Bobby R. Alford Department of
Otolaryngology-Head and Neck Surgery

Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature.

The Modern Tracheotomy
Shane Pahlavan, M.D.
January 24, 2008

This is the Michael DeBakey VA Medical Center Grand Rounds, and today’s topic of discussion will be the modern tracheotomy.  I will start with a case presentation along with some historical perspective on the tracheostomy placement, surrounding anatomy, and indications as well as some complications.  I will discuss percutaneous tracheostomies, compare different techniques, and follow-up on the case presentation and conclusion.

For the case presentation, J.K. is a 65-year-old male with a past medical history of hypertension, hypothyroidism, obstructive sleep apnea, diabetes mellitus, and atrial fibrillation who was admitted to the medical intensive care unit status post  fall with a subarachnoid hemorrhage.  He was taken off his anticoagulation at that time.  He subsequently developed an acute ischemic stroke in the left middle cerebral artery territory.  He was intubated at that time for airway protection, and he has been unable to be weaned from the ventilator since that time.  A consult was placed by the Medical Institute Care Team for evaluation for open tracheostomy placement after the patient had been intubated for 14 days.  He had no surgeries previously.  He was on multiple medications for his hypertension.  He had no allergies.  As to social history, he was just a social drinker. He did have a 25-pack year smoke history, denied any illicit drug use, and was a retired banker.  Family history was significant for coronary artery disease in both parents.  On physical exam, he was intubated and sedated at that time.  He had previously been held off sedation during tests of weaning off the ventilator, which were, as I mentioned, unsuccessful.  He did have an 8.0 endotracheal tube that was secure and in position.  His neck was supple, no lymphadenopathy.  Cricoid and thyroid cartilage were both prominent and easily palpable. 

I chose this topic and this patient primarily because I feel that, as residents in an otolaryngology profession, we really do not see much of the percutaneous technique.  I have had a couple of families, and actually this patient’s family, ask me about the pros and cons and benefits of either technique.  So, this was a learning issue for me. 

As far as tracheostomies in general, the ancient Egyptian Ebers papyrus was the first record made of the t tracheostomy back in 100 BC by Asclepiades of Bithynia.  Interestingly, during my research, I came across the story about George Washington in 1799.  George Washington passed away from an acute airway obstruction that was most likely from epiglottitis or abscess.  Washington’s physician at that time was familiar with the tracheotomy procedure, but had not actually performed one on any of his patients.  He was unwilling to do his first tracheotomy on a person of Washington’s stature, and Washington subsequently died. 

The indications for the first tracheotomy were always for airway obstruction.  As such, the procedure did carry with it significant mortality.  Until the mid-1900s, the tracheostomy continued to be only indicated for an emergent airway procedure.  Chevalier Jackson became quite a proponent for its application in 1909.  Before his work in establishing techniques, sterile technique, exposure, control of the airway, there had been about a 25% mortality rate in tracheostomies performed by Trousseau during the diphtheria age.

Just a brief mention of tracheal anatomy.  The trachea extends from the cricoid cartilage here down to the carina.  It is approximately 10cm in length in adults.  The diameter of the tracheal lumen ranges between 1.5cm and 2.5cm.  It consists of 20-25 cartilaginous rings down to the carina.  The trachea is membranous posteriorly and has cartilaginous rings anteriorly and laterally.  The space in between these rings is membranous.  An important anatomical note with regard to the trachea-innominate fistulas, is that the innominate artery crosses from the left to right anterior to the trachea at the superior thoracic and meets the sternum.  The microanatomy of the trachea consists of pseudostratified columnar cells, which you can see with numerous goblet cells and cilia.  These numerous goblet cells form a protective barrier by creating a mucosal blanket protection where inhaled dust particles are trapped and swept away from the lungs.

Tracheostomy was indicated mainly for emergent airways problems historically.  The development of endotracheal intubation changed the indications and reduced the need for emergent tracheostomy placement.  This introduced the question of proper timing for surgical intervention and mechanically ventilating the patient, which is the most prominent indication currently for tracheostomy placement. 

Controversy does exist as to the exact time to convert an endotracheal tube to a tracheostomy.  Literature states periods between three days to three weeks.  Most literature does say that prolonging endotracheal intubation past ten days does increase the severity and acuteness of the injury to the tracheal ring. 

Here are some other guidelines in mechanically ventilated patients that are generally followed.  If the anticipated need for an artificial airway for less than 10 days, generally a translaryngeal route is recommended.  If an artificial airway is needed essentially for more than 21 days, it is important to consider performing a tracheostomy at that time.  If the anticipated artificial airway is uncertain, it is important to evaluate the appropriate time to convert it to a tracheotomy.  But once that decision is made, it should be done as expeditiously possible. 

There are some indications for tracheotomy outlined by the American Academy of Otolaryngology: Upper airway obstruction (including foreign body, stridor, retraction), prolonged or expected prolonged intubations, inability of the patient to manage his/her secretions, and to facilitate ventilation support.  An inability to intubate oftentimes is an adjunct to head and neck cancer and also is an adjunct to head and neck trauma patients. 

Here are some of the complications of tracheotomy that are usually divided into immediate, early, and late. Many of the studies that I will discuss use these divisions to stratify their complications and the different techniques to perform tracheotomy.  Some of the immediate ones are apnea, hemorrhage, pneumothorax, and pneumomediastinum, injury of the adjacent structures, and postoperative pulmonary edema.  Some of the early complications are tracheal erosion, displacement of the tube, obstructions with mucus plug, subcutaneous emphysema, aspiration or lung abscess.  The late complications can be more serious and include tracheal-innominate fistula and persistent tracheocutaneous fistula. 

Benefits of tracheostomy are increased patient comfort, spared direct laryngeal injury when an endotracheal tube is in place for a prolonged period of time due to translaryngeal injury.  It also facilitates nursing care of cleaning and suctioning the trachea.  It improves the patient’s ability to communicate with the use of valve. It facilitates oral intake, which provides psychological benefit to the patient as well.  It provides a secure airway and may facilitate ICU discharge to a more long-term care setting and decreases airway resistance and aid in weaning patients from the ventilator. 

Tracheostomy technique involves quite a bit of controversy in the literature regarding the superiority of the time-heralded open tracheostomy procedure compared with the percutaneous procedure.  The important thing to realize with either technique of choice is that the selection of a particular technique should accomplish a tracheotomy tube placement based on the safest, most effective, and most efficiently stabilizing airway in critically ill patients. 

In 1969, Toye and Weinstein described a technique of tracheostomy performed percutaneously at the bedside using progressive dilation with the modified Seldinger technique.  The main advantage is that it can be performed at the bedside.  This was prior to many of the open tracheotomies being performed at the bedside.  The proponents say that the expense and logistics of transporting an acutely ill intensive care patient to the operating room would be eliminated.  Disadvantages are decreased exposure and, thus, decreased visualization and control of the airway.  Some of the principles used by the critical care specialists in performing a percutaneous tracheotomy were extrapolated from their use in vascular catheter placement, which is arteriovenous catheterization. The consequences of the complications of performing this type of procedure in the trachea and airway is that this can be more severe and long lasting and result in false passage or tracheal stenosis. 

This is a diagram of how the percutaneous tracheostomy is performed.  You can see on the left here that a large-bore needle is placed into the anterior wall of the trachea.  The guide wire is passed though the needle.  The needle is retracted back, and then sequential dilation is performed until the stoma site is large enough to accommodate the tracheal tube itself.  This is the view from above using a flexible bronchoscope. You can see the puncture site in the anterior tracheal wall that comes through with a large-gauge needle.  Once they have entered the airway, they will pass the guide wire through and remove the needle.  You can appreciate on the video how easy it is in the percutaneous technique or blind technique to accidentally side-wall the trachea or pierce the posterior tracheal wall with the needle.  There are guidemarks or hashmarks on the needle to help avoid complications, but these problems still occur and can result in tracheal stenosis in these patients.  You can see the dilator coming through and then the sequential dilation.  This is a view through the flexible bronchoscope in the tracheotomy tube showing the tube to be in proper position.

Many patients are recognized to be unfavorable candidates for this procedure.  These include individuals with morbid obesity, those with abnormal or poorly palpable midline neck anatomy, those who need emergent airways, pediatric patients, those with marked enlarged thyroid glands, and patients with coagulopathy.  Many of these will make it difficult to perform this procedure without direct visualization and adequate exposure of the anatomy. 

Kost in 2005 published a paper in Laryngoscope on 500 consecutively intubated patients in ICU that required tracheostomy placement.  When performed in conjunction with a bronchoscopy, as the video showed, their complication rate, they felt, was acceptably low at 9.2%.  There were no serious complications such as pneumothorax, pneumomediastinum, or death.  However, the two most common complications were oxygen desaturation in 14 patients (defined as a drop in oxygenation saturations less 90%), and bleeding in 12 patients that required intervention to control.  Dulguerov et al., in Critical Care Medicine Journal, presented a paper which is the most often cited article with regard to percutaneous tracheostomies.  This analysis had three different cohorts that were studied.  The open tracheostomy techniques between 1960 and 1984 were compared to the percutaneous techniques from 1985 to 1996.  Their findings showed that there were more perioperative complications with the percutaneous technique (10%) compared to the open technique (3%). Postoperative complications were more frequent with the open technique, 10% versus 7% for the percutaneous technique.  Their definition of complications has been questioned by many as the open technique was shown to have more complications postoperatively.  Their postoperative complications included cheloid formation and esthetically unpleasing scars.  Furthermore, in this study, the perioperative deaths and serious cardiopulmonary events in the percutaneous group were higher.

Freeman et al. in 2000, presented a pooled analysis on 236 patients in the journal Chest. It suggested that the percutaneous tracheostomy was comparable to that of the open tracheostomy. They found shorter overall operative times with an absolute difference 9.84 minutes favoring the percutaneous technique.  No difference with respect to overall operative complications was found.  Percutaneous technique was associated with less perioperative bleeding, lower overall postoperative complication rate, and lower incidence of stomal bleeding.

In contrast, Massick and Schuller’s prospective study cited in Laryngoscope finds favor with open tracheotomy.  The same operators performed both the open and percutaneous procedures in the ICU in a prospective, randomized fashion. Patients were randomized after meeting selection criteria for percutaneous tracheotomy.  Bedside tracheotomy criteria included: palpable cricoid cartilage at least 3cm above the sternal anglewith appropriate head extension; history of uneventful/uncomplicated translaryngeal intubation; and, positive end-expiratory pressure requirement of less than 10cm H2O.

In this series, they were found to have only a 2% complication rate for both perioperative and postoperative complications. Furthermore, strict selection criteria can serve as a possible guideline to tracheotomy outside the operating room.

To follow-up on our patient, he underwent bedside open tracheostomy without complications.   There were no perioperative or postoperative complications to date.  He was able to be weaned from the mechanical ventilator to a trach collar. He was subsequently transferred to a long-term acute care setting.

In conclusion, observance of good selection criteria may help lower complication rates for both procedures while increasing patient safety.  Perioperative complication rates are similar between the procedures and poorly performed tracheotomies, whether open or percutaneous, can have catastrophic consequences. Cost savings between the techniques are equalized by performing them in the same setting.
The medical team must be prepared for conversion to open tracheotomy when difficulty is encountered in the percutaneous technique.  The use of a team approach with a surgeon present provides the safest alternative for the patient.  Percutaneous tracheotomy does require a longer period of stomal maturation, and early dislodgment, whether accidental or with tracheotomy tube change, can having devastating consequences.  The possibility of losing control of the airway acutely and the risk of developing post-extubation tracheal stenosis chronically are intuitively greater with percutaneous tracheotomy.  Percutaneous tracheotomy has shown itself to be a useful technique in both surgical and intensive care settings, but further advances are needed before it would supplant the time-honored open technique.

Case Presentation:

JK is a 65-year-old male with PMH of HTN, hypothyroidism, OSA, DM, and atrial fibrillation admitted to the MICU status post fall with a subarachnoid hemorrhage.  He was taken off anticoagulation after his admission and subsequently developed an acute ischemic stroke in the left middle cerebral artery territory. He was intubated for airway protection and had been unable to be weaned from mechanical ventilation. Consult placed for evaluation for open tracheostomy after the patient had been intubated for 14 days.

JK underwent open tracheostomy without complication.  He has no reportable perioperative or postoperative complications to date.  He was able to be weaned from the ventilator and is now tolerating tracheotomy collar oxygenation and was able to be transferred out of the MICU.

Bibliography

Bernard AC, Kenady DE. Conventional surgical tracheostomy as the preferred method of airway management. J Oral Maxillofac Surg 1999;57:310-315.

Berrouschot J, Oeken J, Steiniger L, Schneider D. Perioperative complications of percutaneous dilational tracheostomy. Laryngoscope 1997;107:1538-1544.

Couch ME, Bhatti N. The current status of percutaneous tracheotomy. Adv Surg 2002;36:275-296.

Donovan DT. Percutaneous tracheotomy may be useful in both surgical and intensive care settings, but is no replacement for the open procedure. Arch Otolaryngol Head Neck Surg 2001;127:

Dulguerov P, Gysin C, Perneger TV, Chevrolet J-C. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999;27:1617-1625.

Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000;118:1412-8.

Friedman Y, Mizock BA. Percutaneous versus surgical tracheostomy: procedure of choice or choice of procedure. Crit Care Med 1999;27:1684-1685.

Griffen MM, Kearney PA. Percutaneous dilational tracheostomy as the preferred method of airway management. J Oral Maxillofac Surg 1999;57:316-320.

Hill BB, Zweng TN, Maley RH, Charash WE, Toursarkissian B, Kearney PA. Percutaneous dilational tracheostomy: report of 356 cases. J Trauma 1996;41:238-243.

Kost KM. Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases. Laryngoscope 2005;115:1-30.

Lewis RJ. Tracheostomies. Indications, timing, and complications. Clin Chest Med 1992;13:137-149.

Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen JN, Schuller DE. Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Laryngoscope 2001;111:494-500.

Moe KS , Stoeckli SJ, Schmid S, Weymuller EA Jr. Percutaneous tracheostomy: a comprehensive evaluation. Ann Otol Rhinol Laryngol 1999;108:384-391.

Powell DM, Price PD, Forrest LA. Review of percutaneous tracheostomy. Laryngoscope 1997;107:1538-1544.

Quintel M, Roth H. Tracheostomy in the critically ill: clinical impact of new procedures. Intensive Care Med 1999:25:326-328.

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Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery
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Last modified: Nov. 21, 2008