Tracheostomy

Video

2.1 Tracheostomy

Introduction

Tracheotomy (tracheostomy) is one of the oldest surgical procedures known, with the first reference in 3600 BCE. Chevalier Jackson is credited with standardizing the tracheotomy procedure in 1932, outlining the individual steps for establishing a direct airway through the anterior neck tissues and into the trachea. This technique was subsequently used during the polio epidemic. Throughout the years, this technique has evolved to include three primary techniques: percutaneous dilatational, open surgical, and other new percutaneous techniques. This chapter focuses primarily on the open technique and briefly reviews the classical percutaneous dilatation technique. At present, the tracheostomy is more commonly used for prolonged mechanical ventilation rather than for upper airway obstruction.

Indications and Principles of Tracheotomy

Indications for tracheotomy are multiple and include the need to bypass an airway obstruction caused by congenital anomaly, vocal cord paralysis, inflammatory disease, benign or malignant laryngeal pathology, laryngotracheal trauma, facial trauma, or severe sleep apnea refractory to other interventions. Currently, the most common indication for tracheostomy is acute respiratory failure with need for prolonged mechanical ventilation. The second most common indication is in patients with neurologic insult requiring a safe, comfortable airway with possible need for home mechanical ventilation. Upper airway obstruction is currently a less common indication for tracheostomy.

Preoperative Considerations

Once a tracheotomy is planned, certain factors influence whether patients should have an open tracheotomy or a percutaneous dilatational tracheotomy (PDT), as first described by Ciaglia in 1985.

If the consideration for PDT is present, the following ideally should also be present: (1) easily palpable tracheal landmarks, (2) a skilled bronchoscopist who helps guide the proceduralist and prevent extubation, and (3) knowledge of when conversion to open tracheostomy is necessary.

Regardless of the tracheotomy method chosen, a patient’s overall medical condition must be optimized, body habitus assessed, and coagulation profile addressed, because these too help determine which tracheotomy method is most ideal. Other important considerations include the urgency of the procedure, which is often directly related to the current status of the airway.

In determining whether to perform the procedure open vs. percutaneously, surgeons must consider availability of proper equipment, patient portability, surgeon’s experience (open vs. percutaneous technique), and capability of the institution to perform bedside procedures. This will determine which team performs the procedure and whether it will be done in the operating room or at the bedside in the intensive care unit.