Tracheostomy

Other than being a surgical technique, tracheostomy has many aspects that merit discussion; hence, I thought it best to consider these in a section of this book which is otherwise devoted to diseases of the trachea. Included elsewhere are historical notes on tracheostomy, surgical technique (see Chapter 22, "Tracheostomy, Minitracheostomy, and Closure of Persistent Stoma"), tracheostomy devices (see Chapter 38, "Tracheal Appliances" and Chapter 39, "Tracheal T Tubes"), and stents (see Chapter 40, "Tracheal and Bronchial Stenting").

Indications

For many years, tracheostomy was the primary means of providing emergency relief for upper airway obstruction. In the period following World War II, tracheostomy was considered to have three primary purposes: 1) emergency relief of airway obstruction, 2) management of secretions, especially after chest and central nervous system injury, and 3) to decrease respiratory dead space in order to improve ventilation. During the poliomyelitis epidemics of the early 1950s, tracheostomy was increasingly used to provide a route for administration of positive pressure ventilation for respiratory failure or impending respiratory insufficiency. This widespread use increased awareness of the many potential complications of tracheostomy and also introduced a new spectrum of lesions that resulted from intubation and mechanical ventilation. The immediate complications of tracheostomy, now very much reduced in incidence, are noted in this chapter, but the later complications, largely of postintubation origin, are dealt with in Chapter 11, "Postintubation Stenosis," Chapter 12, "Acquired Tracheoesophageal and Bronchoesophageal Fistula," and Chapter 13, "Tracheal Fistula to Brachiocephalic Artery." Also considered in this chapter is the special topic of tracheostomy in children.

Today, tracheostomy is rarely performed to provide an emergency airway. The airway is usually reestablished emergently by speedy insertion of an endotracheal tube, usually orally. Benign stenosis, such as that resulting from intubation, is best managed emergently by systematic dilation, without tracheostomy. Even in the presence of organic upper airway obstruction by a tumor, it is usually possible to slip an endotracheal tube into the airway, above or past an obstruction, in order to provide emergency ventilation until the obstruction can be dealt with bronchoscopically (see Chapter 19, "Urgent Treatment of Tracheal Obstruction"). For difficult intubations, a flexible bronchoscope is frequently of great help (Figure 10-1). The endo-tracheal tube is passed over the bronchoscope, which has been advanced beyond the obstruction. This technique is also valuable in patients with anatomically difficult airways or in those whose access is limited by severe cervical arthritis or temporomandibular arthritis, or by malformations. The rigid bronchoscope may also be a last resort for airway access, and in most cases, except the last mentioned, it can be introduced per-orally by a skilled bronchoscopist. On rare occasions, an endotracheal tube may be threaded over a rigid pediatric bronchoscope, with a short length of proximal "pusher" tube also threaded proximal to the endo-tracheal tube (see Figure 10-1). With the aid of a straight bladed laryngoscope (Miller blade), the assembly is passed into the airway, the endotracheal tube pushed into the trachea, and the bronchoscope and "pusher" tube withdrawn. The laryngeal mask airway is a useful option if all else fails (see Figure 10-1). Roberts discusses the many aspects of these problems in Clinical Management of the Airway.1 Finally, if obstruction is high, a large bore needle or a small bore catheter may be inserted through the cricothyroid membrane to provide emergent oxygenation while either intubation or tracheostomy is accomplished. Many previously seen immediate complications of tracheostomy were incurred during the emergent placement of a tra-

figure 10-1 Tools for the management of difficult intubations. From top to bottom. A, Endotracheal tube (ET) threaded over a flexible bronchoscope. B, Endotracheal tube over a pediatric rigid bronchoscope. Note the short segment of plastic "pusher" tube on the bronchoscope proximal to the ET. The assembly is introduced with a straight-bladed, open laryngoscope. The ET adapter is replaced after intubation is effected. C, Laryngeal mask airway, which is introduced to rest upon and seal over the larynx.

cheostomy tube under poor conditions. With tracheostomy now being almost always an elective procedure, these early complications, such as injury to carotid vessels or pneumothorax, have vanished.

The second classic indication for tracheostomy, the management of secretions, has not been entirely replaced. However, with adequate humidification of the airway, effective employment of skilled pulmonary physiotherapy, endotracheal catheter suctioning, and more commonly, frequent flexible bronchoscopic aspiration, intubation is rarely necessary for secretions alone. Minitracheostomy, considered in detail later in this chapter, is an effective method for the management of persistent copious secretions.

With the advent of positive pressure ventilatory support, tracheostomy is no longer used to facilitate ventilation by reducing dead space.

A current major use of tracheostomy is as a route for mechanical ventilatory support. Endotracheal tubes are used for prolonged periods of time for ventilatory support. Although endotracheal tubes may produce their unique spectrum of complications, tracheostomy is often deferred for some time.2 No definitive studies are available to dictate a universally accepted management policy. If an endotracheal tube must be left in for more than 48 hours, it is often replaced with a more comfortable nasotracheal tube. Secretions are more easily managed by nursing staff through a tracheostomy tube than through an endotracheal tube. For this reason, as well as for patient comfort, and, importantly, in order to avoid serious injury to the glottis and subglottis, we usually replace an endotracheal tube with a tracheostomy tube in an adult in between 5 to 7 days, unless it appears that the patient may be weaned in a further short period of time. If it is clear that a patient will require prolonged mechanical ventilation, as in polyneuritis, then tracheostomy is done earlier.

Tracheostomy continues to be useful to establish an airway temporarily or permanently wherever chronic obstruction presents, and definitive correction must be postponed or is not possible. In many such situations, a T tube will be preferable (see Chapter 39, "Tracheal T Tubes").3 In the case of an obstructive benign stenosis which is accessible in the neck, it is mandatory that the tracheostomy or T tube stoma be located in the stenotic segment. In this way, further damage to the trachea is prevented, and if resection is later possible, the stoma and stenotic lesion will be simultaneously resected. Unfortunately, surgeons continue to place tracheostomies below such lesions, thereby damaging a further centimeter or two of the trachea (Figure 10-2A). Often, it becomes necessary to relocate such a misplaced stoma to the stenotic segment and allow the initial stoma to heal, in order to recapture this length of trachea and so facilitate or make possible later reconstruction. If a stenotic lesion is very low, even retrosternal, the stoma is carefully placed at the conventional level (second and third rings), leaving a generous segment of normal trachea between the stoma and lesion. The tracheostomy tube must then be long enough to pass through the dilated stenosis to splint it open. If the tracheostomy tube tip lies above the stenosis, it will only create an illusion of airway control (Figure10-2B).

Additional indications for tracheostomy include complementary use with laryngeal anastomoses that may suffer transient glottic edema and for management of aspiration due to laryngeal dysfunction. Postoperative tracheal anastomotic complications may require tracheostomy (or T tube placement), sometimes for definitive management, but most often to permit resolution until reconstruction may again be safely considered (see Chapter 21, "Complications of Tracheal Reconstruction"). Tracheostomy should generally not be used for an obstructing tumor. Tumor is best managed in emergency by intubation past the tumor and then by the coring-out of tumor bronchoscopically (see Chapter 19, "Urgent Treatment of Tracheal Obstruction"). Definitive treatment then follows, either surgical resection or irradiation. Occasionally, under emergency circumstances in non-hospital settings, the need arises for external opening into the airway. Most often, the Heimlich maneuver accomplishes dislodgement of an acute supraglottic obstruction, such as that caused by an aspirated chunk of food. If this fails, and in the absence of laryngoscopic equipment, cricothyroidotomy should be employed. The cricothyroid membrane is the most superficial portion of the cervical airway. Even in obese individuals, this area can usually be palpated with the neck in hyperexten-

sion. In my opinion, cricothyroidotomy should almost never be used as an elective route of airway intubation because of the likelihood of serious and possibly irreversible laryngeal damage. Emergency cricothyroidotomy is preferably converted to tracheostomy if its use will be prolonged.

Jackson in 1921 cautioned against "high tracheostomy" (cricothyroidotomy) as a cause of subglottic stenosis (Figure 10-2C-E).4 The precept was challenged by Brantigan and Grow in 1976, although they later reported an incidence of subglottic stenosis following the elective procedure.5,6 Antecedent endotracheal intubation for a length of time appeared to predispose to such a stenosis.7,8 An overall incidence of at least 2% stenosis and up to 32% permanent voice changes followed cricothyroidotomy.7 Since there are few real advantages, if any, to cricothyroidotomy over tracheostomy, and since subglottic laryngeal stenosis is sometimes poorly correctable or impossible to correct, whereas nearly all postintubation tracheal stenoses are initially correctable, there is no reason to subject a patient to the hazard of cricothyroidotomy. The concern which led to the use of cricothyroidotomy, that is, separation of the stoma from median sternotomy for cardiac surgery, may be addressed by a few days of endotracheal tube ventilation to allow tissue planes to seal, thereby permitting tracheostomy to be done safely. However, the question of whether cricothyroidotomy poses a threat to median sternotomy remains controversial.9,10

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