Tracheotomy
Tracheotomy, or tracheostomy, is a surgical airway management procedure which consists of making an incision on the front of the neck to open a direct airway to the trachea. The resulting stoma can serve independently as an airway or as a site for a tracheal tube to be inserted; this tube allows a person to breathe without the use of the nose or mouth.
Etymology and terminology
The etymology of the word tracheotomy comes from two Greek words: the root tom- meaning "to cut", and the word trachea. The word tracheostomy, including the root stom- meaning "mouth", refers to the making of a semi-permanent or permanent opening and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma at the time it is created.Indications
There are four main reasons why someone would receive a tracheotomy:- Emergency airway access
- Airway access for prolonged mechanical ventilation
- Functional or mechanical upper airway obstruction
- Decreased/incompetent clearance of tracheobronchial secretions
File:VIP Bird2.jpg|thumb|left|Tracheotomy tubes and endotracheal tubes are often attached to ventilators to assist in breathing.
In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet. Tracheotomy may result in a significant reduction in the administration of sedatives and vasopressors, as well as the duration of stay in the intensive care unit.
In extreme cases, the procedure may be indicated as a treatment for severe obstructive sleep apnea seen in patients intolerant of continuous positive airway pressure therapy. The reason tracheostomy works well for OSA is that it is the only surgical procedure that completely bypasses the upper airway. This procedure was commonly performed for obstructive sleep apnea until the 1980s, when other procedures such as the uvulopalatopharyngoplasty, genioglossus advancement, and maxillomandibular advancement surgeries were described as alternative surgical modalities for OSA.
If prolonged ventilation is required, tracheostomy is usually considered. The timing of this procedure is dependent on the clinical situation and an individual's preference. An international multicenter study in 2000 determined that the median time between starting mechanical ventilation and receiving a tracheostomy was 11 days. Although the definition varies depending on hospital and provider, early tracheostomy can be considered to be less than 10 days and late tracheostomy to be 10 days or more.
Alternatives
is a form of non-invasive mechanical ventilation that can — in a small subset of cases — allow people to avoid a tracheostomy.Components
A tracheostomy tube may be single or dual lumen, and also cuffed or uncuffed. A dual lumen tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The obturator is used when inserting the tracheostomy tube to guide the placement of the outer cannula and is removed once the outer cannula is in place. The outer cannula remains in place but, because of the buildup of secretions, there is an inner cannula that may be removed for cleaning after use or it may be replaced. Single-lumen tracheostomy tubes do not have a removable inner cannula, suitable for narrower airways. Cuffed tracheostomy tubes have inflatable balloons at the end of the tube to secure them in place. A tracheostomy tube may be fenestrated with one or several holes to let air through the larynx, allowing speech.Special tracheostomy tube valves have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound.
Surgical procedure
Open surgical tracheotomy (OST)
The typical procedure done is the open surgical tracheotomy and is usually done in a sterile operating room. The optimal patient position involves a cushion under the shoulders to extend the neck. Commonly a transverse incision is made two fingerbreadths above the suprasternal notch. Alternatively, a vertical incision can be made in the midline of the neck from the thyroid cartilage to just above the suprasternal notch. Skin, subcutaneous tissue, and strap muscles are retracted aside to expose the thyroid isthmus, which can be cut or retracted upwards. After proper identification of the cricoid cartilage and placement of a tracheal hook to steady the trachea and pull it forward, the trachea is cut open, either through the space between cartilage rings or vertically across multiple rings. Occasionally a section of a tracheal cartilage ring may be removed to make insertion of the tube easier. Once the incision is made, a properly sized tube is inserted. The tube is connected to a ventilator and adequate ventilation and oxygenation is confirmed. The tracheotomy apparatus is then attached to the neck with tracheotomy ties, skin sutures, or both.Percutaneous dilatational tracheotomy (PDT)
The first widely accepted percutaneous tracheotomy technique was described by Pat Ciaglia, a New York surgeon, in 1985. The next widely used technique was developed in 1989 by Bill Griggs, an Australian intensive care specialist. In 1995, Fantoni developed a translaryngeal approach of percutaneous tracheostomy. The Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison studies have been undertaken between these two techniques with no clear differences emerging. An advantage of PDT over OST is the ability to perform the procedure at the patient's bedside. This significantly decreases costs and time/people-power needed for an operating room procedure. Contraindications for percutaneous tracheostomy include infection at the site of tracheostomy, uncontrolled bleeding disorder, unstable cardiopulmonary status, patient unable to stay still, abnormal anatomy of the tracheolaryngeal structures.Risks and complications
As with most other surgical procedures, some cases are more difficult than others. Surgery on children is more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open. There are other difficulties with patients with irregular necks, the obese, and those with a large goitre.The many possible complications include hemorrhage, loss of airway, subcutaneous emphysema, wound infections, stoma cellulites, fracture of tracheal rings, poor placement of the tracheostomy tube, and bronchospasm.
Early complications include infection, hemorrhage, pneumomediastinum, pneumothorax, tracheoesophageal fistula, recurrent laryngeal nerve injury, and tube displacement. Delayed complications include tracheal-innominate artery fistula, tracheal stenosis, delayed tracheoesophageal fistula, and tracheocutaneous fistula.
A 2013 systematic review studied the complications and risk factors of percutaneous dilatational tracheostomy, identifying major causes of fatality to be hemorrhage, airway complications, tracheal perforation, and pneumothorax A similar systematic review in 2017 studying fatality in both open surgical tracheotomy and PDT identified similar rates of mortality and causes of death between the two techniques.
Hemorrhage is rare, but the most likely cause of fatality after a tracheostomy. It usually occurs due to a tracheoarterial fistula, an abnormal connection between the trachea and nearby blood vessels, and most commonly manifests between 3 days to 6 weeks after the procedure is done. Fistulas can result from incorrectly positioned equipment, high cuff pressures causing pressure sores or mucosal damage, a low surgical trachea site, repetitive neck movement, radiotherapy, or prolonged intubation.
A potential risk factor identified in a 2013 systematic review of the percutaneous technique was the lack of bronchoscopic guidance. Use of the bronchoscope, an instrument inserted through a patient's mouth for internal visualization of the airway, can help with proper placement of instruments and better visualization of anatomical structures. However, this can also be dependent on the skills and familiarity of the surgeon with both the procedure and the patient's anatomy.
There are a multitude of potential complications related to the airway. The main causes of mortality during PDT include dislodgment of the tube, loss of airway during procedure and misplacement of the tube. One of the more urgent complications include displacement or dislodgment of the tracheotomy tube, either spontaneously or during a tube change. Although uncommon, the associated fatality is high due to the loss of airway. Due to the seriousness of such a situation, individuals with a tracheotomy tube should consult with their healthcare providers to have a specific, written, emergency intubation and tracheostomy recannulation plan prepared in advance.
Tracheal stenosis, otherwise known as an abnormal narrowing of the airway, is a possible long term complication. The most common symptom of stenosis is gradually-worsening difficulty with breathing. However incidence is low, ranging from 0.6 to 2.8% with increased rates if major bleeding or wound infections are present. A 2016 systematic review identified a higher rate of tracheal stenosis in individuals who underwent a surgical tracheostomy, as compared to PDT, however the difference was not statistically significant.
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and a procedural mortality of 0%, which is comparable to those of other series reported in the literature from the Netherlands and the United States. A 2013 systematic review calculated procedural mortality to be 0.17% or 1 in 600 cases. Multiple systematic reviews identified no significant difference in rates of mortality, major bleeding, or wound infection between the percutaneous or open surgical methods.
Specifically a 2017 systematic review calculated the most common causes of death and their frequencies, out of all tracheotomies, to be hemorrhage, loss of airway, and misplacement of tube.
A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. The comparative study above also identified ring fractures in 9 of 30 live patients while another small series identified ring fractures in 5 of their 20 patients. The long term significance of tracheal ring fractures is unknown.