Speech-Ready, Long-Term Tube-Free Tracheostomy for Obstructive Sleep Apnea

1

Introduction

Obstructive sleep apnea (OSA) is caused by obstacles to the free flow of air through the upper airway from the lips or nasal tip to the larynx and therefore is within the otolaryngologist's sphere of responsibility. Management can involve weight loss, treatment of nasal obstruction, surgery of the pharynx, or the use of various ventilatory assist devices such as continuous positive airway pressure (CPAP). This condition has serious health risks and consequences and should be thoroughly researched and investigated to be treated effectively. Furthermore, it is often multifactorial, requiring a multidisciplinary approach to identify the etiology and optimal treatment for each patient.

Tracheotomy (or tracheostomy) provides the most efficacious bypass of upper airway obstruction and is rightfully considered among the treatments of OSA. Although they can singularly cure OSA, tracheotomy/tracheostomy are regarded as extreme modes of treatment due to associated surgical and postoperative morbidities. In various instances these procedures are reserved for emergencies such as difficult intubation or are considered as last resorts in patients with severe, refractory, or life-threatening apnea. Other less frequent indications include morbid obesity, complicated oropharyngeal obstruction with severe hypoxia, failed management attempts, and disabling daytime somnolence.

2

Patient Selection

As a treatment option for patients with OSA, tracheotomy/tracheostomy can be performed either as definitive therapy or as a temporary means to control the airway while another upper airway surgery is performed. For instance, the risks of difficult intubation or postoperative airway obstruction due to perioperative edema and hemorrhage may necessitate short-term tracheotomy before, during, or after other surgeries. For most patients, the perioperative risks of such other surgery can be obviated through CPAP or remain low enough that temporary tracheotomy is not necessary. When tracheotomy is performed for this indication, the technique may be in some instances similar to that for any other short-term, tube-dependent procedure. However, as will be further discussed, the degree of obesity and the difficult anatomy that frequently causes OSA may lead to higher rates of intraoperative and/or postsurgical complications that mandate modification of traditional tracheotomy. Furthermore, as patients may fail to lose weight or may not benefit from other surgeries, tracheotomy may not always be as short term as originally planned. For these reasons, traditional tracheotomy has given way to both tube-dependent and tube-free tracheostomy techniques in the management of OSA.

When permanent tracheostomy is considered, it is generally indicated for one of three scenarios. The first scenario is dictated by the patient's abnormal anatomy that cannot be managed under the limitations of traditional tracheotomy and therefore requires tracheostomy. The second scenario may be encountered in patients with OSA who have failed more conservative medical and/or surgical therapies. As the rest of this book demonstrates, CPAP may not always be applicable, effective, or well tolerated, and other surgical techniques lack the 100% success rate of bypassing obstruction, which is the hallmark of tracheostomy. For patients who fail at weight loss or continue to have medically significant OSA despite conservative medical and/or surgical management, tracheostomy may be considered the final measure of what is a graduated, stepwise approach to treatment.

In the last scenario, tracheotomy/tracheostomy is performed as the primary procedure for control of severe disease and/or life-threatening cardiopulmonary manifestations of OSA. Polysomnographic indications for tracheostomy as a primary treatment modality for OSA include Respiratory Disturbance Index >50 and oxygen desaturation to <60%. Additionally, if OSA of any severity causes significant cor pulmonale or cardiac dysrhythmias in association with the apneic episodes, tracheostomy might be warranted as the initial management of choice. For instance, severe bradycardia, asystole, multiple premature ventricular contractions, and even runs of ventricular tachycardia in association with apneas may all serve as indications for primary tracheostomy. Lastly, other comorbid states such as impending or recent myocardial infarction, unmanageable hypertension, or diabetes mellitus might serve as indications for immediate and conclusive management through urgent tracheostomy. For example, an epileptic who experiences seizures while apneic or a patient with coronary artery disease who develops nocturnal angina in association with OSA might be promptly and effectively managed with tracheostomy. When indicated, such patients may benefit from the use of modified transtracheal ventilation (e.g. CPAP) at all stages of their treatment (see later).

3

Tracheotomy and Tube-Dependent Tracheostomy

“Standard tracheotomy” might be performed in situations in which the duration of cannulation is not expected to exceed several days. These tracheotomies might be performed in OSA if they are used to temporarily secure the airway while other upper airway surgery is performed. Even then, the technique may require modifications such as lipectomy or resort to specially designed and constructed tubes to be safe and effective. Once postoperative edema is resolved and the risk of perioperative hemorrhage and any other problems have been overcome, the tracheotomy tube may be withdrawn and the tracheotomy site allowed to heal by secondary intent. If prolonged cannulation is expected, such “standard tracheotomy” (even when modified) is not the procedure of choice. Patients with severe OSA are prone to developing more serious complications as they often have short, thick necks and high incidence of anatomic deformations. Chondritis, granulation tissue, infection, and stenosis make long-term maintenance of a “temporary standard tracheotomy” undesirable.

Techniques for “permanent” tracheostomy were developed to minimize these complications whenever cannulation is expected to be prolonged. Among the several indications for establishment of a “permanent” skin-lined tracheostoma are severe laryngeal or laryngotracheal stenosis, bilateral vocal cord fixation (conditions that may cause OSA in and of themselves), neurologic conditions such as myasthenia gravis and amyotrophic lateral sclerosis, and, of course, severe OSA. The first report of permanent tracheostomy for the management of pulmonary disease was by Penta and Mayer in 1960; the technique was subsequently popularized for OSA by Fee and Ward in 1977. These techniques aim to decrease the length of the tracheocutaneous tract and bring the margins of the tracheal fenestration into direct contact and continuity with the cervical skin. Shortening the skin-to-trachea tract limits granulation tissue within the wound bed, promotes primary healing of the mucocutaneous junction, inhibits stomal stenosis, and aims to limit other complications associated with prolonged tracheotomy.

There are several techniques for creating a “permanent” tracheostoma depending upon the degree of continuity established between the trachea and the cervical skin. One early method for creating a permanent tracheostomy was the Bjork flap, in which an inferiorly based tracheal flap (generally created from the anterior portion of the second or third tracheal ring) is sutured to the inferior skin margin. Use of this flap relative to standard tracheotomy reduced rates of accidental decannulation and facilitated reinsertion of a displaced tracheotomy tube. Later methods for tracheostomy attempted to further improve the primary attachments between the trachea and the skin. An example is the “H-flap” technique described by Mickelson. By mobilizing both cervical skin and tracheal flaps, a fully circumferential stoma is created through this technique.

More extensive surgical approaches were researched with the intent to achieve maximal shortening of the tracheocutaneous tract, at the same time producing a tension-free, fully circumferential, permanently patent mucocutaneous junction. These modifications are designed to promote primary healing, ease wound care, and facilitate recannulation more readily than the Bjork flap or the H-flap. Protracted healing by secondary intent, which is often accompanied by stenosis or scar formation, is thus minimized. In past experiences, even these permanent tracheostomies depended upon prolonged placement of irritating foreign bodies in the form of tracheotomy tubes or designated stoma stents. As will be discussed later, these tube- or stent-dependent tracheostomy techniques, although better tolerated than standard tracheotomy, still develop inevitable tube-related complications, which have led to the evolution of the tube-free concepts advocated by the authors.