Tracheostomy

Description:

Tracheostomy provides direct access to the trachea via the anterior neck, allowing for insertion of an airway that bypasses the pharynx and larynx.

Indications for Surgery:

Airway obstruction at the level of the pharynx, larynx, or proximal trachea resulting from malignancy, benign growth, stenosis, trauma, or inflammatory disease. Tracheostomy may also be performed in severe, refractory cases of obstructive sleep apnea, for prolonged respiratory failure (chronic ventilator dependency, failure to wean), for chronic aspiration, or in patients who are unable to maintain adequate pulmonary toilet.

Contraindications to Surgery:

• In rare cases, tracheostomy may not be possible if the patient’s neck cannot be adequately extended to expose the trachea, if there is ongoing severe soft tissue infection of the neck, or if there is extensive involvement of the anterior neck by tumor.
• Excessive risk of bleeding due to coagulopathy, anticoagulation or anti-platelet medication; hemodynamic instability; and high positive pressure ventilation are relative contraindications.

Pre-Operative Evaluation:

• No pre-operative imaging is typically required
• The physical exam should note whether anatomic landmarks can be palpated, amount of soft tissue around the neck, ability to extend the patient's neck, presence of a high-riding innominate artery, and evidence of any prior procedures on the neck.

Anesthesia:

General endotracheal if possible; may be performed under local anesthesia in emergent cases

Surgical Technique:

1. The patient is placed supine on the operating table and general anesthesia is induced via orotracheal intubation.
2. A shoulder roll is placed and the neck is extended.
3. The skin of the anterior neck is injected with 1% lidocaine with 1:100,000 epinephrine.
4. A transverse skin incision is made at the level of the second and third tracheal rings.
5. The incision is carried down to the strap muscles, which are parted in the midline down to the pretracheal fascia, which is incised in a vertical fashion.
6. The thyroid isthmus is divided, clamped, and oversewn.
7. The anterior tracheal wall is freed and the interspace between the second and third tracheal rings is visualized.
8. A cricoid hook is placed under the inferior border of the cricoid cartilage to provide cephalad retraction of the trachea and to stabilize the airway.
9. A transverse incision is made in the interspace to enter the airway. In patients with difficult anatomy or a tenuous airway, or if a long-term tracheostomy is anticipated, a Mayo scissor may be used to excise a window of cartilage or to create an inferiorly based flap from the anterior tracheal wall, known as a Bjork flap, which is sutured to the skin.
10. The endotracheal tube balloon is deflated and the tube is withdrawn until the tip is just superior to the tracheal incision. A tracheostomy tube is inserted into the trachea via the incision.
11. The tracheostomy tube cuff is inflated, the anesthesia circuit is connected, and adequate ventilation is confirmed.
12. The faceplate of the tracheostomy tube is sutured to the anterior neck skin, and the tracheostomy tube ties are secured. A clean dressing is placed around the tracheostomy tube.
13. Care of the patient is returned to the anesthesiologist for recovery.

Post-Operative Care

• The initial tracheostomy tube should be left in place for 5-7 days.
• Tracheostomy care with frequent suctioning and cleaning of the inner cannula should be ordered along with constant humidification.
• Patients are generally kept in the hospital until after the first tracheostomy tube change and all home care and equipment have been arranged.

Complications:

• Bleeding
• Tracheitis
• Stomal granulation
• Subcutaneous emphysema
• Tracheoesophageal fistula
• Tracheoinnominate fistula
• Tracheal or subglottic stenosis
• Dislodgement of tracheostomy tube/loss of airway