Introduction
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Tracheostomy is essentially a “shortcut” into the airway that “bypasses” the upper airway.
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Most tracheostomies are performed for ventilator support in critically ill patients or as a temporary airway to accompany surgical procedures on the oral cavity, pharynx, or larynx ( Fig. 19.1 ).
Fig. 19.1
Large-volume papilloma obstructing the airway in a young child.
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Less common indications include sleep apnea, chronic lung disease, primary alveolar hypoventilation syndrome (Ondine curse), and conditions requiring prolonged mechanical ventilation.
Key Operative Learning Points
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Performance of a tracheostomy is substantially easier than making the decision to perform the procedure and where, when, and how to perform it.
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Most adverse outcomes from tracheostomy occur in the postoperative period, not intraoperatively.
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Cricothyroidotomy is the preferred procedure in emergency airway settings where seconds count.
Preoperative Period
History
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Why does this patient need a tracheostomy?
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How soon will it be necessary?
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How long will it be required?
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Will the patient be on mechanical ventilation?
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If so, for how long?
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Are there any alternatives?
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Where and by whom will the tracheostomy be managed?
Past Medical History
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Has the patient undergone prior tracheostomy or other neck surgery?
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Can the patient tolerate general anesthesia?
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Is the patient anticoagulated? If so, can it be stopped for the procedure?
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If on mechanical ventilation, what are the peak pressures?
Physical Examination
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Position of cricoid cartilage and trachea in the neck
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Presence of overlying masses or open wounds
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Evidence of blood dyscrasias (bleeding from puncture sites, gums)
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Ability of the patient to extend the neck
Imaging
Not required
Indications
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Relief of upper airway obstruction (both acute and chronic)
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Provide a means for assisted mechanical ventilation
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Facilitate efficient tracheobronchial toilet
Contraindications
There are almost no absolute contraindications to tracheostomy. Those most commonly encountered are uncorrectable coagulopathies such as in patients with end-stage liver failure and extremely high ventilation pressures that may lead to flash pulmonary edema if the pressure is relieved suddenly for the time required for a tracheostomy.
Preoperative Preparation
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Decide whether a tracheotomy is indicated.
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The decision to proceed with a tracheostomy is complex. Factors to consider include the following:
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Relative advantages and risks of tracheostomy
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Expected duration of endotracheal intubation
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Capabilities of the institution and its personnel
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Unique features of the patient’s airway and respiratory physiology
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Specific disorder or disease process and its likely course
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Every effort should be made to ensure that the patient’s condition is optimized before the tracheostomy. Coagulopathies should be corrected and aspirin or other nonsteroidal anti-inflammatory medications stopped if possible.
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Patients presenting with stridor require that a safe airway be established as rapidly as possible.
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Often, emergency control of the airway can be most rapidly accomplished with endotracheal intubation with or without endoscopic guidance.
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Inability to intubate due to pharyngeal or laryngeal edema or tumor, or severe facial or laryngeal trauma, may mandate awake tracheostomy or cricothyroidotomy.
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In an emergency, when seconds count, most surgeons would choose to perform cricothyroidotomy. Although it avoids the thyroid isthmus, cricothyroidotomy is not bloodless.
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Location: Tracheostomy in many institutions is routinely performed in the operating room (OR), whereas in others it is safely performed in the intensive care unit. Adequate instrumentation, lighting, suction, and assistance are required.
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Anesthesia or critical care teams should be present to manage the patient’s cardiorespiratory function during tracheostomy. Patients with chronic respiratory insufficiency may require assisted ventilation and even cardiopulmonary resuscitation once obstruction is relieved.
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Preoperative planning should consider appropriate tracheostomy tube selection.
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The tube must provide an adequate airway, facilitate artificial positive pressure ventilation if necessary, seal the trachea to reduce aspiration of material from above, and provide a means of suctioning the tracheobronchial tree.
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Aspects of tube selection include the length, diameter, and shape of the tube and the neck plate. Typically, cuffed tubes are placed in adults to reduce aspiration of secretions. Tubes with an inner cannula provide an added safety dimension because the inner cannula can be quickly removed in case there is a mucous plug, leaving the outer cannula in situ and the airway protected.
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Obese patients with thick pretracheal soft tissues may require extended-length tubes to decrease the risk of accidental decannulation or tube displacement.
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Extended-length tracheostomy tubes with proximal or distal extensions are available, as are tubes with adjustable flanges and length.
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Surgeon protection: All personnel in the OR should wear masks with face shields because splattering of purulent tracheal secretions commonly occurs at the time the cannula is inserted into the trachea.
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Operative Period
Anesthesia
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Tracheostomy may be performed under general, local, or awake sedation.
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The choice of local or general anesthesia is dictated by the circumstances.
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Patients with a marginal airway and respiratory distress must be managed with local anesthesia alone without sedation, which may suppress respiratory drive.
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In children, the procedure is usually carried out under general anesthesia.
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When performing the procedure under local anesthesia, additional plain lidocaine is injected into the pretracheal tissues as the dissection deepens, because early airway injection may precipitate panic with subsequent obstruction.
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The surgeon should always stand by during intubation because adverse airway events can occur unexpectedly.
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Decisions and discussions regarding oxygen saturation should occur before starting the procedure. If the patient requires higher than 30% oxygen to maintain saturation, then electrocautery should not be used when the trachea is opened. Many teams routinely switch to 100% oxygen at this point due to the risk of desaturation from loss of airway pressure.
Positioning
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Position the patient supine with the neck extended.
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Usually the patient is placed on the operating table with a rolled towel or sheet under the shoulders to extend the neck, unless the patient has documented or suspected cervical spine injuries.
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Adults with airway obstruction may not be able to lie flat, and the tracheostomy may need to be performed with the patient sitting up at 45 degrees.
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Patients with severe cervical osteoarthritis, kyphoscoliosis, or other conditions in which the neck cannot be hyperextended present a formidable surgical challenge.
Perioperative Antibiotic Prophylaxis
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Although considered a “clean contaminated” procedure, tracheostomy is often performed in the presence of purulent tracheal secretions.
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If the patient is not already on antibiotics, they must be administered during induction of anesthesia and continued for a minimum of 24 hours.
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Antibiotic choices are typically driven by prior cultures in ill patients.
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Clindamycin
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Amoxicillin-clavulanate
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Cephalosporin and metronidazole
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Monitoring
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Routine anesthesia monitoring is needed with careful attention to oxygen saturation.
Instruments and Equipment to Have Available
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Routine tracheostomy set
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Confirm the presence of a “trachea hook” in the set.
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Tube should be selected and the cuff tested and then deflated
Key Anatomic Landmarks
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Thyroid notch
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Cricoid cartilage
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Sternal notch
Prerequisite Skills
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Basic surgical skills
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Experience with anterior neck surgery
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Familiarity with the anatomy of the cricoid, thyroid, and trachea and the accompanying venous structures
Surgical Technique
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Lidocaine 1% with 1:100,000 epinephrine is injected into the skin and subcutaneous tissue where the incision will be made. The neck, face, and upper chest are prepared with a suitable solution, and a drape is placed to allow easy access to the neck and oral cavity.
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A transverse incision is made in a skin crease approximately 1 cm above the suprasternal notch or 2 cm below the cricoid cartilage.
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Sharp dissection is carried through the subcutaneous tissue. Small rake retractors are used to provide good exposure. The anterior jugular veins should be identified and retracted laterally ( Fig. 19.2 ); they need not be ligated unless inadvertently cut.
Fig. 19.2
The anterior jugular veins do not need to be sacrificed if uninjured.
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The strap muscles are split in the midline and retracted laterally ( Fig. 19.3A ).
Fig. 19.3
A, The strap muscles are split in the midline and retracted laterally. B, The trachea and thyroid isthmus are identified. C, The trachea is entered through an incision between the second and third tracheal rings as the thyroid isthmus is retracted superiorly, or divided, as required.
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The thyroid isthmus is visualized and the anterior wall of the trachea identified (see Fig. 19.3B ). Some surgeons routinely divide the thyroid isthmus, whereas others routinely retract it superiorly (see Fig. 19.3C ). Ligation of the isthmus is facilitated by first incising the fascia inferiorly to the cricoid, exposing the trachea, then undermining the isthmus, which is then clamped, transected, and suture-ligated.
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Once the trachea is identified, a tracheal hook is placed under the cricoid or at the second tracheal ring and held by an assistant to immobilize the trachea.
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In infants and children, a vertical incision is made between the second and the third or the third and the fourth tracheal rings without removing any cartilage. Traction sutures are then placed just lateral to the incision ( Fig. 19.4 ).
Fig. 19.4
Traction sutures are placed lateral to the stoma in children. No cartilage is removed.
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In adults, the trachea is opened transversely between the second and third or third and fourth rings. Caution should be exercised when using electrocautery close to the trachea because of the risk of airway fire.
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Resection of the anterior portion of a tracheal ring may facilitate insertion of the tracheostomy tube. In older patients, the tracheal ring is calcified, and heavy scissors or a Kerrison rongeur must be used to excise the anterior portion of the tracheal ring.
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Traction sutures are placed in the midline around the inferior and superior rings with a ligature carrier ( Fig. 19.5 ) or curved needle. Traction is applied to both sutures to exteriorize the stoma and retract the wound edges.
Fig. 19.5
Traction sutures are placed superior and inferior to the stoma in adults.
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The endotracheal tube or bronchoscope can be withdrawn to a point above the stoma at this point.
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Once the traction sutures have been satisfactorily placed and the endotracheal tube withdrawn, the tracheal cannula, with the obturator inserted, may be introduced into the stoma ( Fig. 19.6A ). Introduction of the tube is facilitated by beginning with the cannula at right angles to the trachea; then, as the cannula is inserted, it is rotated so that its axis is parallel to that of the trachea. Once the cannula is properly placed in the trachea, the obturator is removed and the inner cannula inserted. When the tracheostomy tube is in place and adequate ventilation through the tracheostomy tube is assured, the endotracheal tube or bronchoscope used to stabilize the airway may be removed.
