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Chapter

40Indications for and Management of TracheostomyJudi Anne B. RAmiscAl, michAel s. hAyAshi, and mihAe yu

InTroducTIon

A translaryngeal endotracheal tube (ETT) is the primary method of securing an airway in the majority of critically ill patients. In patients with penetrating neck trauma and obvi-ous tracheal injury, placement of an ETT directly through the existing defect is an option for initial airway management, and here, early tracheostomy has a clear role. For the majority of patients, consideration for tracheostomy placement arises after the initial airway management, when ventilator support is required for extended periods of time. The decision to per-form tracheostomy, however, is not always an easy one. With the increased use of high-volume, low-pressure ETT cuffs, there is no time interval when conversion to a tracheostomy is mandatory based on potential damage to the trachea from pressure necrosis. The main considerations for placement of a tracheostomy are the anticipated duration of ventilator sup-port, secretion management, and patient comfort. Predicting the duration of ventilator support is difficult, and the opti-mal timing of tracheostomy in critically ill patients with acute respiratory failure is controversial.

Tracheostomy is one of the most commonly performed surgical procedures in critically ill patients (1). The modern surgical tracheostomy (ST) was first described in 1909 by Che-valier Jackson (2). In 1985, Ciaglia et al. (3) first described the technique of percutaneous dilatational tracheostomy (PDT); it has since become a common bedside procedure in the intensive care unit (ICU). Tracheostomy is typically an elective proce-dure and should not be performed on patients receiving high-pressure ventilator support (except on rare occasions when there are mechanical problems with the ETT) as loss of airway pressure during the procedure may cause significant morbidity. Although PDT has evolved into a safe and common proce-dure, continued awareness of the complications and pitfalls associated with this procedure is essential.

IndIcaTIons and TIMIng

The primary indication for tracheostomy is the requirement for prolonged ventilator support and/or failure to wean from mechanical ventilation for 2 to 3 weeks (4). In 1989, the ACCP Consensus Conference on Artificial Airways in Patients Receiving Mechanical Ventilation recommended translaryn-geal intubation for an anticipated need of the artificial air-way up to 10 days and tracheostomy for an anticipated need of the artificial airway for greater than 21 days (5). It also recommended that the decision for tracheostomy be made as early as possible to minimize the duration of translaryngeal intubation. Other indications include severe head injury with

inability to protect the airway, high spinal cord injuries, laryn-geal trauma, upper airway obstruction, and for management of pulmonary secretions. Though a mortality benefit for tra-cheostomy is not consistently seen in the literature, the benefits of tracheostomy include sparing the larynx from further direct injury from the translaryngeal tube, improved comfort and presumed psychological benefit (6), ability to speak and eat, improved oral care, and possibly quicker wean from ventila-tion with earlier transfer from the ICU (5). In patients with limited reserve, tracheostomy reduces the work of breathing (shorter length of tubing than the ETT) and may allow more flexibility in weaning (7,8).

Optimal timing of converting a translaryngeal intubation to a tracheostomy remains controversial because there is no accurate way to predict the need for prolonged mechani-cal ventilation in the first few days. A high acuity of illness (Acute Physiology and Chronic Health Evaluation [APACHE] II scores >25) and the presence of shock at the time of ICU admission are two of the best predictors (9–11). Pena et al. (12) reviewed 56 cases of subglottic stenosis and found that 86% had a history of tracheal intubation, with a mean dura-tion of 17 days. Current Eastern Association for the Surgery of Trauma (EAST) practice management guidelines support early tracheostomy (3 to 7 days) to decrease total days of mechanical ventilation and ICU length of stay in patients with severe head injuries. They also recommend early tracheostomy be consid-ered in all trauma patients anticipated to require mechanical ventilation for greater than 7 days, such as those with neuro-logic impairment or prolonged respiratory failure (13).

Several studies have provided additional support for early tracheostomy. Rumbak et al. (14) randomized 128 medical patients to either early (within 48 hours) or late (14 to 16 days) percutaneous tracheostomy and found significantly shorter ICU stays, fewer days on the ventilator, and a lower mortal-ity in the early tracheostomy group. A prospective review of trauma patients by Arabi et al. (15) also found that patients who received early tracheostomy (by day 7 of mechanical ven-tilation) had shorter ICU stays and fewer days on the ven-tilator. In a meta-analysis, Griffiths et al. (16) reviewed five clinical trials with a total of 406 patients that compared early (within 7 days) versus late tracheostomy in critically ill adult patients. Mortality and the risk of pneumonia were the same in the two groups, but early tracheostomy significantly reduced the duration of artificial ventilation and length of stay in the ICU. A retrospective study of patients with cervical spinal cord injury by Menaker et al. (17) supports early tracheostomy in patients with American Spinal Injury Association (ASIA) “complete” cervical spinal cord injury or “incomplete” injury with a motor score less than 10. Similarly, in a retrospective cohort study of patients with isolated severe traumatic brain injury, Alali et al. (18) found that early tracheostomy (8 or less

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days from admission) led to a shortened duration of mechani-cal ventilation, ICU and hospital LOS, though there was no significant reduction in hospital mortality.

There continues to be debate over the actual impact of tracheostomy on overall outcome. In two studies of patients requiring prolonged mechanical ventilation, Combes et al, (19) found that tracheostomy was associated with lower ICU and in-hospital mortality rates, whereas Clec’h et al. (20) found no reduction in mortality but increased post-ICU mortality if the tracheostomy was left in place.

PaTIenT selecTIon

All patients requiring prolonged mechanical ventilation are candidates for tracheostomy. The 2003 ACCP Guidelines for Interventional Pulmonary Procedures identified uncontrol-lable coagulopathy, infection over the site, extreme ventilator and oxygen demands, and tracheal obstruction as contraindi-cations to PDT (21). Other mitigating circumstances to con-sider include hemodynamic instability, unfavorable anatomy, obesity, previous neck surgery or radiation, risk of infection to adjacent surgical wounds (neck and upper chest incisions), and central line sites. While cricothyroidotomy remains the recommended method of securing an emergency surgical airway, familiarity and expertise with PDT has allowed it to emerge as an alternative for emergency airway access in select situations.

oPen Versus PercuTaneous TracheosToMy

PDT has largely replaced the traditional open approach to tracheostomy as it has several advantages. PDT is usually per-formed in the ICU which eliminates the need to transport the patient to and from the operating room (OR); it also avoids the additional costs and logistics associated with use of the OR and possibly anesthesia. This transition of tracheostomy to a bedside ICU procedure has also allowed PDT to be performed by a broader range of providers.

Delaney et al. (22) identified randomized clinical trials that compared PDT to open or ST. Seventeen studies involv-ing 1,212 patients were reviewed, and the authors concluded that PDT reduced the incidence of wound infection and may further reduce clinically relevant bleeding and morbidity and mortality when compared with ST performed in the OR. There are now large-series single-institution reports demonstrating that with proper preparation, PDT can be safely performed on most critically ill patients with low complication rates, even those deemed high risk (23,24). The choice between ST and PDT ultimately depends on the operator experience and indi-vidual patient issues.

Patient issues favoring ST include:• Coagulation abnormalities: Larger blood vessels are more

easily controlled under direct vision during ST, but the smaller wound opening and snug fit of the tracheostomy placed by PDT may help tamponade clinically relevant bleeding from small vessels at the wound edges.

• High level of oxygenation support with a high FiO2 and/or high PEEP: During PDT, the endotracheal tube is with-

drawn until the tip is in the larynx. This often results in a substantial gas leak and possibly hypoxia in these patients. In ST, the endotracheal tube is only withdrawn when the tracheostomy tube is ready to be inserted, minimizing the gas leak and loss of PEEP.

• Unstable cervical spine: Dilation and tracheostomy tube insertion during PDT requires a significant exertion of force that may result in excessive cervical spine motion which can be avoided with ST.

• Unusual neck anatomy such as masses, previous surgery, or poor mobility: In these cases, ST can allow direct visualiza-tion of the neck structures.

Surgical Tracheostomy

ST can be performed in either the OR or the ICU. The patient usually has an endotracheal tube in place. A shoulder roll is placed to elevate the shoulders and extend the head, which elevates the larynx and exposes more of the upper trachea. The skin is prepped from the chin to below the clavicles. Ster-ile drapes are used to create a surgical field from the top of the larynx to the suprasternal notch. The thyroid notch and cricoid cartilage are identified by palpation (Fig. 40.1). Local anesthetic with a vasoconstrictor, such as epinephrine, is then injected into the skin and subcutaneous tissue overlying the second tracheal ring.

A 2-cm midline vertical or horizontal incision is then made. The vertical incision extends from the inferior edge of the cricoid cartilage toward the suprasternal notch whereas the horizontal incision is made over the second tracheal ring. Dissection is carried sharply through the platysma muscle and a vertical dissection through the middle of the strap muscles will avoid bleeding from the paired anterior jugular veins. Bleeding is controlled with cautery and/or hemostats and ties. Careful blunt dissection is then used to expose the thyroid isthmus, if this overlies the second and third tracheal rings it may need to be partially or completely transected to expose the trachea.

Thyroid cartilage

Incision

Cricoid cartilage

1st Tracheal ring

2nd Tracheal ring

3rd Tracheal ring

FIgure 40.1 Tracheal anatomy and placement of incision.

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Chapter 40 indications for and management of Tracheostomy e195

Once the trachea is dissected free of the overlying tissues, the second ring is identified. The oxygen fraction should be decreased to prevent OR fires. An incision is made in the trachea between the first and second rings and extended lat-erally through the second ring (see Fig. 40.1). This results in a tracheal flap (Fig. 40.2) that can be sutured to the inferior edge of the skin incision, creating a stoma. The endotracheal tube is withdrawn, and the tracheostomy tube is inserted into the trachea under direct vision. The creation of a stoma may facilitate reinsertion of the dislodged tube in the first few days when the fistula tract may not have stabilized. Another technique is to make a criss-cross incision on the trachea and simply insert the tracheostomy under direct vision after lift-ing the edges with a tracheal hook. Suturing the tracheos-tomy tube in place may help decrease the risk of accidental decannulation.

Percutaneous Dilatational Tracheostomy

The most common technique for performing PDT is that of Ciaglia. Originally, the technique used sequential dilators (3), but it has since been simplified to using a single tapered dila-tor. This dilator has a hydrophilic coating that is activated by immersing it in sterile water or saline. This procedure can be performed blindly, although many clinicians use fiberoptic bronchoscopy to observe the placement, as well as to prevent inadvertent injury to the posterior wall of the trachea and/or misplacement of the tracheostomy (25,26). The procedure requires at least two operators, one to control the ETT and one to perform tracheostomy tube placement; good prepa-ration and communication are essential. For large necks, a longer tracheostomy tube—such as the Shiley XLT—may be necessary. The availability and functionality of all appropriate supplies should be confirmed before initiating the procedure. Loss of an airway can be life threatening, any procedure of the airway should include personnel who are skilled at intubating and managing the airway emergently.

The patient is positioned, and the neck is prepped and draped as described for ST. The neck is palpated to identify

the thyroid notch and cricoid cartilage. Local anesthetic with a vasoconstrictor is then injected into the skin and subcuta-neous tissue inferior to the cricoid cartilage, followed by a 1.5-cm incision made either horizontally or vertically over the intended tracheostomy site. A curved hemostat is then used to dissect gently down to the anterior trachea. A fingertip is used to palpate the local anatomy including cricoid cartilage and tracheal rings. The endotracheal tube is withdrawn under direct bronchoscopic vision until the upper tracheal rings are visualized; the light from the scope may also be visible through the surgical field as it traverses this area. The bronchoscope and ETT should be adequately withdrawn to avoid impaling them; it is also recommended that the tip of the bronchoscope be positioned within the ETT.

Although seemingly easy, finding the airway with the needle is the most important and most difficult part of the procedure. The trachea should be stabilized with the nondominant hand and the trachea air column is located by directing the needle posterior and caudally in the midline. To avoid injury to adja-cent structures and the subsequent associated complications, the depth and direction of needle insertion should not exceed what is expected to enter the airway. Entry into the trachea is visualized with the bronchoscope; the goal is to place the needle between the first and second or the second and third tracheal rings at the anterior midline of the trachea (see Fig. 40.1). If the percutaneous entry site into the trachea is unde-sirable, the steps may be revised to reposition needle entry as needed.

Once free flow of air is obtained, the outer sheath is advanced and the inner needle is removed. The J-wire is then advanced through the sheath into the trachea and should be visualized as it progresses to the lower airways by bron-choscopy. The sheath is then removed and serial dilation per-formed over the guidewire. Placing a finger on the tracheal opening between dilation and tracheostomy tube insertion will minimize the gas leak and loss of PEEP. Finally, the tracheos-tomy tube with a guide (the largest one that will fit within the tracheostomy tube) is threaded over the guidewire, and then into the trachea. The dilation and tracheostomy tube insertion requires significant force, and visualization of the process with the bronchoscope is invaluable in minimizing the risk of an unintended or unidentified injury to the posterior wall of the trachea.

After placement of the tracheostomy tube, the bron-choscope is inserted into the fresh tracheostomy to confirm placement and remove blood and secretions. The mechanical ventilator attachment can then be transitioned to the tracheos-tomy tube and the ETT removed. The ACCP recommends that trainees should perform at least 20 PDT in a supervised setting to establish basic competency; 10 PDT should be performed annually to maintain the skill set.

Other methods for percutaneous tracheostomy described in the literature include the translaryngeal, dilating forceps, PercuTwist, and balloon dilatational techniques, as well as combinations of these approaches (27).

coMPlIcaTIons

The important complications of tracheostomy include infec-tion, bleeding, inadvertent extubation, paratracheal place-ment, esophageal perforation, subcutaneous emphysema,

Thyroid cartilage

Tracheal flap

Tracheostomy

Cricoid cartilage

1st Tracheal ring

2nd Tracheal ring

3rd Tracheal ring

FIgure 40.2 Tracheal flap created in open tracheostomy.

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pneumothorax, tracheal stenosis, tracheoinnominate fistula, tracheoesophageal fistula, tracheocutaneous fistula after decannulation, cardiopulmonary arrest, and death. In a meta-analysis of 1,212 patients, the most common clinically relevant complications noted were wound infections (6.6%) and bleeding (5.7%) (22). Intraprocedural and postprocedural airway complications remain an infrequent but important source of morbidity and mortality associated with tracheos-tomy. Inadvertent postoperative decannulation with inability to recannulate the trachea due to the absence of a formed tract may occur. Immediate endotracheal intubation is mandatory rather than attempting to push the tracheostomy tube back into a semioccluded orifice.

A specific complication of ST is the risk of airway fire. Occurring when a spark from the electrocautery ignites the oxygen leaking from the opened trachea, significant injury to the airway can result. This can be prevented by meticulous hemostasis during the pretracheal dissection, avoiding the use of electrocautery to make the tracheal incision or while the trachea is open, and decreasing the oxygen fraction through the ETT.

In 2013, the largest study to date addressing the safety of bedside PDT was performed, including over 3,000 procedures. Among the conclusions was that a low complication rate for the procedure was attainable across a broad spectrum of criti-cally ill patients without the routine use of bronchoscopy. Of note, their practice involved a specific well-trained experi-enced procedure team and the routine use of preprocedural and equipment checklists. Bronchoscopy was still utilized in 2% of patients and early major complications included three airway losses and one major bleeding event requiring formal exploration with three procedure-related deaths in the 10-year study (23).

Obesity is associated with higher rates of complications in PDT, including posterior tracheal wall injury, malposi-tioning, and accidental decannulation (28,29); however, this technique may be safely used in experienced hands (30). The use of bronchoscopy and an extra-long tracheostomy (XLT) tube may help minimize the incidence of these complications (28,31).

Infrequent major complications, including death, related to PDT are well described in the literature, mainly as small series or case reports (32). Airway complications resulting in mortality included tracheostomy tube dislodgement, extralu-minal placement, and intraprocedural loss of airway. Can-nulation of the mediastinum may result in catastrophe with acute asphyxiation or subsequent sepsis from mediastinitis. Bronchoscopic guidance is recommended to increase the safety of PDT by preventing complications related to trache-ostomy misplacement as well as perforation of the esopha-gus or pharynx. Routinely suturing the tracheostomy tube in place may also decrease the risk of inadvertent decannulation of a freshly placed tube (28). Ultrasound may also serve a role to delineate vascular structures and avoid major bleeding complications.

There is a learning curve using PDT, and it has been reported that complications are higher in the earlier cases of the operator (28). As PDT is increasingly performed by phy-sicians across a variety of disciplines, patient safety must be ensured through careful patient selection and recognition of the pitfalls of this now common bedside procedure in the criti-cally ill patient.

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• Tracheostomy may be required for patients who require prolonged mechanical ventilation; a high severity of injury or shock on admission may predict this need.

• Early tracheostomy may benefit specific patient popula-tions, such as those with severe head and cervical spi-nal cord injury by decreasing ventilator days and ICU length of stay.

• The choice between ST and PDT depends on local operator expertise and patient-specific issues. Bedside PDT is performed as safely as ST in the OR and may be associated with more efficient use of health care resources.

Key Points

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28. Kost KM. Endoscopic percutaneous dilatational tracheotomy: a prospec-tive evaluation of 500 consecutive cases. Laryngoscope. 2005;115(10 Pt 2): 1–30.

29. Byhahn C, Lischke V, Meininger D, et al. Peri-operative complica-tions during percutaneous tracheostomy in obese patients. Anaesthesia. 2005;60:12–15.

30. Heyrosa M, Melniczek D, Rovito P, Nicholas GG. Percutaneous tra-cheostomy: a safe procedure in the morbidly obese. J Am Coll Surg. 2006;202:618–622.

31. Blankenship D, Kulbersh B, Gourin C, et al. High-risk tracheostomy: exploring the limits of the percutaneous tracheostomy. Laryngoscope. 2005;115:987–989.

32. Simon M, Metschke M, Braune SA, et al. Death after percutaneous dilata-tional tracheostomy: a systematic review and analysis of risk factors. Crit Care. 2013;17(5):R258.

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