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.

Adult Tracheostomy
Romaine F. Johnson, M.D.
March 6, 2003

During three months I spent at the Methodist Hospital, we typically saw stereotypical patients for tracheotomy evaluation. They were older with multiple medical problems, especially cardiovascular disease. This particular patient had severe aortic valve regurgitation requiring replacement. Unfortunately, in many of these patients, the physiological reserve is just not enough to overcome the insult of surgery and postoperatively many of them develop multi-organ failure. In his case, he developed respiratory and renal failure.

When we spoke with the family we said that we thought tracheotomy would be beneficial because it would decrease the amount of muscle loading on his diaphragm, it would be easier for him to breathe, and perhaps we would be able to wean him off the machine faster. We told them that the nurses would better be able to take care of him with gentle suctioning and humidification. And we told them that it would be much more comfortable for the patient, and that he would have an increased ability, perhaps even swallow eventually and talk, even with the tracheotomy in place. We did a bedside mini-tracheotomy without complication. Unfortunately, the patient did not have enough physiological reserve to overcome his medical problems and eventually he succumbed to multi-organ failure several weeks later.

Just as I go through the talk, keep in mind that tracheotomy is generally referred to as the surgical creation of the stoma in the trachea, and tracheostomy is the stoma itself.

Brief bit on the history, this is the Ebers papyrus, the oldest known medical document, it is from ancient Egypt and it has many references to depression, common colds; it also has an obscure reference to emergency tracheotomy. Approximately 100 B.C. Greek physicians were felt to be the first to do elective tracheotomy and this period is classically known as the "Period of Legend."

In 1546, Antonius Bracivalla performed the first well-documented tracheotomy, and that ushered in the "Period of Fear." Surgery was performed only by the brave few because at that time the complications from tracheotomy were so high, including significant mortality.

In 1833, Trousseau reported 200 successful cases of tracheotomy to help treat diphtheria and prevent the sequelae of upper airway obstruction resulting in death. That ushered in a new area, the "Period of Drama" where tracheotomy was done for emergencies only.

In 1932, Chevalier Jackson, an important name in otolaryngology and surgery in general, helped standardize the procedure of tracheotomy, recommending a midline incision, minimal dissection, entering the trachea very high between the second and third cartilaginous rings, meticulous care of the patient. And that helped reduce the mortality and morbidity from the patient from roughly 1 out of every 4 patients to 2 percent. And of course, this ushered in the "Period of Enthusiasm," where if you thought about tracheotomy, you did tracheotomy.

I think the current period that we live in is the "Period of Rationalization." We try to look at the indications and whether or not tracheotomy will actually benefit the patient before we rush in to perform it.

The anatomy—the trachea extends from the cricoid to the carina. It is approximately 10 cm in length in the average adult. The diameter is roughly 2.5 cm, the root of the index finger will approximate the diameter. It is flat posteriorly and curved anteriorly. The smooth muscle cells help regulate the diameter of the trachea and they are approximately, as I said, about 20-22 cartilaginous rings.

Interestingly, as I used to think, the trachea really is not parallel to the sternum; it extends from an anterior position in the neck to the posterior mediastinum in the thorax. Half of the trachea is in the neck and half is in the thorax. An important relationship to remember is that at the thoracic inlet, the trachea butts the innominate artery and as we, as many of us know, an innominate artery fistula, fistula between the trachea and the innominate artery, is a significant source of mortality if it happens.

The vascular supply is very important to understand. Superiorly, the relationship is pretty constant; it is supplied by the inferior thyroid artery. The thoracic blood supply of the trachea is variable; however, it is important to remember that the vessels enter laterally, so dissection posteriorly and anteriorly, you will not disrupt the blood supply, but a lot of dissection laterally will disrupt the blood supply. Additionally, the cartilaginous ring is supplied by a submucosal plexus of veins and vessels, so anything inside the lumen that obstructs the flow of blood can cause mucosal injury and trachea injury, particularly things like an over-inflated tracheostomy tube or an over-inflated endotracheal tube.

The microanatomy is ciliated pseudo-stratified columnar epithelial cells; there are numerous goblet cells. As I mentioned, the smooth muscle cells help regulate the diameter, and of course, this all helps contribute to natural pulmonary toilet creation of secretions and the natural ciliary flow to help the patient cough out debris from the lungs and help, again, promote pulmonary toilet.

One thing to keep in mind, if a tracheotomy is performed, the physiology of the airway changes significantly. Here is the tracheostomy tube, the upper airway. By bypassing the upper airway, you decrease the cough. Again, the patient cannot form increased subglottic pressure because the air escapes, so there is a poor cough reflex. Additionally, because air is not passing through the vocal cords, there is a loss of voice. As I mentioned, there is incomplete glottic closure, as well as increased risk of aspiration because the cephalad motion of the trachea is impeded by the tracheostomy tube. Additionally, by bypassing the upper airway, you decrease humidification. That also causes ciliary impedance, as well as thickening of secretions, and we all know that stasis is bad. With stasis you get mucosal injury, you get increased risk of infection, crusting, etc.

There are four basic indications for tracheotomy. First I am going to talk mostly about "open" tracheotomy, and then later I will talk about percutaneous dilatational tracheotomy. But, if you think about open tracheostomy, there are four basic indications: as an adjutant to aspiration therapy, for pulmonary toilet, to help assist with long-term mechanical ventilation, as well as to bypass upper airway obstruction. This is a patient who recently presented to Ben Taub with laryngeal fracture, had a submucosal hemorrhage, upper airway obstruction, was taken to the operating room, a tracheotomy was performed, patient is now doing well.

There are really no absolute contraindications to open tracheotomy. Granted, there are more or less ideal situations, a patient who is coagulopathic, a patient who is hemodynamically unstable, you would want to avoid any surgical procedure; however, if a patient needs an airway and one cannot be established through a transoral/transnasal means, it does not matter what the situation is, tracheotomy can be performed and it can be performed safely and accurately in skilled hands.

The American Academy of Otolaryngology published a set of clinical indicators. These indicators are not meant as guidelines, specifically, but just to help assist in our decision-making. And, of course, as I mentioned, they have certain indications for tracheotomy, including upper airway obstruction, and interestingly, they thought that you should document the signs of upper airway obstruction, such as stridor, air hunger, or retractions. If you are doing surgery for obstructive sleep apnea, are there well-documented O 2 saturations, is there evidence of bilateral true vocal cord paralysis? Also, whether or not there is prolonged intubation, aspiration, or excessive secretions. Again, these are all the four major indications for tracheotomy.

The physical examination, the only one they thought that was required, was the neck exam. That should be documented. Postoperatively, you should document the patient's breathing, whether or not there is bleeding, subcutaneous emphysema, and in this document, a chest x-ray was actually suggested. There is some controversy whether or not a postop chest x-ray is always required in every tracheotomy, but in their indicator list, they felt chest x-ray should be documented.

Long-term outcomes: you want to make sure that there is documentation whether or not the stoma closed once the patient is decannulated, whether or not the patient has an adequate airway after decannulation, is there any evidence of tracheal stenosis, and whether or not the voice has returned to pre-tracheotomy levels.

So, I wanted to talk a little bit about prolonged bent toward dependence. This is one of the most common reasons that adult tracheotomies are done, and we all, at least when I talk to patients I say that it is beneficial to them. And I thought that it was, and I wanted to go and actually see whether or not the literature supported my claim. And so, I would often claim that the benefits of tracheotomy would be improved patient comfort. They would have decreased airway resistance. The patient's mobility would be enhanced; we could move them out of the ICU setting into acute care setting, that they would have the opportunities for speech, as well as oral intake, and that the airway was more secure.

The outcomes that I try to look at in the literature were whether or not there was a decreased amount of mechanical ventilation complications, whether or not there was really accelerated weaning from the ventilatory machine, as well as was there not expanded disposition options beside the ICU, whether or not it was true patients were able to be moved faster, etc. etc. And then I tried to look at the risk and weigh the risks as well.

And what I found was that the true impact of tracheotomy is not well-established. There really are not any ideal studies that are performed. You can imagine, most of the studies are non-randomized, there is a great deal of selection bias. Patients who tend to be sicker tend to be failed mechanical weaning, tend to need tracheotomy, tend to have a higher morbidity and mortality. Many of the published studies and published trials really do not have an A-priority protocol. They did not say at the beginning of the trial, "These are the indications that we are going to use… this is the criteria that we are going to follow while we examine whether or not tracheotomy is beneficial."

But, in general, there is good evidence that tracheotomy does promote patient well-being by facilitating opportunities for speech, oral intake, and greater mobility. There is good evidence that tracheotomy decreases airway resistance and muscle loading in many patients by shortening airway distance and improving pulmonary toilet.

Currently there is insufficient evidence to say that there is a decreased risk of ventilatory- associated pneumonia. There is also insufficient evidence to say whether or not it impacts ICU outcome, such as the length of stay, the number of days on the ventilator, or overall mortality.

Another common reason that tracheotomy is often done is for aspiration, and we often get consults for patients who are chronically aspirating and ask to perform a tracheotomy as a step. Again, I just wanted to know whether or not it actually did benefit the patient to do a tracheotomy. So, just looking at the literature, it seems that tracheotomy is more of an interim step. It helps provide pulmonary toilet, that is the key thing. You are able to suction the patient better and help control their secretions better.

Also, a cuffed tracheostomy tube can decrease the amount of aspirate. However, with time tracheotomy does tend to worsen outcomes. One, it impedes cephalad motion so the larynx, the patients have more difficulty swallowing. It does promote stagnation of secretions because you bypass the upper airway, decrease humidification, ciliary motion is impeded, increased secretions. It compromises normal cough, which helps patients clear their secretions, and as shown here, cuffed tracheostomy tubes can actually promote reflex, reflux by impeding gastric flow or esophageal peristalsis.

So, one way to think about tracheotomy for aspiration is it will decrease the amount of aspirate and it will allow you to give better pulmonary toilet, but over time it probably will increase the number of individual episodes.

Various types of tracheostomy tubes—we are all familiar with these—cuffed tubes, uncuffed tubes, and metal tracheostomy tubes. Any situation you can imagine, there is a tracheostomy tube that is made and readily available for patient care.

So, open tracheostomy is the most common technique done. It is typically performed in the OR or at the bedside. The patient is laid flat in a supine position. It is nice to extend the neck with a shoulder roll. You can make a skin incision that is either vertical or horizontal, and typically you stay in the midline, you dissect down through the subcutaneous tissue, identify the cricoid and the thyroid. The thyroid gland can either be retracted out of the way or if it is blocking your view of the trachea it can be divided and tied off with suture ligature or it can be Bovie-cauterized. The tracheal rings are identified, and typically we try to make an incision between the second and third tracheal rings, and then the tracheostomy tube is inserted. Many people create this inferior base, flap, but you can also resect an anterior part of the tracheal ring just as well.

So, the Björk flap, which is that anterior-based flap, was invented in the '60s. Here is the flap itself. It is an inferior-base flap. You take the flap, you suture it to the skin, and interestingly enough, it actually not only helps facilitate putting the tracheostomy tube back in if it is dislodged, but it actually helps prevent that from occurring in general.

The one complication that seems to be greater with the Björk flap is you cannot have an increased risk of persistent tracheataneous fistula. That is when the tracheostomy tube is decannulated, the track that was created remains open long after the tracheostomy tube has been removed.

So, complications are typically divided by the integral from the procedure. There is immediate or perioperative; there is intermediate, which occur hours to days; and then there is late, which occurs weeks to months.

Patients who are at highest risk for these types of injuries are patients who are head-injured, patients who are obese, patients who are seriously debilitated are much more susceptible. The average risk is about 15 percent, and the overall mortality of the surgery is very low, less than 1 percent, about 0.5 percent.

So of the perioperative complications: major hemorrhage remains the most common. It is about a 4 percent incidence, and surgical technique plays a large role in that. Typically, the vessels that are bleeding are the anterior jugular veins, thyroid isthmus, as well as the thyroid ima artery, if it is present. Another immediate complication is the creation of a false tract. That is where the tracheostomy tube is not in the trachea lumen itself, it is in the tissue plane outside of the trachea lumen. Electrocautery fire, if the cautery is used. You can also have significant injuries to adjacent structures. Again, that is related to surgical technique. If you dissect too far to the left, too far to the right, too far up or down, you can injure the esophagus, you can injure the recurrent laryngeal nerves, you can injure the lung apices resulting in significant morbidity.

Complications that occur hours to days after the surgery. Hemorrhage, again, remains the most common. It is generally a little bit of oozing from granulation tissue or from the thyroid. This can be managed most often with just gentle packing. It is important, as all the residents know, that we want to avoid circumferential packing because air escape from the tracheal lumen will begin to dissect in tissue planes creating possible pneumomediastinum, air surrounding the mediastinum or pneumothorax, air surrounding the pleura. And that can result in significant morbidity if not mortality.

Wound infection is rare. The tracheotomy is an open wound, so in general there is not a high risk of forming an abscess or significant cellulitis, however, it can occur. And this can be avoided by strict local hygiene. If infection does occur, there seems to be a higher risk of tracheal stenosis, and there have been case reports of mediastinitis and necrotizing fasciitis, although this is very, very rare.

Subcutaneous emphysema can occur hours to days after the surgery, and if that occurs, the risk of pneumothorax, although should not be laughed at, is still pretty small, less than one percent.

Tube obstruction is an important complication. It can occur hours to days after the procedure. Typically, in the first several hours, it is clotted, it is obstructed by blood. Later, in terms of days later, it can, it is obstructed by mucus. And the incidence is about 2½ percent, and we can decrease that just by gentle suctioning, humidification, having an inner cannula, changing it—just patient care. Of course, if that happens and it is unrecognized, you can have significant morbidity and mortality. Tube dislodgement is one of the more feared complications of tracheotomy, especially before the tract is well formed. It is frequently fatal. Factors that affect this risk are length of the tube, how thick is the patient's neck, whether or not the tracheotomy was done in an emergency procedure, and how is the tracheostomy tube secured. In general, the recommendation is for secure ties, you want to try to fix the trachea before the first few days with suture as well, and again, a Bjork flap really helps prevent it as well as if it happens, being able to recannulize the trachea.

So, complications that can occur weeks to months—Hemorrhage is still the most common, and most, most times it is due to granulation tissue. One of the more feared complications of tracheotomy, late complications, is the innominate artery fistula. As I mentioned, at the thoracic inlet the innominate artery sits just anterior to the left or the right of the trachea. And if you have a tracheostomy tube that is either placed too low so the distal tip erodes the cartilage, remember, from the histology and the microanatomy, the blood supply to the trachea cartilage is from submucosal plexus in the internal lumen, and that you can cause ischemic damage from compression and that can lead to mucosal injury, inflammation, ulceration, and eventually fistulization formation. Or if you have an over-inflated cuff, the same thing can happen and you can create a fistula between a major blood vessel and the trachea and mortality is significant. Ninety percent of the patients will not live through a significant episode. It is generally heralded by a sentinel bleed and that is where you need to have your highest index of suspicion. You get a consult for a tracheal bleeding, the trach has been there for several months, you need to strongly consider that in your differential and use flexible endoscopy to exam the patient and perhaps even take the patient to the OR if your suspicion is high enough to really look for it. If it happens, like I said, most patients will not survive, but, in general principles of trauma, if there is bleeding, put direct pressure on it. You can either use a cuff tube, try to over-inflate the cuff, or in some instances you can even maybe try to get something in there like your finger and just hold pressure, and hope for the best. If it is found early, surgical exploration is mandatory because that is the way it is repaired.

Tracheal esophageal fistula is also a late complication that occurs. The incidence is very small; the mortality, however, is also very high, and generally that is from an over-inflated cuff tube as well as an NG tube.

The diagnosis is made by index of suspicion. Patients coughing with eating, they have chronic aspiration, they have recurrent pneumonia, you just have to kind of think about it, and then investigate it. You can make the diagnosis with the methylene blue, you have them swallow the methylene blue and you should be able to see blue secretions come out of the trachea thereafter. If it is found, you should repair it surgically.

Tracheal stenosis is another complication that we see weeks to months after tracheostomy or tracheotomy. It is increased in closed-head injured patients. The etiology is multi-factorial, and it is often related to surgical technique, infection, over-inflated cuff, mucosal injury, and necrosis is always the common final pathway, and the treatment will depend on the length of stenosis and degree of stenosis. This patient we saw recently at Ben Taub who had a tracheotomy. When we plugged his trach, the patient was totally aphonic and began to get short of breath. We ordered an MRI and and you can see just above the trach site there was a complete stenotic segment.

Persistent tracheotaneous fistula is probably one of the most common long-term complications. It is really under-reported. As I mentioned earlier, that is where you decannulate the patient in the tract that you created for the tracheotomy, now remains patent. It increases with the length, the tube placement, and it can be repaired surgically in most patients.

So, percutaneous dilatational tracheotomy—it is the new hot thing. It is a minimally invasive technique, but it has actually been around for a long time. Sactorini, in the 1500s reported using a needle to enter the trachea, and then using a perforated cannula to cannulize the trachea. Berrouschot in 1748 described a bronchotome to use to help cannulize the trachea, and in 1955, Shelden re-introduced this technique in the modern, era. This picture here is from Santorini. Toye and Weinstein built upon Shelden's technique and they used the Seldinger wire to help cannulize the trachea, and then Seglia, who is the most recent proponent, really popularized it over the last fifteen years. He added dilators to the procedure.

The technique, this is the most current technique and it has evolved some. But, typically what you do is, this is the endotracheal tube, you use a bronchoscope, the smallest caliber bronchoscope you can find, because you want to be able to maintain ventilation. And you visualize the airway, you withdraw the bronchoscope just proximally, and then using an angiocatheter, you catheterize the lumen. You use a guidewire then to maintain that tract. Then you use the various size dilators to dilate the tract.

Now, initially, a small incision is made and then this is done under local anesthesia. You can use hemostats to provide minimal dissection to expose the trachea. And these skin marks are important in all the kits, because they say if you go past these skin marks, there is a higher risk of going through the posterior tracheal wall and causing damage to the esophagus, etc.

And, again, just bigger and bigger dilators, direct visualization, paying attention to the skin position mark, and then finally inserting the tracheostomy tube with the dilator over the wire, withdrawing the wire, inflating the cuff, and withdrawing the endotracheal tube.

So, the technique has evolved. Originally it was seen as part of a mini-tracheotomy for patients who were requiring long-term ventilation where they did not necessarily want to do a full open tracheotomy. They would make small incisions to help provide suctioning. At first, it was blind entry into the trachea, and this is why the risks were so high initially. The original kits, as well, were not really designed for safety. For example, the guidewires themselves could create false passages, they were not strong enough to maintain the lumen, and this has all evolved to where the current techniques, they use bronchoscopes to aid placement, and the tracheostomy sets are much safer.

So, what are the indications? This is considered a minimally invasive technique. It is performed in an ICU setting with appropriate monitoring. The selection criteria is much more stringent than open tracheotomy. Remember, open tracheotomy can be done on anyone. There are more or less ideal situations, but if they need an airway, you do it. This is not to be performed on any and everyone, very select criteria. Patients already need to be intubated. You have to be able to appreciate the neck anatomy, obese patients are not good candidates, and you also have to be able to intubate easily, because as you withdraw the endotracheal tube in order to visualize the trachea, you can accidentally extubate a patient. And if the patient is difficult to reintubate, that becomes a major problem. So, patients, you want to be able to make sure that they can be reintubated easily. Again, as I mentioned, contraindications: emergencies, because they already have to have an airway established, any kind of difficult airway is a contraindication, patients who are not intubated, obese patients, patients with poor anatomy, enlarged thyroids, coagulopathic patients, and high vent pressures.

So, what are the advantages, then? Well, the proponents claim that it is safe, it eliminates transport issues, it will expedite ICU flow, it will reduce cost, and I just, I mentioned Ben Taub here, there is no study that has been done at Ben Taub, but just thinking about it as I was reading the articles, OR time is very limited at Ben Taub. We often have to reschedule and schedule patients months in advance, and sometimes it takes days to weeks to perform a tracheotomy, and there's all kinds of transportation issues, and whether or not we can do it at the bedside, etc., etc. Proponents would say that percutaneous tracheotomy would be a good resource, or good thing to have in our armament to help reduce some of these problems that we see.

So, what are the complications with the procedure? They really parallel open technique. They feel bleeding is less likely because of the tamponade effect. Inadvertent extubation is a major problem and you need to be well aware of it. Tracheostenosis, this is that picture that I showed you earlier with the complete stenotic ring, that was originally felt to be a major concern, and it was, and it was due most often to blind technique and either entering the trachea through the side wall or fracturing the cricoid cartilage, resulting in inflammatory changes. The newer studies have shown that this complication is probably similar to the open technique now if you use the bronchoscope.

On a whole, if you look at all the literature, it looks like the risks of percutaneous tracheotomy are low, but, they may be more life-threatening when they occur, more likely to have injury to an adjacent structure, more likely to have a pneumothorax, etc.

So, there are special situations, just to reiterate, emergency situations are a strong contraindication, it would be a blind technique. Blind techniques are associated with the highest risk. Also, neck extension is necessary and of course, in a trauma patient who cannot have their neck extended, it would be more difficult to perform the surgery. Cardiac patients—there is always concern about cross-contamination between the tracheostomy wound and the sternotomy wound and it does not appear to be at increased risk for that, so that may be a good indication. It may have an acceptable role in cardiac patients. Obese patients—it is a poor choice. They are difficult to reintubate, have poor landmarks, and they also may need tubes that are longer than the tubes that are in your sets, as well as the tubes may not be compatible with the introducers that you use to perform the tracheostomy.

Stable trauma patients, again, at a place like Ben Taub, this may help reduce costs, expedite care, the evidence is not necessarily clear, but that is what proponents would say.

So, looking at the cost-effectiveness, why would we do this new procedure unless it somehow benefited either individual patients or populations of patients, or society? And one of the things that proponents would say is that it is cost-effective. Well, if you look at the literature, there really has not been a comprehensive cost-analysis done. To do one you have to calculate personnel costs, equipment costs, and also you want to do sensitivity analysis, looking at whether or not if you change the length of ICU stay, if you change the complication and mortality from the procedure, does that reduce costs. Well, that really has not been done. If you look at the literature, it looks at the basic cost: How much does a surgeon charge to do the procedure, how much does the operating room charge to do the procedure? And it appears looking at that evidence that percutaneous is less expensive than tracheotomy in the operating room. If you look at the difference between bedside tracheotomy and percutaneous tracheotomy, there is no difference.

So, comparing them directly is really comparing apples to oranges, because percutaneous will always favor healthier candidates. Again, if you include every patient who has a tracheotomy, we do trachs on patients who are in acute distress, etc., higher risk, higher morbidity, higher mortality where tracheotomy, percutaneous tracheotomy, always favors healthier patients. Additionally, I'm sorry, there was one study that I found that looked at "minimally invasive tracheotomy" versus "percutaneous tracheotomy." It was a prospective study, and that study concluded that bedside tracheotomy was safer and cost less than percutaneous.

I was speaking with Dr. Stewart recently about coming up with some evidence for some different things, and he reminded me that surgeons like to know what other surgeons do. They want to know what Dr. Kennedy does for his sinuses, what Dr. Coker does for his stapes, and, so I sought the expert opinion on this topic, and Dr. Donovan recently wrote an article on percutaneous tracheotomy and mini-bedside tracheotomy, and I think he always mentions to the residents that good surgical technique is about exposure and control. And if you look at open tracheotomy, it is still superior in this regard. If you look at the complication rates, they are similar, but severity still favors open tracheotomy, in that ultimately our surgical armature should be diverse, but we must adhere to basic surgical principles.

In conclusion, tracheotomy remains one of the most commonly done operations, has a long, rich history that is still evolving, and further research on minimally-invasive approaches will continue to advance its utility.

Case Presentation:

G.P. is 75-year-old man with multiple medical problems including HTN, CHF, and severe aortic valve regurgitation. He underwent an uncomplicated aortic valve replacement. His postoperative course was complicated by multi-organ failure with resultant respiratory failure and ventalitory dependence. He underwent a bedside mini-tracheotomy for ventalitory support, greater patient comfort, and improved pulmonary toilet. Unfortunately he succumbed to overwhelming sepsis and expired approximately two-weeks after the tracheotomy.

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