Problem: Tracheostomy is a utilitarian surgical procedure of access and as such, should be discussed in light of the problem it addresses: access to the tracheobronchial tree. The trachea is a conduit between the upper airway and the lungs. It delivers moist warm air, and it expels carbon dioxide and sputum. Failure or blockage at any point along that conduit can be corrected most readily by providing access for mechanical ventilators and suction equipment. In the case of upper airway obstruction, tracheostomy provides a path of low resistance for air exchange.

Clinical: Suspect airway obstruction if presentations include the following:

• Dyspnea
• Stridor
  • Inspiratory-usually a supraglottic obstruction being sucked into the glottis with inspiration
  • Expiratory-usually a subglottic obstruction being blown up into the glottis during expiration
  • Biphasic-both of the above or a lesion isolated to the glottis (eg, edema)
• Voice change
• Pain
• Cough
• Decreased or absent breath sounds
• Bleeding
• Drooling
• Restlessness
• Hemodynamic instability (late)
• Loss of consciousness (very late)

INDICATIONS

• To bypass obstruction
  • Congenital anomaly (eg, hypoplasia, vascular web)
  • Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS) maneuvers
• Suprasternal and intercostal retractions, increased work of breathing in general
• Neck trauma
• Subcutaneous emphysema
  • Appears in face, neck, or chest
  • Air dissects readily, especially through inflamed or traumatized tissue planes.
• Palpable fractures (eg, mid-face, hyoid, thyroid, cricoid, mandible, midface)
• Tumor
• Bilateral vocal cord paralysis
• Edema
  • Trauma
  • Burns
  • Infection
  • Anaphylaxis
• Indicated to provide a long-term route for mechanical ventilation in cases of respiratory failure (not enough oxygen in)
• Hypoxia - Symptoms of agitation and confusion
• Cyanosis - Indicates ventilatory failure (reduced carbon dioxide exhalation)
• Hypercarbia - Increased carbon dioxide - symptoms of headache, dizziness, twitching, sweating, and flushing
• To provide pulmonary toilet
  • Inadequate cough due to chronic pain or weakness
  • Aspiration and the inability to handle secretions. The cuffed tube allows the trachea to be sealed off from the esophagus and its refluxing contents. Thus, this intervention can prevent aspiration as well as provide for the removal of any aspirated substances.
• Prophylaxis (as preparation for extensive head and neck procedures and the convalescent period)

RELEVANT ANATOMY AND CONTRAINDICATIONS

Relevant Anatomy:

• The larynx comprises 3 large cartilages: the epiglottis, the thyroid, and the cricoid cartilage, described as a reverse signet ring just inferior to the thyroid cartilage. The arytenoid cartilages lie on the posterior border. The cricothyroid membrane stretches between the thyroid and cricoid cartilages. The cricothyroid muscle arises from the anterior surface of the cricoid and travels superiorly, posteriorly, and laterally to attach laterally to the surface of the thyroid cartilage. This muscle rotates the thyroid anteriorly and lengthens the vocal cords. The vocalis muscles arise from the inner surface of the thyroid cartilage in the midline and pass superiorly and posteriorly to attach to the length of the vocal cords. They shorten the cords and vary the tension on the cords. These 2 pairs of muscles, as well as the cords themselves, are vulnerable to injury during cricothyrotomy.
• The innominate artery, or brachiocephalic trunk, crosses from left to right anterior to the trachea at the superior thoracic inlet and lies just beneath the sternum.
• The trachea itself is membranous posteriorly, and it is formed of semicircular cartilaginous rings anteriorly and laterally. The spaces between the rings are membranous.
• Paratracheal structures vulnerable to injury if dissection strays from the midline are the recurrent laryngeal nerves and inferior thyroid veins that travel in the tracheoesophageal groove. The great vessels (ie, carotid arteries, internal jugular veins) could be damaged should dissection go far afield. This is a real risk in obese or pediatric patients.
• The thyroid gland lies anteriorly to the trachea with a lobe on either side and the isthmus crossing the trachea at approximately the level of the second and third tracheal rings. This tissue is extremely vascular and must be divided with careful hemostasis.

Contraindications: There are no absolute contraindications to tracheostomy. A strong relative contraindication to discrete surgical access to the airway is the anticipation that the blockage is a laryngeal carcinoma. The definitive procedure (usually a laryngectomy) is planned, and prior manipulation of the tumor is avoided as it may lead to increased incidence of stomal recurrence.

"End-of-life" issues also may come to bear on the decision to perform a tracheostomy, as it may represent further mechanization of the patient's care to family members. In fact, the decision to extend or withdraw care is not affected by the performance of a tracheostomy. Hygiene is improved, quality of life (speaking and eating, if relevant) is improved, and placement in long-term care is facilitated; however, dependence on mechanical ventilation may not be changed. The patient is still "being kept alive by machines."

WORKUP

Lab Studies:

• So many tracheostomies are performed electively on patients with secure airways (eg, for prolonged intubation) that it is reasonable to check the hematocrit and coagulation factors preoperatively so that adequate correction can be made. As with any emergent procedure, the decision to perform an emergent tracheostomy is not altered by any lab values.

TREATMENT

Surgical therapy:

• Endoluminal: Intubation may replace or precede tracheostomy. It is comparably easy and more rapidly performed and is tolerated well for short periods of time (debate rages, but generally between 7 days and 3 weeks). Tracheostomy itself is facilitated by the intraoperative control an endotracheal tube provides. The only reason not to intubate is the inability to intubate. Contraindications to intubation include C-spine instability, midface fractures, laryngeal disruption, and obstruction of lumen. Supplements to intubation include the nasal airway trumpet, which provides dramatic relief of airway obstruction caused by soft tissue redundancy, collapse, or enlargement in the nasopharynx. The oral airway prevents the tongue from collapsing against the back wall of the oropharynx. Ironically, alert patients do not tolerate the oral airway, and patients obtunded enough to tolerate the oral airway without gagging should probably be intubated. Intubation can be performed orally or nasally. That
  decision generally depends on local trauma and the logistics of planned operative intervention.
• Transluminal

Cricothyrotomy

• Emergent: The advantage of performing emergent cricothyrotomy is that the cricothyroid membrane is superficial and readily accessible with minimal dissection required. The disadvantage is that the cricothyroid membrane is small and adjacent structures (eg, conus elasticus, cricothyroid muscles, central cricothyroid arteries) are jeopardized; moreover, the cannula may not fit. Damage to the cricoid cartilage, from scalpel or from pressure necrosis, will lead to perichondritis and possibly stenosis. The overall complication rate of emergent cricothyrotomy is 32%, which is 5 times that of the procedure under controlled circumstances.
• Elective: Cricothyrotomy has enjoyed a renaissance in cardiothoracic surgery. Recent studies have rehabilitated its image and raised questions about its inherent risks (recently 6.1%, which is comparable to the risk of tracheostomy). The advantage claimed by its practitioners is the increased distance between the airway stoma (unsterile) and the supposedly more sterile sternal wound.
• Jet: Using the Seldinger technique, a catheter can be threaded into the cricothyroid membrane and its tiny diameter can be compensated for by a stream of pressurized oxygen, which must be administered cautiously and manually. This is useful in endotracheal procedures (eg, microdebridement) that preclude intubation. The risk of barotrauma and the labor-intensive method of oxygen instillation dictate that this is a short-term intervention.

Tracheostomy

• Emergent ("slash"): This should only be considered when the patient is in extremis, which is when a cricothyrotomy should be performed. No procedure known, even colloquially, as a "slash" should be performed by the conscientious physician.
• Urgent ("awake"): Patients in acute respiratory distress may need acute surgical intervention. This can be performed in a controlled environment (eg, the operating room) under local anesthesia. The awake patient will be contributing to the operative environment both negatively and positively. The patient's anxiety and restless movements will challenge the surgeon and the anesthesiologist; however, the patient's vigilance is required to maintain the airway. These patients should be sedated and paralyzed only with extreme caution. It is better to have an agitated patient with an open airway than a relaxed patient with a complete obstruction. The risk of pneumothorax is increased in a patient with increased work of breathing, as the cupulae expand high into the neck with high negative inspiratory pressures.
• Elective: Most elective tracheostomies are performed on patients who are already intubated; who are, in fact, having a tracheostomy for "prolonged intubation." Additionally, patients undergoing extensive head and neck procedures may receive a tracheostomy during the operative procedure to facilitate airway control during convalescence. A smaller population of patients with chronic pulmonary problems (eg, sleep apnea) elect to undergo tracheostomy.

Intraoperative details: Cricothyrotomy

The patient's neck is extended and stabilized. Palpate for the cricoid cartilage approximately 2-3 cm below the thyroid notch. A 1-cm horizontal incision is made just above the superior border of the cricoid (this will avoid the vessels that run under the inferior border, in the same manner as the intercostal neurovascular bundles) to expose the cricothyroid membrane, which is then punctured in the midline. The blade must be directed inferiorly to avoid trauma to the true vocal cords. Care is taken not to extend this puncture through the back wall of the larynx and into the esophagus. Insert a blunt instrument (eg, the knife handle) into the incision and rotate it perpendicularly to widen the incision to accommodate a small cannula. Later conversion to a tracheostomy is addressed below.

Tracheostomy

More variation exists in the performance of an open tracheostomy. Again, position the unconscious or anesthetized patient supine with the neck extended, the shoulders elevated on a small roll. The awake patient will not tolerate this; therefore, the procedure will be performed with the patient in a sitting or semi-recumbent position. Overextension of the neck should be avoided as it further narrows the airway; additionally, it can lead to placement of the tracheostomy too low (towards the carina) and too close to the innominate artery (especially in the very mobile pediatric trachea).

Palpate the landmarks (eg, thyroid notch, sternal notch, cricoid cartilage) and mark them with an ink pen. Plan a 3-cm vertical incision extending inferiorly from the cricoid cartilage and infiltrate Lidocaine (1%) with 1:150,000 parts epinephrine. This is sufficient anesthesia in the awake patient and facilitates hemostasis in all patients. Make the vertical incision. Many advocate the horizontal skin incision, which is made along relaxed skin tension lines, giving better cosmesis. A horizontal incision may trap more secretions. Meticulous hemostasis is important throughout, beginning with the skin edges.

Subcutaneous fat may be removed with electrocautery to aid in exposure and prevent later fat necrosis. Dissection proceeds through the platysma until the midline raphe between the strap muscles is identified. Palpate the inferior limit of the field to assess the proximity of the innominate artery. Cauterize or ligate aberrant anterior jugular veins and smaller vessels. Midline dissection is essential for hemostasis and avoidance of paratracheal structures. The strap muscles are separated and retracted laterally, exposing the pretracheal fascia and the thyroid isthmus. The lateral retraction also serves to stabilize the trachea in the midline.

Although in some cases the thyroid isthmus, which typically lies anteriorly over the first 2-3 tracheal rings, may be retracted out of the field, often it must be divided. A retracted isthmus may be irritated by rubbing against the tracheostomy tube in the postoperative period, causing bleeding. Division is performed sharply or with electrocautery and suture ligature. Elevate the isthmus off the trachea with a hemostat and divide it. Attention is turned to drying the field. Clean the remaining fascia off of the anterior face of the trachea and warn the anesthesiologist of impending airway entry.

When preparations for transfer of circuitry tubes are complete, deflate the endotracheal tube balloon and enter the trachea. Injection of topical anesthesia can stem the cough reflex of the awake patient. Absolute hemostasis prior to this point obviates the threat of blood entering the trachea and exacerbating the cough reflex. Securing the cricoid with a hook and elevating it superiorly facilitates control of the tracheal entry. Several options for the tracheal stoma are available, including the following:

 

• T-shaped tracheal opening: Make a 2-cm incision horizontally through the membrane between the second and third or third and fourth tracheal rings. Use heavy scissors to cut vertically and inferiorly in the midline through the distal 1-2 tracheal rings. With this incision, one can place a silk stay suture through the tracheal wall on each side, and tape the suture to the neck skin on either side. This facilitates tube replacement should it become dislodged in the immediate postoperative period. It is prudent to mark "Do Not Change or Remove" on the tape holding these sutures to skin. These sutures are removed after the first tracheostomy tube change at 5-7 days postoperative.
• U- or H-shaped tracheal opening: Reflect tracheal flaps inferiorly or both inferiorly and superiorly. These can be tacked to skin edges with absorbable sutures to create a semipermanent stoma, or silk stay sutures can be placed in each tracheal 'flap', and taped to the chest and neck skin, facilitating replacement of a displaced tube in postoperative care. This is beneficial in the obese patient.
• Permanent stoma: Create with skin flaps developed and sutured to a rectangular tracheal opening. Removal of small anterior portions of the tracheal rings is required. This is desirable only in those patients who are expected to require secure transluminal access indefinitely (eg, patients with sleep apnea). Resecting part of the anterior tracheal wall predisposes to stenosis; thus, it is unwise in a temporary tracheostomy.

After the trachea is entered, suction secretions and blood out of the lumen and withdraw the endotracheal tube slowly to a point just proximal to the opening. Replace the lateral retractors into the trachea and insert the previously tested tracheostomy tube. After an intact airway is confirmed with carbon dioxide return and bilateral breath sounds, secure the tracheostomy tube to the skin with 4-0 permanent sutures. Attach a tracheostomy collar with the head flexed to avoid unnecessary slack in the collar. The skin is not closed to avoid the risk of subcutaneous emphysema and subsequent pneumomediastinum. Place a sponge soaked with iodine or petrolatum gauze between the skin and the flange for 24 hours to deflect infection as well as anxiety about minor skin edge oozing.

Choice of tube

Typically, the smallest feasible tube should be used. A general rule is that the tube should be three fourths of the diameter of the trachea. In patients of average habitus, a #6 Shiley Cuffed Tracheostomy tube (SCT) is appropriate for most women and #8 SCT is appropriate for most men. More care must be taken with the obese patient; a flexible single lumen, variable length tube may be most appropriate. A tube that is too short will abut the posterior tracheal wall, causing obstruction and ulceration. A tube that is too long will curve forward and erode the anterior tracheal wall, which can be perilously close to the innominate artery. Cuffed tubes allow positive pressure ventilation and prevent aspiration. If the cuff is not necessary for those reasons, it should not be used because it will irritate the trachea and provoke and trap secretions, even when deflated. Even modern low-pressure cuffs should be deflated regularly (qid) to prevent pressure necrosis. Standard fenestrations are rarely in theright place. If flush with the tracheal wall, they will instead cause irritation and granulation and should not be used.

Extra long tracheostomy tubes are available and should be used in the obese patient in whom the distance between the skin and the trachea is too great to safely be bridged by a standard tracheostomy tube. The Bivona tracheostomy tube is much like a foreshortened endotracheal tube. It has a grip that secures the tube at the desired position. Disadvantages include the fact that it is a single lumen tube. Care must be meticulous as there is no inner cannula to remove for cleaning, plus obstruction of the tube by secretions necessitates removal of the outer cannula in the patient with an admittedly difficult airway. Additionally, the variable length of the tube requires that placement be checked, either endoscopically or radiographically, to avoid mainstem ventilation.

Postoperative details: Postoperative care is critical. The recently insulted trachea produces copious secretions and irrigation with saline and suctioning every 15 minutes is not unreasonable initially. Suctioning should be limited to the length of the tube to avoid tracheal ulceration and tracheitis, and it should be limited to a duration of no more than 15 seconds as the act of suctioning not only blocks the airway but also sucks the air out of the lungs. Humidified oxygen helps prevent inspissation of the secretions. Additional mucolytic agents (eg, Mucomyst, guaifenesin) may be employed. Mucus plugging of the inner cannula, if uncorrected, can cause a life-threatening obstruction.

The original tube is left sutured in place for 5-7 days to allow the tract to heal. Then the sutures are removed, and the tube is replaced. For patients in whom the tracheostomy was an acute intervention, this is an opportunity to downsize the tube or to change to a metal tube. The site should be kept clean and dry to minimize infection from what will be a chronically colonized location. Patient and family education should begin as soon as possible.

Follow-up care:

• Speaking: As soon as the cuff can be deflated, the patient should be encouraged to occlude the tube with a finger and to begin to phonate. As long as there is not significant edema, enough air should pass by the tube and through the vocal cords. This also encourages the patient to reestablish normal airflow through the upper airway, and it diminishes psychological reliance on the lesser resistance of the tracheostomy.
• Passy-Muir valves are special one-way valve caps that allow automatic occlusion with exhalation for speech. Negative pressure (inspiration) opens the valve.
• Fenestrations: As mentioned above, these are rarely in the correct place. Simply deflating the cuff, or preferably downsizing to a cuffless tracheostomy tube, should suffice for audible speech.
• Plugging: In preparation for decannulation, the tracheostomy tube may be plugged. It is essential that the patient be able to remove the plug should dyspnea develop. Patients with sleep apnea frequently keep their tubes plugged except when they go to sleep.
• Swallowing: Swallowing is more difficult while the tube is in place because of decreased laryngeal elevation; however, oral intake is certainly possible. Thoroughly evaluate the patient's risk of aspiration before feeding begins.
• Home care and equipment: Tracheostomy is still socially stigmatized and intimidating to both the patient and the family. Education must begin early, and preparations for going home must be complete. Before leaving the hospital, all members of the household should feel comfortable with replacing the outer cannula. Equipment includes saline, suction catheters, and a suction machine for hygiene; replacement inner cannulas; and a spare tube with an obturator. Occasionally, a patient will require humidification via tracheal collar. Most important is the family's understanding and comfort. The most commonly overlooked or misunderstood item is the obturator, which is important in the atraumatic reinsertion of the outer cannula.

COMPLICATIONS

Immediate complications

• Apnea due to loss of hypoxic respiratory drive. This is mainly important in the awake patient. Ventilatory support must be available.
• Bleeding: Intraoperative bleeding arises from laceration of vessels in the field that should be cauterized or ligated and from the cut edges of the very vascular thyroid gland. Care should be taken to stop all thyroid bleeding before allowing the cut edges to retract laterally, where they become difficult to expose.
• Pneumothorax or pneumomediastinum: These can result from direct injury to the pleura or the cupola of the lung (especially in children) or from high negative-inspiratory pressures of patients who are awake and distressed. Early recognition is critical and routine post-operative chest radiographs should be considered after tracheotomy.
• Injury to adjacent structures: The paratracheal structures vulnerable to injury are the recurrent laryngeal nerves, the great vessels, and the esophagus. This danger is most prevalent in children because the softness of the trachea hinders its identification if it is not distended with a rigid object.
• Post-obstructive pulmonary edema; although rare, a transient pulmonary edema can occur after tracheostomy, which provides relief of upper airway obstruction.

Early complications

• Early bleeding: This is usually the result of increased blood pressure as the patient emerges from anesthesia (and relative hypotension) and begins to cough. Although this may necessitate a return to the OR, it may be controlled with local packing and control of hypertension. Packing should be antibiotic-impregnated gauze (eg, iodophor), and while it is in place, the patient should given antistaphylococcal antibiotics. Bloody secretions issuing from the tube itself may represent diffuse tracheitis (most commonly), rundown bleeding from the skin or thyroid, or ulceration from an ill-fitting tube or overzealous suctioning.
• Plugging with mucus: The use of dual cannula tubes makes this less of a threat, as the inner cannula can be removed for cleaning while the outer cannula safely maintains patency of the fresh tract. Vigilance, however, is still required, and all measures to thin and remove secretions should be undertaken.
• Tracheitis: To some degree, tracheitis is present in all fresh tracheostomy patients. Again, humidification, minimizing the fraction of inspired oxygen (FIO₂) as high oxygen exacerbates drying, and irrigation are essential. Moreover, motion of the tube within the trachea is extremely irritating and should be prevented by stabilizing the ventilator circuitry so that torsion is minimized.
• Cellulitis: The wound will quickly be colonized; however, infection is unlikely if the incision has not been closed tightly and drainage is allowed. Opening the wound and instituting appropriate antibiotics should suffice to treat any early cellulitis.
• Displacement: It is not uncommon to be called to the bedside to replace a new tracheostomy tube. In the heat of the moment it is important not to forget the access that the upper airway still affords. Bag ventilate the patient and prepare for intubation if the tracheostomy tube cannot be replaced. Initial management includes passing something (eg, a smaller tube, a clear nasogastric tube [which will show the fogging of respiration]) into the open wound. A physician may attempt recannulation. This is facilitated by placing the tube over the fiberoptic laryngoscope and reentering the trachea under direct vision. However, endotracheal intubation remains the mainstay of airway management and should not be ignored while laboring over an increasingly traumatized tracheostomy site. Misplacement of the tracheostomy tube into the dreaded "false passage," usually in the pretracheal space, should be suspected if there is difficulty ventilating or passing a suction catheter or if there is subcutaneous air orpneumothorax.
• Subcutaneous emphysema: This results from a tight closure of tissue around the tube, tight packing material around the tube, or false passage of the tube into pretracheal tissue. It can progress to pneumothorax and/or pneumomediastinum and should be treated by loosening the closure or packing and by making a tube thoracotomy if necessary. Incidence of pneumothorax after tracheostomy is 0-4% in adults and 10-17% in children; thus, postoperative chest radiograph is recommended in children.
• Atelectasis: An overly long tube can mimic a unilateral mainstem intubation, causing atelectasis or collapse of the opposite lung.

Late complications

• Bleeding: Bleeding more than 48 hours after the procedure may be a herald of a tracheoinnominate fistula caused by a low (further along the trachea toward the carina) tracheostomy or an ill-fitting long tube. Half of all patients with significant bleeding more than 48 hours after the procedure will have a tracheoinnominate erosion. This occurs in 0.6-0.7% of all tracheostomy patients, and the mortality rate of this complication approaches 80% if treated aggressively. Patients with an impending tracheoinnominate fistula may have a 'sentinel' bleed (ie, a brief episode of brisk bright red blood from the trach site) hours or days before catastrophic bleeding. Some physicians prefer to investigate all such episodes of bleeding with a careful tracheobronchoscopy, looking for suspicious areas in the appropriate area of the trachea. If diagnosis is made only when catastrophic bleeding occurs, management includes replacement of the tracheostomy tube with an endotracheal tube with the balloon inflateddistally to the site of the bleeding in order to protect the airway. If the balloon does not tamponade the bleeding, a well-placed finger can temporize while the thoracic surgery team mobilizes for median sternotomy to locate and control the bleeding vessel. Occasionally, granulation tissue at the tip of the tracheostomy tube can bleed vigorously. This can be identified by flexible laryngoscopy and can be treated with excision or cautery via bronchoscope in the operating room.
• Tracheomalacia: This usually is caused by a poorly fitting tube. Improved fit may allow recovery of the softened cartilage.
• Stenosis: Injury to the cricoid cartilage, the only circumferential ring in the trachea, can lead to laryngeal stenosis. Stenosis typically occurs at the site of the tracheostomy or at the area irritated by the cuff. Over the course of his life, Chevalier Jackson saw the incidence of posttracheostomy stenosis drop from 75% to 2%. Modern high-volume, low-pressure cuffs have reduced the rate of this complication; however, care must still be taken not to overinflate these cuffs and to let them down periodically. Tracheal stenosis typically presents several weeks after decannulation as a subacute distress, often mistaken for bronchitis. Treatment is surgical and ranges from formal resection and reconstruction to less invasive means of debridement or stenting for palliation.
• Tracheoesophageal fistula: Typically caused by friction between a posteriorly displaced tracheostomy tube, or overinflated cuff, and a rigid nasogastric tube, a tracheoesophageal fistula almost always requires surgical repair, possibly with a muscle flap and/or skin graft. This presents with aspiration and subsequent chemical pneumonitis and should be evaluated with a plain film (which may show an air-filled esophagus) or barium swallow, followed by bronchoscopy. Preoperative management includes gastrostomy decompression and jejunostomy nutrition. This complication occurs in less than 1% of patients with tracheostomy.
• Tracheocutaneous fistula: Epithelialization of the tract from skin to trachea can result in a nonhealing fistula. This can be repaired by coring out the epithelial layer and allowing the wound to granulate in. Alternatively, a 3-layer closure can be performed, but this is associated with more complications. A persistent tracheocutaneous fistula can be indicative of proximal resistance or remaining obstruction, and it should be evaluated by direct laryngoscopy.
• Granulation: This can occur at the site of the stoma and should be cauterized with silver nitrate. It also can occur distally where it may cause partial or complete obstruction or bleeding of this friable tissue. As it matures into fibrous scar, it can contribute to stenosis.
• Scarring: Both vertical and horizontal incisions heal with small but visible scars that can be revised if bothersome to the patient.
• Failure to decannulate: Sometimes, patients fail plugging trials or even decannulation for no readily apparent reason. Possibilities to consider include obstructing granuloma previously held out of the way by the tube, bilateral vocal cord paralysis, infractured cartilage, and anxiety. Evaluation should include fiberoptic laryngoscopy and bronchoscopy through the stoma, looking down at the carina, up at the glottis, and then through the nose to look at the hypopharynx and the supraglottis.

Special cases

• Obese patients: In particular, the obese patient with obstructive sleep apnea (OSA) poses a challenge. The apnea can be corrected with a tracheostomy and, until the acceptance of uvulopalatopharyngoplasty and the availability of continuous positive airway pressure (CPAP), this was the standard treatment. Yet the same obesity that impairs ventilation also challenges the surgeon during the operation and the nursing staff engaged in postoperative care. Techniques have been developed to facilitate the creation and maintenance of the permanent airway. Skin flaps are raised and subcutaneous fat removed. They are then sutured circumferentially to corresponding tracheal flaps to create a permanent stoma. Intraoperatively, taping the chest down and the chin up may help. Reverse Trendelenburg position recruits the help of gravity.
• Pediatric patient: Infants and children have relatively short necks and are at high risk for tube displacement. This makes both the operation and the postoperative course much more perilous. Use of a rigid bronchoscope or endotracheal tube in place to define the location of the trachea should be considered as paratracheal dissection is not uncommon. In particular, the infant's pleural spaces extend far superiorly into the paratracheal spaces and can easily be injured. Thus, a postoperative chest radiograph is necessary in infants and children. Tracheal stay sutures can be placed bilaterally in the incised tracheal wall and, when clearly identified, can be taped to the neck. In the event of displacement, these sutures can pull the trachea up into the field and facilitate replacement. Even today, long-term tracheostomy in an infant carries a mortality rate of 20%. Thus it is imperative to perform these procedures judiciously and to use every precaution.
• The patient who only requires improved pulmonary toilet: A tracheal fenestration, which is an oval opening, allows the passage of a suction catheter. Covered by an operculum when not in use, it allows speech.

• Duration of tracheostomy: A tracheostomy can be used for days or, with proper care, years.
• Decision to decannulate: The tracheostomy tube should be removed as soon as feasible and should therefore be downsized as quickly as possible. This allows the patient to resume breathing through the upper airway and reduces dependence (psychological and otherwise) on the lesser resistance of the tracheostomy tube. Decannulation may be performed when the patient can tolerate plugging of the tracheostomy tube overnight while asleep, without oxygen desaturation. After the tube is removed, the skin edges are taped shut, the patient is encouraged to occlude the defect while speaking or coughing, and the wound should heal within 5-7 days.
• Reversal of permanent stoma

• Prolonged intubation: Prolonged mechanical ventilation has become possible and increasingly necessary as advances have been made in the care of the critically ill patient. Antibiotics, total parenteral nutrition (TPN), and dialysis-current interventions allow almost indefinite support. Complications of prolonged intubation include: ulceration, granulation tissue formation, subglottic edema, and tracheal and laryngeal stenosis. Pulmonary hygiene as well as oral hygiene is difficult. Communication is frustrating, and deglutition can be very difficult. Changing an endotracheal tube to a tracheostomy tube decreases dead space by 10-50%. Decreased resistance increases compliance and facilitates independent breathing. Work of breathing is significantly less through a 6- to 12-cm tracheostomy tube than through a 27-cm endotracheal tube. Weaning a patient off mechanical ventilation is greatly facilitated by this decreased work of breathing. Intermittent "rests" on the ventilator, usually at night, are also possible. Tracheostomy is a more secure airway; it is less likely to be displaced and more readily replaced than the traditional endotracheal tube is. Tracheostomy has not been shown to pose a greater risk of pneumonia than intubation, as both interventions lead to colonization of the airway with potential pathogens.
• Conversion of cricothyrotomy to tracheostomy: The cricothyrotomy was condemned by Chevalier Jackson in 1921 and since that time has been accepted only as an emergent procedure blessed with ease of performance in the field. Jackson blamed cricothyrotomy, the "high" tracheostomy, for 93 of the 100 cases of laryngeal stenosis in his series. Brantigan and Grow published data on a large series of elective cricothyrotomies with a 6.1% complication rate, which is comparable to that for traditional tracheostomies. This has raised the question of whether to convert cricothyrotomies to tracheostomies and indeed whether to perform elective cricothyrotomies instead of tracheostomies. This study is limited by the fact that one third of the patients died before discharge and, therefore, were not included in the follow-up documentation.
• Percutaneous versus open tracheostomy: In 1969, Toye and Weinstein described a technique of tracheostomy performed percutaneously at the bedside using essentially a Seldinger technique modified by using progressive dilation. Its advantages are mainly that it can be done at the bedside; therefore, the expense and logistics transportation and operating room usage are eliminated. These advantages are mitigated by the fact that bedside anesthesia is required, and that recently advocated bronchoscopic visualization adds to the expense and personnel required. Moreover, it is important to prepare for the possibility of an emergent open tracheostomy. Its disadvantages stem from the decreased exposure and thus decreased visualization and control. It is commonly acknowledged that the following patients are not good candidates: the obese, those with abnormal or poorly palpable anatomy, those needing emergency airway, the coagulopathic patient, and the patient with an enlarged thyroid.

PICTURES

BIBLIOGRAPHY

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