The use of tracheostomy in palliative care offers a viable option for airway control. Through a dialogue with the patient, family, and a multidisciplinary set of providers, this procedure can be a useful component to a patient’s overall palliative care plan. The authors discuss techniques for placing a tracheostomy tube and indications for placement in palliative care for alleviation of chronic and acute symptoms.
Tracheostomy is a procedure with a long history. The earliest account of tracheostomy is depicted in Egyptian tablets dating back around 3600 bc . Although other accounts from Egypt and India describe what are believed to be tracheostomy procedures, a formally recognized account of elective tracheostomy is credited to Aesclepiades of Bithynia in the first century bc . The earliest accounts of tracheostomy largely described the procedure as a life-saving maneuver associated with a high mortality risk. Although early physicians such as Galen hailed the procedure as holding promise for patients, millennia would pass before the inherent risks could be overcome to make the procedure more acceptable.
Pierre Bretonneau is credited as being one of the pioneers in making tracheostomy an accepted procedure. In the 1820s, he described the use of tracheostomy for treatment of obstructive diphtheria. The procedure had a 73% mortality rate, which was still an improvement over the overall mortality of diphtheria at the time. Chevalier Jackson’s pioneering work in laryngology and bronchoesophagology during the late 1800s helped to improve the tracheostomy procedure. His work in understanding and manipulating the airway helped improve the surgical techniques of tracheostomy to make it a safer procedure. Use of the procedure, particularly in the treatment of airway obstruction, became a more viable alternative with a lower mortality. The use of tracheostomy decreased with the development of a diphtheria antiserum. When cases of diphtheria dropped by the early 1900s, removing this disease as a significant health threat, the rate of tracheostomy decreased concomitantly.
One could credit the ravages of polio and post polio syndrome as leading to the resurgence of tracheostomy and its consideration in palliative care. In 1928, the iron lung was successfully used on a pediatric patient with polio-induced respiratory failure. As a noninvasive means of ventilation, this device was useful and saved many lives; however, it was large and expensive, costing as much as the average home at the time. Such limitations led James Wilson to propose the use of tracheostomy in 1932 as a means of ventilation. This consideration by Wilson helped moved tracheostomy from a treatment in obstruction to palliative ventilation.
Anatomy and surgical technique
Knowledge of the relevant anatomy is important in tracheostomy. Although this anatomy is well known to those who perform the procedure, key elements are described herein for those who are less familiar. The trachea is palpable in the midline neck below the level of the thyroid cartilage and cricoid cartilage. Important landmarks to identify include the sternal notch, thyroid notch, thyroid cartilage, and cricoid cartilage. In patients with thick necks, intervening neck tumor, or life-threatening infection, the landmarks may be less prominent. The position of the thyroid gland is identified and is necessarily encountered in tracheostomy placement. One must be careful to identify these structures, because the trachea may be diverted off midline in some patients due to pathologic processes pushing the trachea to the side; in other patients the trachea may dive deep and away from the neck skin.
Tracheostomy may be performed by several means. The main divisions of tracheostomy methods are open and percutaneous. One version of the open method, preferred by the authors, is described briefly herein. The skin is palpated and marked below the level of the cricoid cartilage at the approximate level of the second tracheal ring. With the patient’s neck extended using a shoulder roll and the skin prepared in a sterile fashion, a horizontal incision is made long enough to facilitate access to the deeper tissues and trachea. Once the strap muscles are encountered, they are pulled laterally after division of the median raphe. The thyroid isthmus is encountered and divided. The trachea is identified, and the interspace between the second and third tracheal rings is located ( Fig. 1 A ). In any airway surgery clear communication with the anesthesia team is maintained because they need to assist in completing a successful tracheostomy without losing the airway. This interspace is sharply incised, and the trachea is entered.
Once the airway is entered, the final steps to creating a tract are at hand. For a long-term tracheostomy, it is recommended that a skin-trachea flap be developed. This flap allows for rapid creation of a well-defined tract and permits easy tracheostomy tube exchange in the short and long term. A common method is a Bjork flap. By making an inferiorly based U-shaped flap in the trachea, the skin is sutured down to this flap to create a tract ( Fig. 1 B). Another method is to remove a section of the trachea and suture the skin to the edges of the trachea circumferentially ( Fig. 1 C). Both of these methods can be particularly helpful in the palliative care setting in which a family member, visiting nurse, or nursing home practitioner primarily cares for the tracheostomy on a regular basis. After creating the opening and tract, an appropriately sized tracheostomy tube is placed within the opening and secured to the patient ( Fig. 2 ). The authors prefer to suture the flanges to the skin and place a tracheostomy tie around the neck at the time of surgery.
The percutaneous method respects the same anatomic boundaries as in the open method. The airway is entered by first making a small skin incision. Concurrent tracheobronchoscopy to visualize the percutaneous airway instrumentation may be performed to reduce complications. A needle is used to enter the tracheal interspace. Through the needle, a wire is passed in to the airway, which allows for percutaneous dilators to pass into the trachea. In this manner, the airway tract is developed for placing a tracheostomy tube.
There is an ongoing discussion over the merits of each method. Extensive review of this discussion is beyond the scope of this text; the notes provided in the following sections are offered as general considerations. Each method has its advantages and disadvantages. The open method allows for excellent visualization and creation of a stable tract. Generally, it requires an operating room setting but can be performed at the bedside with the proper set-up. The percutaneous method is facile at the bedside and in the operating room. It should not be performed in patients who have thick necks or distorted cervical anatomy, because there is increased risk of airway and cervical complications. Both methods carry the risk of airway loss, bleeding, trauma to the airway, and other complications. When compared with the earliest efforts at the procedure, the surgery is generally safe and well tolerated by patients.
Indications and decision making in palliative care
The indications for tracheostomy as part of a palliative care plan do not differ greatly from those in the acute or intensive care setting; however, the decision is often guided by a different set of objectives, such as symptom relief, improvement in patient well-being, facilitation of activities of daily living, and, if possible, optimization of long-term function. Surgical intervention is not decided on the basis of curative outcomes which are for the most part measurable and objective; instead, the decision must address the foreseeable and imminent course of a patient’s disease and take into account other more humanistic factors such as spiritual needs and psychosocial resources. Whenever tracheostomy is considered in the setting of palliative care, it is necessary to have a dialogue about the patient’s desire for his or her quality of life, their projected prognosis, and the optimal timing in the natural progression of their disease.
Of utmost importance is preservation of the quality of life. What this means may differ widely from patient to patient. In the setting of terminal illness, this discussion naturally extends into the topic of the quality of dying as well. Patients and their families are often concerned about the potential limitations that tracheostomy and eventual ventilator dependence will place on the patient’s quality of life. Often, there are concerns that tracheostomy serves to prolong life without contributing significantly to quality of life. Additionally, for most patients, a tracheostomy implies an impending change in swallowing and speech function. It is necessary for the physician to address these fears, to present possible options for voice and swallowing preservation, and to discuss realistic outcomes for the individual patient before proceeding. In the setting of progressive motor neuron or neuromuscular disease, this conversation is often complicated by the anticipated decline in bulbar function which was perhaps the impetus for discussion of tracheostomy in the first place. Early involvement of a speech and language pathology team may be helpful in optimizing long-term outcomes.
Tracheostomy should be considered in the context of a patient’s desires and beliefs and integrated as part of a larger long-term palliative care plan. If needed and timed properly, it can contribute greatly to the quality of a patient’s life.
Common reasons for placement of a tracheostomy include airway obstruction, chronic aspiration, or the need for pulmonary toilet or prolonged ventilation from general deconditioning, an acute neural insult, or progressive neuromuscular decline. Loss of control of any one of the closely coordinated functions of the upper aerodigestive tract (respiration, deglutition, or speech) often may result in difficulties with the others. Each of these indications is discussed herein with particular attention to relevant issues in palliative care.
Airway Obstruction or Prolonged Ventilation
The need to secure an airway in the setting of impending airway compromise seems at first glance to require little discussion. Examples of possible airway obstruction encountered in the palliative care setting include unresectable malignancies of the oral cavity, oropharynx, larynx, and thyroid; vocal cord fixation from invasive tracheal tumors; and obstructive cervical metastases. In addition to obstructive processes, decline in muscular control of the upper aerodigestive tract or generalized deconditioning may necessitate long-term mechanical ventilation and intubation.
In the setting of palliative care when impending airway obstruction or compromise may not be on the order of minutes but projected on the order of weeks to months, anticipation is key. As Ross and Abrahm advocate in their article, discussion of palliative surgery should ideally happen on a continuum of disease management rather than when the patient reaches the point of distress or extremis. This dialogue should be an ongoing and paced discussion that anticipates but does not unduly burden the patient or family physically, psychologically, socially, or spiritually.
Symptom anticipation is an advanced approach to the principle of symptom management in palliative care. Anticipatory management before catastrophic events is desirable and supported by outcomes. There is a greater complication rate with emergency airway management in the field and in the hospital. Cricothyroidotomy carries with it the highest risk of complication, ranging from 13% to 40%. Elective tracheostomy has about a 15% complication rate, and emergency tracheostomy is estimated to be associated with two to five times the risk of elective tracheostomy. Moreover, within a hospital setting, cricothyroidotomy was successful in only 87% of attempts to establish an airway, whereas tracheostomy was successful in securing the airway in 100% of attempts. In the field, the adequacy of cricothyroidotomy decreased to 64%, but this was not recognized until arrival at a trauma center. In fact, advanced life support providers judged that they had adequately secured these airways via cricothyroidotomy in 89% of patients.
The primary physician responsible for coordinating the patient’s palliative care plan should engage the patient, family members, and appropriate consultants in an interdisciplinary dialogue early in the onset of disease. This collaboration may include disease specialists such as oncologists, surgeons, anesthesiologists, speech language pathologists, nurses, social workers, and clergy. This discussion should ideally occur when airway compromise is foreseen as the natural course of disease, before the point when the urgency of the decision obscures the ability to weigh the patient’s values and desires adequately. The discussion of tracheostomy should be integrated as a part of an ongoing discussion of the patient’s long-term plan rather than a separate singular surgical intervention. The patient should be presented with any reasonable alternatives for airway management, such as surgical debulking of a tumor or palliative radiation and chemotherapy with the goal of relieving tumor burden.
Ultimately, the decision for or against tracheostomy should be left to the patient; however, specialists and primary palliative care providers have the obligation to ensure that a patient understands the ramifications of his or her decisions. For instance, a patient with an unresectable cancer of the upper aerodigestive tract who refuses tracheostomy as part of their care plan must understand what he or she is choosing in terms of comfort and dignity in dying by progressive respiratory compromise.
Chronic Aspiration and the Need for Pulmonary Toilet
Chronic aspiration and pulmonary toilet requirements are common, closely related indications for tracheostomy in palliative care. Loss of specific muscle coordination due to decline of bulbar function, loss of lower cranial nerves secondary to stroke, the mass effect or fixation of any part of the swallowing apparatus from a sizable head and neck tumor, excessive gastric secretions in gastrointestinal cancers or carcinomatosis of the bowel, and general deconditioning are all situations that may predispose a patient to chronic aspiration and the need for aggressive pulmonary toilet.
Tracheostomy should not be thought of as a cure for aspiration. In fact, tracheostomy can worsen aspiration by preventing elevation of the larynx with swallowing. Schonhofer and colleagues reported a 30% aspiration rate in patients who were tracheotomized.
First-line measures for the prevention of aspiration include pharmacologic control of excessive secretions, limitation of food consistencies based on swallow evaluation, reinforcement of swallowing techniques by a speech language pathologist, and the use of nonoral feeding options (eg, parenteral nutrition and nasogastric tube feeds). If all other medical alternatives have been attempted and deemed ineffective for a long-term solution, consideration of surgical management options including tracheostomy is appropriate. In the palliative care setting, surgical intervention may be justified for intractable life-threatening aspiration and on the basis of improving patient comfort.
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