Tracheostomy

Tracheostomy

David Ray Velez, MD

Table of Contents

Indications and Timing
Materials and Types
Complications

See Also:

*Open Tracheostomy (Technique)
*Percutaneous Tracheostomy (Technique)
*See Tracheostomy Care and Long-Term Ventilator Weaning

Indications and Timing

Benefits (Compared to Prolonged Endotracheal Intubation)

  • More Comfortable and Better Tolerated
  • Decreased Work of Breathing
  • Decreased Dead Space and Airway Resistance
  • Improved Pulmonary Toilet, Oral Care, and Secretion Clearance
  • Facilitates Liberation from the Ventilator
  • Decreased Ventilatory Dependent Days
  • Shorter Hospital Stay
  • Shorter ICU Stay

Indications

  • Will Require Prolonged Mechanical Ventilation > 7 Days
  • Unable to Protect the Airway:
    • Unable to Clear Secretions
    • Severe TBI
    • Severe Maxillofacial Injury
    • Severe Neck/Vocal Cord Injury
  • Complex Tracheal Repair
  • Cervical Spinal Cord Injuries
  • Ventilator Dependent Due to Frequent Trips to the OR

Contraindications

  • Absolute Contraindications:
    • Soft Tissue Infection at the Insertion Site
  • Relative Contraindications:
    • FiO2 > 60%
    • PEEP > 12
    • Hemodynamic Instability
    • Anatomic or Vascular Abnormalities
    • Midline Neck Mass
    • Moderate-Severe Coagulopathy
    • Morbid Obesity
  • Percutaneous Approach is Contraindicated in Infants (Collapsible/Mobile Trachea)

Timing

  • Definitions Vary
    • Early: Performed within 2-14 Days
    • Late: Performed Around 14-21 Days
  • Benefits of Early Tracheostomy:
    • Higher Likelihood of Ventilator Liberation
    • Earlier Return to Walking, Talking, and Eating
    • No Change In:
      • Ventilator Associated Pneumonia (VAP)
      • ICU Length of Stay
      • Hospital Length of Stay
      • Mortality
  • Severe TBI and Cervical Spinal Cord Injuries May Particularly Benefit from Early Tracheostomy

Surgical Approach (Open vs Percutaneous)

  • Percutaneous Tracheostomy
    • Lower Risk of Surgical Site Infection
    • Improved Scar Cosmesis
    • Faster Procedure
    • Lower Cost
  • Similar Bleeding Risk, Decannulation Risk, and Mortality

Laryngotomia by Julius Casserius (1552-1616)

Materials and Types

Material

  • Shiley (Coviden) – Polyvinyl Chloride (PVC) Plastic
    • The Most Commonly Used Material
  • Bivona (Portex) – Silicone
    • Softer and More Flexible
  • Jackson – Metal
    • Rarely Used in Modern Practice

Tracheostomy Material: Shiley (Left), Bivona (Middle), Jackson (Right)

Size

  • In General, Use the Largest Size Possible for the Initial Placement
  • Most Common Sizes:
    • Adult Males: 8.0-8.5 mm
    • Adult Females: 7.5-8.0 mm

Cuff

  • Cuffed: Balloon at the End to Occlude the Surrounding Trachea
    • Benefits:
      • Allow Secretion Clearance
      • Protects from Aspiration
      • Allows More Effective PEEP
    • Generally Preferred for the Initial Placement
    • Cuff Pressure Should Be Maintained at 15-22 mmHg to Avoid Injury (Tracheal Capillary Perfusion Pressure is Normally 25-35 mmHg)
  • Uncuffed: Straight Tip with No Balloon at the End
    • Allows Airway Clearance but No Protection from Aspiration
    • Used More Commonly in the Long-Term Care and Ventilator Weaning

Tracheostomy Cuff: Cuffed (Left), Uncuffed (Right)

Fenestration

  • Has an Additional Opening in the Posterior Tube, Above Any Cuff
  • Also Requires a Fenestrated Inner Cannula
  • Allows Airflow Past the Tube but Does Not Prevent Aspiration
  • Used During the Weaning Process, Generally Not Used for the Initial Placement

Tracheostomy Fenestration: Fenestrated (Left), Non-Fenestrated (Right)

Length

  • Standard
  • XLT (Extended-Length Tube)
    • XLTP – Extra Length Proximally (In-Neck Before the Radial Turn)
      • For Swollen/Thick Neck Anatomy
    • XLTD – Extra Length Distally (After the Radial Turn into the Trachea)
      • For Long Tracheal Anatomy or Tracheal Stenosis

Tracheostomy Length

Complications

Accidental Decannulation/Dislodgement

Bleeding and Tracheoinnominate Fistula (TIF)

Tracheoesophageal Fistula (TEF)

  • Risk Factors:
    • High Cuff Pressure (#1)
    • Concomitant Nasogastric (NG) Tube
    • Excessive Motion
  • Presentation:
    • Ono’s Sign – Uncontrolled Coughing After Swallowing
    • Respiratory Distress
    • Recurrent Pneumonia
  • Initial Management: Large Volume Cuff Endotracheal Tube Below the Fistula to Prevent Aspiration
  • Definitive Treatment: Surgical Repair (Primary Repair vs Resection)
    • May Consider Combined Tracheal and Esophageal Stenting if Not a Surgical Candidate
      • Tracheal Stent Before Esophageal Stent – Esophageal Expansion May Compress the Trachea

Tracheoesophageal Fistula (TEF) 1

Tracheostomy Obstruction

  • Causes:
    • Mucous Plugging
    • Clotted Blood
    • Passage into A False Lumen (Paratracheal Soft Tissue)
    • Tube Angulation
  • Presentation:
    • Acute Respiratory Deterioration
    • Elevated Peak Airway Pressures
    • Unable to Pass a Suction Catheter Through the Tracheostomy Tube
  • Management:
    • Can Initially Attempt Suctioning of the Tracheostomy Tube to Clear the Obstruction
    • If Suctioning Fails: Exchange the Inner Cannula
    • If Exchanging the Inner Cannula Fails or Cannot Be Removed:
      • May Attempt Exchanging the Entire Tracheostomy Tube if the Tract is Mature
      • Low Threshold to Secure the Airway by Endotracheal Intubation if in Respiratory Distress

Tracheal Stenosis

  • The Most Common Late Complication
    • Almost All Have Some Degree of Stenosis
    • Only 3-12% Have Clinically Significant Stenosis
  • Typically Seen at the Level of the Stoma
  • Often Asymptomatic Until the Lumen is Reduced to < 5 mm (25-50% of Original Diameter)
  • Presentation:
    • Elevated Peak Airway Pressures if Infra-Stomal Stenosis
    • Dyspnea, Stridor, and Respiratory Failure After Decannulation
  • Grading:
    • Grade I: ≤ 50%
    • Grade II: 51-70%
    • Grade III: 71-99%
    • Grade IV: 100% (Complete Obstruction)
  • Complexity:
    • Simple:
      • Length < 1 cm
      • Only Involves the Mucosa
    • Complex:
      • Length ≥ 1 cm
      • Involves the Cartilage
      • Presence of Tracheomalacia
  • Diagnosis: Bronchoscopy
  • Treatment:
    • Simple: Serial Bronchoscopic Dilations
      • Possibly Bronchoscopic Resection or Laser Ablation
    • Complex: Tracheal Resection (Up to 6 cm) and End-to-End Anastomosis

References

  1. Paraschiv M. Tracheoesophageal fistula–a complication of prolonged tracheal intubation. J Med Life. 2014 Oct-Dec;7(4):516-21. (License: CC BY-2.0)