. Ann Otol Rhinol Laryngol 108:384–391,
1954. 1999.
23. West JB: The physiological challenges of the 1952 Copenhagen 50. Durbin CG: Techniques for performing tracheostomy. Respir Care
poliomyelitis epidemic and a renaissance in clinical respiratory 50(4):488–496, 2005.
physiology. J Appl Physiol 99(2):424–432, 2005. 51. Kost KM: Endoscopic percutaneous dilatational tracheotomy: a
24. Pontoppidan H, Wilson RS, Rie MA, et al: Respiratory intensive prospective evaluation of 500 consecutive cases. Laryngoscope 115:
care. Anesthesiology 47(2):96–116, 1977. 1–30, 2005.
25. Goldenberg D, Golz A, Netzer A, et al: Tracheotomy: changing 52. Ciaglia P, Firsching R, Syniec C: Elective percutaneous dilatational
indications and a review of 1130 cases. J Otolaryngol 31:211–215, tracheostomy: a new, simple bedside procedure; preliminary
2002. report. Chest 87(6):715–719, 1985.
26. Zeitouni A, Kost K: Trachesotomy: a retrospective review of 281 53. Byhahn C, Ilke HJ, Halbig S, et al: Percutaneous tracheostomy:
patients. J Otolaryngol 23:61–66, 1994. Ciaglia Blue Rhino versus the basic Ciaglia technique of percutane-
27. Scurry WC, Jr, McGinn JD: Operative tracheotomy. Oper Tech Oto- ous dilational tracheostomy. Anesth Anag 91(4):882–886, 2000.
laryngol Head Neck Surg 18:85–89, 2007. 54. Oberwalder M, Weis H, Nehoda H, et al: Videobronchoscopic
28. McWhorter AJ: Tracheostomy: timing and techniques. Curr Opin guidance makes percutaneous dilational tracheostomy safer. Surg
Otolaryngol Head Neck Surg 11(6):473–479, 2003. Endosc 18(5):839–842, 2004.
29. Blot F, Similowski T, Trouillett JL, et al: Early tracheotomy versus 55. Fernandez L, Norwood S, Roettger R, et al: Bedside percutaneous
prolonged endotracheal intubation in unselected severely ill ICU tracheostomy with bronchoscopic guidance in critically ill patients.
patients. Intensive Care Med 24(10):1779–1787, 2008. Arch Surg 13(2):129–132, 1996.
30. Durbin CG, Jr: Tracheostomy: why, when and how? Respir Care 56. Griggs WM, Worthley LI, Gilligan JE, et al: A simple percutaneous
55:1056–1068, 2010. tracheostomy technique. Surg Gynecol Obstet 170(6):543–545, 1990.
31. Plummer AL, Gracey DR: Consensus conference on artificial 57. Fantoni A, Ripamonti D: A non-derivative, non-surgical trache­
airways in patients receiving mechanical ventilation. Chest 96:178– ostomy: the translaryngeal method. Intensive Care Med 23:386–392,
180, 1989. 1997.
103.e2 PART II  |  GENERAL OTOLARYNGOLOGY

58. Westphal K, Maeser D, Scheifler G, et al: PercuTwist: a new single- 75. Grant CA, Dempsey G, Harrion J, et al: Tracheo-innominate artery
dilator technique for percutaneous tracheostomy. Anesth Analg 96: fistula after percutaneous tracheostomy: three case reports and a
229–232, 2003. clinical review. Br J Anaesth 96:127–131, 2006.
59. Sherman JM, Davis S, Albamonte-Petrick S, et al: Care of the child 76. Jones JW, Reynolds M, Hewitt RI, et al: Tracheo-innominate artery
with a chronic tracheostomy. Am J Respir Crit Care Med 161:297–308, erosion. Ann Surg 184:194–204, 1976.
2000. 77. Allan JS, Wright CD: Tracheoinnominate fistula: diagnosis and
60. Hess DR: Tracheostomy tubes and related appliances. Respir Care management. Chest Surg Clin North Am 13:331–341, 2003.
50(4):497–510, 2005. 78. Deguchi J, Furuya T, Tanaka N, et al: Successful management of
61. Mullins JB, Templer JW, Kong J, et al: Airway resistance and work tracheo-innominate artery fistula with endovascular stent graft
of breathing in tracheostomy tubes. Laryngoscope 103(12):1367– repair. J Vasc Surg 33:1280–1282, 2001.
1372, 1993. 79. Palchik E, Bakken A, Saad N, et al: Endovascular Treatment of
62. Das P, Zhu H, Shah RK, et al: Tracheotomy-related cata- Tracheoinnominate Artery Fistula: A Case Report. Vasc Endovasc
strophic events: results of a national survey. Laryngoscope 122:30– Surg 41(3):258–261, 2007.
37, 2012. 80. De Leyn P, Bedert L, Delcroix M, et al: Tracheotomy: clinical review
63. Rogers SA, Mills KG, Tufail Z: Airway fire due to diathermy during and guidelines. Eur J Cardiothorac Surg 32:412–421, 2007.
tracheostomy in an intensive care patient. Anesthesia 56:441–446, 81. Liu YH, Ko PJ, Wu YC, et al: Silicone airway stent for treating
2001. benign tracheoesophageal fistula. Asian Cardiovasc Thorac Ann
64. Berg LF, Mafee MF, Campos M, et al: Mechanism of pneumothorax 13:178–180, 2005.
following tracheal intubation. Ann Otol Rhinol Laryngol 97:500–505, 82. Macchiarini P, Verhoye JP, Chapelier A, et al: Evaluation and
1988. outcome of different surgical techniques for postintubation tra-
65. Tobler WD, Mella JR, Ng J, et al: Chest X-ray after tracheostomy is cheoesophageal fistulas. J Thorac Cardiovasc Surg 119:268–276, 2000.
not necessary unless clinically indicated. World J Surg 36:266–269, 83. Jacobs JR: Bipedicled delayed flap closure of persistent radiated
2012. tracheocutaneous fistulas. J Surg Oncol 59:196–198, 1995.
66. Epstein SK: Anatomy and Physiology of Tracheostomy. Respir Care 84. Khaja SF, Fletcher AM, Hoffman HT: Local repair of persistent
50(3):476–482, 2005. tracheocutaneous fistula. Ann Otol Rhinol Laryngol 120(9):622–626,
67. White AC, Purcell E, Urquhart MB, et al: Accidental Decannulation 2011.
Following Placement of a Tracheostomy Tube. Respir Care 57(12): 85. Garrubba M, Turner T, Grieveson C: Multidisciplinary care for
2019–2025, 2012. tracheostomy patients: a systematic review. Crit Care 13:R177,
68. Koitschev A, Simon C, Blumenstock G, et al: Suprasomal tracheal 2009.
stenosis after dilational and surgical tracheostomy in critically ill 86. Cetto R, Arora A, Hettige R, et al: Improving tracheostomy care: a
patients. Anesthesia 61:832–837, 2006. prospective study of the multidisciplinary approach. Clin Otolaryn-
69. Raghuraman G, Rajan S, Marzouk JK, et al: Is tracheal stenosis gol 36:482–488, 2011.
caused by percutaneous tracheostomy different from that by surgi- 87. Hettige R, Arora A, Ifeacho S, et al: Improving tracheostomy man-
cal tracheostomy? Chest 127:879–885, 2005. agement through design, implementation and prospective audit 
70. Jacobs JV, Hill DA, Petersen SR, et al: “Corkscrew stenosis”: Defin- of a care bundle: how we do it. Clin Otolaryngol 33:488–491,
ing and preventing a complication of percutaneous dilatational 2008.
tracheostomy. J Thoracic Cardiovasc Surg 145:716–720, 2013. 88. Garner JM, Shoemaker-Moyle M, Franzese CB: Adult outpatient
71. Jones JW, Reynolds M, Hewitt RL, et al: Tracheo-innominate artery tracheostomy care: practices and perspectives. Otolaryngol Head
erosion: successful surgical management of a devastating complica- Neck Surg 136:301–306, 2007.
tion. Ann Surg 84:194, 1976. 89. Mitchell RB, Hussey HM, Setzen G, et al: Clinical Consensus State-
72. Scalise P, Prunk SR, Healy D, et al: The incidence of Tracheoarte- ment: Tracheostomy Care. Otolaryngol Head Neck Surg 148(1):6–20,
rial Fistula in Patients with Chronic Tracheostomy Tubes: a retro- 2013.
spective study of 544 patients in a Long-term care facility. Chest 90. National Health Service (NHS): Caring for the Patient with a
128(6):3906–3909, 2005. Tracheostomy, ed 2, Edinburgh, 2007, NHS Quality Improvement
73. Sue RD, Susanto I: Long-term complications of artificial airways. Scotland.
Clin Chest Med 24:457–471, 2003. 91. Intensive Care Society: Standards for the Care of Adult Patients with a
74. Gelman JJ, Aro M, Weiss SM: Tracheo-innominate artery fistula.  Temporary Tracheostomy: Standards and Guidelines. London, 2008,
J Am Coll Surg 179:626–634, 1994. Council of the Intensive Care Society.

S-ar putea să vă placă și