Tracheostomy: An Airway Surgeon's Perspective

History:

• Egyptian artifacts in 3600 BC

• Sanskrit text (Rigveda) 200 BC

• Alexander the Great described saving a soldier from suffocation by making an incision with the tip of his sword in the man’s trachea

Origin of the tracheostomy I:

• 1546 – Brasavola → first successful trach

• 18th/19th century – Trousseau

  • Diphtheria epidemic

  • Better technique but mortality 75%

Origin of the tracheostomy II:

• 1909 – Chevalier Jackson → standardized tracheostomy technique performed today

• “keeping the pipes both natural & artificial clear of obstruction”

What are the indications for a tracheostomy?

• Upper airway obstruction!

  • H/N cancer

  • Airway stenosis

  • Acute upper airway obstruction

  • Craniofacial abnormalities

  • Bilateral VF paralysis

What falls under acute upper airway obstruction?

• Trauma, inability to intubate/ventilate

• Angioedema

• Infection

Pulmonary hygiene:

• inability to clear secretions/weak cough

• high aspiration risk

• patients requiring ongoing pulmonary toilet

Prolonged mechanical ventilation:

• tracheostomy allows for patient to be more “mobile”

  1. Chronic respiratory failure conditions

  2. Hypoventilation Syndromes

     • Neurological

     • Neuromuscular

What do studies suggest regarding timing of tracheostomy?

• studies suggest early tracheostomy rather than late may be beneficial

  • Terragni et al. (2010):

    • Wean off ventilator faster

    • Transferred from ICU within 28 days

    • Similar mortality

    • Not associated w/ lower rates of PNA

Tracheostomy in upper airway obstruction =

• easy

There are suggestions that early tracheostomy may:

• Improve respiratory mechanics (less resistance = faster wean off mechanical)

• Improve mobility (ETT = sedation + bed rest)

• May enhance patient psychological well-being (ETT uncomfortable)

• Also may lead to reduced duration mechanical ventilation, shorter ICU stay, reduced HAP

• Early tracheostomy may be beneficial in mobilizing patient & early ICU transfer

• Anticipation of long-term mechanical ventilation should consider tracheostomy

  • Multiple failed extubation attempts

  • Inability to wean

• Decision for tracheostomy should be a multi-disciplinary discussion

(Indications for a trach?) Severe OSA:

• Failure tolerate CPAP + unsuccessful

• surgical management

(Indications for a trach?) Central hypoventilation syndrome:

• rare autonomic failure while asleep

• Ondine’s curse

What are contraindications for a trach?

• unstable medically (peak expiratory pressures/PEEP)

• High PEEP/peak airway pressures

  • PEEP > 15, Peak > 35-40 (greater than 15 increases risk for surgical fire)

  • Alveolar collapse

• High oxygen requirements

  • Fire risk

• Coagulopathy or thrombocytopenia

  • i.e., active DIC, PLT <50, INR > 1.5, Hgb <7 (patient not clotting well, making it difficult to control bleeding)

(Surgical Airway Techniques) What is an open tracheostomy?

• open incision made in neck dissected down to trachea & tracheostomy performed

(Surgical Airway Techniques) What is a percutaneous dilatational tracheostomy?

• Performed using needle, guide wire & dilator

• An ICU favorite → most common performed

• Prolonged mechanical ventilation + not a good surgical candidate

What is a cricothyrotomy?

• NOT a “trach” by strict definition

• incision through cricothyroid membrane

• saved for emergency

• must be revised to formal trach <48 hours or when stable

• Prevent subglottic stenosis

Open vs. percutaneous:

• percutaneous carries own risks

• Technical misadventures (tracheal cartilage disruption, subglottic & tracheal stenosis, anterior jugular injury, tracheoesophageal fistula)

• Conflicting comparison studies (slight increased bleeding & wound infection w/ open)

What are percutaneous contraindications?

• airway emergency

  • cricothyrotomy or urgent tracheostomy

• Unable to palpate cricoid

  • perform per cricothyrotomy subglottic stenosis risk

• Children

  • airway too small → crush trachea

• Neck mass, high innominate

• High PEEP

What are intraoperative complications?

• hemorrhage (excess bleeding)

• pneumothorax

• pneumomediastinum

Hemorrhage:

• Risk factors:

  • thrombocytopenia

  • anticoagulation medication (reversal pre-op_

  • coagulopathy, liver disease

• Meticulous midline dissection & identifying sources of bleeding

  • anterior jugular, thyroid, high innominate (hopefully not an issue)

• Oozing postop? Surgical or packing, cuffed trach stays in until first trach change

Pneumothorax:

• violating pleure or by false passage

• children high risk → more superior lung apex

• Chest tube if > 20%

Pneumomediastinum:

• children high risk

• excessive paratracheal dissection or coughing

• asymptomatic → observation

• Both diagnosed w/ CXR

What is post-obstructive pulmonary edema?

• relieving “auto-PEEP”

  • breathing against obstruction causing positive end expiratory pressure

  • alveolar collapse when removed → edema

• Also, can be seen in children undergoing TNA for OSA

• Treatment → positive pressure + diuretics

(Intraoperative Complications) Fire:

• Alcohol prep + cautery

• High oxygen concentration + cautery

• Keep oxygen at minimum

  • If high O₂, avoid cautery when approaching airway

(Intraoperative Complications) Tracheoesophageal fistula:

• Rare in open

• Percutaneous tracheostomy → higher risk

  • “Back-wall w/ needle”

What are examples of early postop complications?

• tube obstruction

• displaced trach tube

• wound infection

• subcutaneous emphysema

Tube obstruction:

• Chevy Jackson → clean pipes!

  • Thick mucous or blood causing obstruction

    • potentially fatal

  • Postop care

    • frequent suctioning

    • humidity

    • cleaning inner cannula

    • trach change

Displaced trach tube:

• May occur at any time; can be fatal

• Obese patients high risk

  • larger neck → deeper hole

• Excessive coughing or agitation

• Should be suspected if patient develops voice

How can a displaced trach tube be prevented?

• suturing trach + foam trach tie

• maturing stoma

• stay sutures in peds or high risk

Wound infection:

• Tracheal wound colonization

  • 24-48 hours → pseudodomonas, staph, strep, E. coli

  • Biofilm

  • Reducing bacterial load

    • clean wound, change ties, de-crust

    • Regular trach tube changing

  • Perioperative antibiotics

  • Rarely, necrotic wound breakdown may occur

    • pressure ulcer + wound infection → exposed carotid

Subcutaneous emphysema:

• air “escaping” into subq tissue thru trach

  • uncuffed trach

  • excessive coughing

• usually, no treatment necessary

What are examples of late postop complications?

• Granulation tissue

• Tracheoesophageal fistula

• Tracheomalacia

• Tracheal stenosis

• Tracheoinnominate artery fistula

  • Deflate cuff & cuffless trach on POD-5-7 if not on PPV

Granulation tissue (up to 80% of all trachs):

• peristomal, suprastomal

• rates in literature 3-80% (it happens)

What are risk factors for granulation tissue?

• fenestrated trach tube, infection, GERD

• Powder from surgical gloves

What can complicate management of granulation tissue?

• bleeding, difficult changes, delayed decannulation

• obstruction!

How is granulation tissue treated?

• silver nitrate, steroid creams, abx ointments, surgical excision

Tracheoesophageal fistula:

• Overinflated cuff or too large of cuff

  • keep less than capillary pressure; i.e., <25 cm H₂O

• NG tube

  • pressure of anterior esophagus + posterior trachea = necrosis (fistula)

• PDT back → walling w/ needle

• TEF → aspiration risk

How is a tracheoesophageal fistula treated?

• NPO, open repair + tissue flap

Tracheal stenosis & tracheomalacia:

• Again, cuff pressure & trach size

• <25 cm H₂O

• > Capillary pressure = ischemia, inflammation, scar formation

• Multiple trachs or revision trachs

• Deflate cuff & cuffless trach on POD5-7 if not on PPV

Tracheoinnominate artery fistula:

• most feared complication (75% mortality)

• Erosion of anterior wall of trachea into innominate artery (brachiocephalic artery)

What are risk factors for Tracheoinnominate artery fistula?

• high innominate/low trach

• prolonged exposure (<25 cm H₂O), XL tube

• Tracheitis (erosion)

• if suspected → OVERINFLATE CUFF + suprasternal pressure, OR immediately for sternotomy & repair

Tracheostomy management:

• changing tach 5-7 days

  • allows for downsizing or replacement

  • allows for good wound care, placement of foam barrier protectants

    • duoderm (the sticky tan thing)

    • polydem (the pink foam thing)

  • Decrusting, decreasing bacterial load

  • Granulation tissue inspection

What should you do if you’re not using the cuff?

• keep cuff deflated if not using

• this is very critical!

• prevents tracheoesophageal fistula, breakdown, stenosis, -malacia

• Prevent TIA fistula!

• Transition to cuffless (if possible)

  • smallest tolerable

Humidifcation & suctioning:

• thickened secretions → why? No nose!

• Respiratory mucosa needs humidified air, having a trach bypasses nose

• Cough affected

• Bypass vocal cords, can’t generate pressure!

  • a cough is generated when there is exhalation against a closed glottis produces temporary increased pressure

• Portable suction & humidified trach collar

• Use personal saline nebs & N-acetylcysteine nebs

• look at self efficacy

(Trach Management) Decannulation:

• Step-wise approach

• Ensure primary indication is resolved for resolving

• Downsize to 4 CFS → PMV → capping trial

  • Tolerate capping for 24-48 hours = decannulate

  • Make sure doing ADLs while capped

  • Desaturations or distress? → Remove cap!

What should the SLP do when they see a tracheostomy patient?

1. Evaluate for cuff status

2. Assess phonation

3. Assess for dysphagia

4. Assess for dyspnea

Cuff Status:

• Need for positive pressure ventilation = need for cuff

• Acute hemorrhage = need for cuff

• Cuff does NOT eliminate aspiration

• Cuff does NOT replace good suctioning

(Phonation) What should the SLP consider when the patient is not tolerating PMV?

• Upper airway obstruction (B TVFI, subglottic or tracheal stenosis)

• ENT consult

• Poor pulmonary reserve, deconditioning

What are considerations for Dyspnea (shortness of breath)?

• Review trach hygiene!

• Are they cleaning inner cannula?

• Should be at least BID (2x/ day, however, varies from patient to patient based on secretions)

• Do they need an upsize?

• Is there distal obstruction?

  • Tracheomalacia, tracheal stenosis/granulation

How can a tracheostomy result in dysphagia?

• can reduce hyolaryngeal elevation!

What are considerations for dysphagia?

• Switch to cuffless trach!

• Downsize when able

• Use PMV

• Trach allows for pulmonary hygiene/pleasure feeds

Conclusions:

• Tracheostomy is a critical part of an ENT’s armamentarium

• Tracheostomy in the ICU setting may be beneficial

• Early generally preferred over later

• Many of the complications can be avoided w/ postop care

• Clean those pipes

• Cuff down, do NOT overinflate!