Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea. The traditional semantic difference between "ostomy" and "otomy" is blurred in this instance, as the hole is variably permanent. With a cannula in place, an unsutured opening will heal into a patent stoma within a week. When decannulated (ie, the tracheostomy cannula is removed), the hole will close in a similar amount of time. The cut edges of the tracheal opening can be sutured to the skin with a few absorbable sutures to facilitate cannulation and, if necessary, recannulation; alternatively a permanent stoma can be created with circumferential sutures. The term tracheostomy is used, by convention, for all of these procedures. It is considered synonymous with tracheotomy.
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
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.
