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Key Points
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Although described in numerous historic texts, tracheotomy did not become a routine surgical procedure until the late 19th to early 20th century.
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Indications for tracheotomy include relief of airway obstruction, access for head and neck surgery, pulmonary toilet, and need for prolonged mechanical ventilation.
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Tracheotomy decreases the risk of laryngeal trauma from translaryngeal intubation and promotes an earlier return to oral feeding and communication.
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Early tracheotomy (<10 days) does not decrease the incidence of ventilator-associated pneumonia compared with late tracheotomy (>10 days).
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Early tracheotomy is associated with reduced duration of sedation, length of intensive care unit stay, and long-term mortality among ventilated patients.
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Proper tube selection depends upon the individual patient's anatomy and ventilatory requirements.
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Multidisciplinary teams and protocols for tracheostomy care decrease morbidity, promote earlier decannulation, and improve the quality of life in tracheostomy patients.
History of Tracheotomy
The history of tracheotomy is long and storied, its origins rooted in legend ( Fig. 7.1 ). The earliest accounts of a procedure resembling tracheotomy are found in Egyptian tablets dating back to 3600 bce . In the Greek and Roman era, physicians and poets alike recorded accounts of opening the airway to relieve obstruction. Hippocrates was vehemently opposed to the procedure, citing potential risk to the carotid artery. The poet Homerus of Byzantium regaled the court with stories of Alexander the Great, who saved a fellow warrior choking on a bone by opening the soldier's airway with his sword. However, it was not until 340 CE that a firsthand account of the surgery was recorded. The physician Antyllus of Rome described making an incision at tracheal rings three and four and pulling the cartilage apart with hooks to allow a patient to breathe more easily.
For much of the next 1500 years, tracheotomy was frowned upon as a “semi-slaughter and a scandal of surgery.” The procedure was largely abandoned until the Renaissance, when anatomists and physicians revived interest in the surgery. In 1543, Andreas Vesalius, best known for his work De Humani Corporis Fabrica, placed a reed into the trachea of a pig and demonstrated lung ventilation by blowing into the cannula intermittently. Antonio Musa Brassavola is credited with providing the first documented successful tracheotomy; he performed the procedure on a patient in 1546 to relieve airway obstruction resulting from a peritonsillar abscess. The patient reportedly made a full recovery.
Despite a growing understanding of respiratory tract anatomy and physiology, tracheotomy was slow to be recognized as a legitimate surgery. Fear and avoidance of the procedure often had dire consequences. One of the most striking examples of this in American history involves George Washington, who awoke one morning in 1799 with a severe sore throat. His physicians, James Craik, Gustavus Brown, and Elisha Dick, were called to the president's Virginia home. Dick, the junior member of the group, suggested that Washington should have a tracheotomy to relieve the obstruction, but the elder physicians disagreed with his assessment and treated Washington for “inflammatory quinsy” in accordance with the practice of the era—blood-letting. The president's airway obstructed, and he died shortly thereafter from complications of what we currently believe to have been epiglottitis.
Attitudes toward tracheotomy began to change in the mid-19th century, when outbreaks of diphtheria in Europe resulted in numerous deaths from airway obstruction. French surgeons Pierre Bretonneau and Armand Trousseau advocated for a more aggressive use of tracheotomy for airway management. Trousseau published his experience in 1869, noting that he had “performed the operation in more than 200 cases of diphtheria, and … had the satisfaction of knowing one-fourth of these operations were successful.”
In time, surgeons began to realize potential indications for tracheotomy beyond management of acute airway obstruction. Friedrich Trendelenburg presented a paper in 1871, in which he described using tracheotomy to provide general anesthesia. In the years that followed, and prior to the advent of orotracheal intubation, elective tracheotomy was used to provide airway control during some surgical procedures. Chevalier Jackson's work in Philadelphia helped to standardize techniques for performing tracheotomy and established protocols for the care of these patients.
The development of vaccines, antitoxins, and antibiotics in the late 19th and early 20th centuries led to improved medical management of many of the upper airway infections that previously necessitated a surgical airway. In 1921, Rowbotham and Magill published their work on endotracheal intubation based on their experience with patients who sustained facial injuries during World War I. Intubation soon became the preferred method for administering anesthetic during surgical procedures, replacing ether or chloroform administered by a mask, and tracheotomy fell by the wayside, reserved for those patients who could not be intubated transorally or transnasally.
In the first half of the 20th century, recurrent outbreaks of poliomyelitis in the United States resulted in the paralysis of tens of thousands of patients. The polio epidemic shaped the evolution of tracheotomy in two ways. Airway protection and secretion management were compromised by pharyngeal weakness in those most severely affected by the disease. Although most could be treated with postural drainage, tracheotomy was occasionally necessary for pulmonary toilet. In addition to pharyngeal weakness, many patients suffered from respiratory failure as a result of paralysis of the diaphragm or disruption of medullary respiratory centers. A negative-pressure ventilator, colloquially referred to as the “iron lung,” was the primary means of assisting ventilation early on in the epidemic. In the 1950s, positive pressure ventilation machines were developed from technology devised for World War II pilots. The combination of tracheotomy with positive pressure ventilation facilitated long-term ventilation in patients with bulbar polio, which reduced mortality in the acute phase from approximately 90% to 25% by some accounts.
Tracheotomy continues to be a useful tool in the management of acute airway obstruction, for the administration of general anesthesia in select head and neck oncologic and oromaxillofacial surgeries, and for pulmonary toilet ( Box 7.1 ). However, advances in critical care in the last half of the 20th century have made prolonged mechanical ventilation the leading indication for tracheotomy in the current era. Almost two-thirds of tracheostomies are performed on intubated patients in the intensive care unit (ICU), and tracheotomy is currently one of the most commonly performed operations in the critically ill patient.
Box 7.1
Indications for Tracheotomy
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Prolonged mechanical ventilation
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Respiratory disease
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Neuromuscular disease
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Depressed mental status (inability to protect airway)
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Pulmonary toilet
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Surgical access
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Head and neck cancer reconstruction
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Extensive maxillofacial fractures
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Airway obstruction
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Epiglottitis/supraglottitis
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Craniofacial abnormalities
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Tumor
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Bilateral vocal cord paralysis
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Angioedema
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Foreign body
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Blunt/penetrating neck trauma
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Timing of Tracheotomy
There are several clear advantages to tracheotomy over orotracheal intubation. Evidence of laryngeal edema, granuloma formation, and ulceration can be seen within days of intubation. By virtue of bypassing the larynx, tracheotomy results in reduced laryngeal damage from local trauma to the posterior commissure and reduces the risk of laryngeal stenosis. Anecdotally, patients report that having a tracheostomy is more comfortable than translaryngeal intubation, which likely accounts for reports of decreased sedation requirements after tracheotomy. Other advantages include the potential for early return to oral nutrition and communication, both of which are impeded by translaryngeal intubation.
Initially, guidelines regarding the timing of tracheotomy were quite broad. In 1989 the American College of Chest Physicians released a consensus statement in which translaryngeal intubation was recommended if fewer than 10 days of ventilation were anticipated. If the need for mechanical ventilation was expected to exceed 21 days, tracheotomy was recommended. Since then, a great deal of interest has been shown in earlier transition to tracheotomy as a means to reduce the incidence of ventilator-associated pneumonia (VAP), the duration of mechanical ventilation, and the length of stay in the ICU. However, what defines “early” versus “late” tracheotomy remains a subject of debate. A number of studies have followed in an attempt to provide evidence to support the appropriate timing of tracheotomy in different populations of patients, based on their respective medical needs.
Critical Care/Intensive Care Unit Patients
In an attempt to resolve some of the questions regarding the ideal timing of tracheotomy among ICU patients, the Intensive Care Society of the United Kingdom completed a large, multicenter, prospective randomized trial that involved ventilated patients in 2009. The Tracheostomy Management in Critical Care (TracMan) trial identified 909 patients were who were expected to require intubation for more than 7 days. Patients were randomized to tracheotomy early (day 1 to 4) or late (>10 days). This trial demonstrated no significant difference in the length of ICU stay, length of hospitalization, or incidence of pneumonia. The only significant difference reported between groups was a reduction of sedation requirement by 2.6 days in the early tracheotomy cohort.
In 2015, Hosokawa and colleagues conducted a systematic review of randomized controlled trials focusing on the utility of early tracheotomy. Timing of tracheotomy was defined a priori as very early (<4 days), early (>4 days but before 10 days), or late (>10 days). Twelve studies, involving pooled data from 2689 patients, met inclusion criteria for the review. Although the overall length of mechanical ventilation was not significantly different between groups, patients receiving tracheotomy before 10 days experienced more ventilator-free days (weighted mean difference [WMD] 2.12 days), shorter ICU stays (WMD 5.14 days), shorter duration of sedation (WMD 5.07 days), and reduced long-term mortality (odds ratio [OR] 0.83). There was no demonstrable difference in the risk of acquiring VAP.
Trauma Patients
Dunham and colleagues queried databases for the Eastern and American Associations for the Surgery of Trauma and Medline, searching for studies that compared early tracheotomy (3 to 8 days) to late tracheotomy (>7 days) in the trauma population. No survival benefit to performing early tracheotomy was demonstrated. The incidence of developing VAP was the same between groups (relative risk [RR] 1.00, 95% confidence interval). The number of days spent on mechanical ventilation and the length of ICU stay were similar between groups, although a trend was noted toward decreased ICU time and decreased ventilator requirements in patients with severe brain injuries.
Stroke Patients
The Stroke-Related Early Tracheostomy Versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT) was a prospective trial in which neurosurgical ICU patients who suffered from intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic stroke with expectations for prolonged intubation were randomized to receive tracheotomy at either 3 days or 7 to 14 days after intubation. Thirty patients were assigned to each group, and researchers found no difference in the primary end point (ICU length of stay) between the early group (17 days) and the standard group (18 days). The overall use of sedatives and narcotics for the early group (42% and 64%, respectively) was significantly lower than in the standard group (62% and 75%, respectively). A subsequent prospective study in subarachnoid hemorrhage patients demonstrated a significant decrease in the use of analgesics, as well as vasopressors used to counteract the effects of the analgesics on mean cerebral perfusion pressure, within 24 hours of tracheotomy.
Cardiothoracic Patients
Tracheotomy in patients after cardiac surgery is controversial largely due to concerns for sternal wound infection from contaminated tracheal secretions. A review of 228 adult patients who had either early (<10 days) or late tracheotomy (14 to 28 days) after coronary artery bypass or valve surgery demonstrated decreased mortality (21% vs. 40%) and decreased length of ICU stay (mean difference, 7.2 days), respectively. Interestingly, the rate of sternal wound infection was found to be less in the early tracheotomy group (6% vs. 20%), raising the question as to the real risk of infection in this population.
Attempts to resolve the wound-infection dilemma have been fraught with conflicting data. A 2008 study looked at 7002 consecutive cardiothoracic surgery patients, 1.4% of whom ultimately underwent percutaneous tracheostomy. The incidences of deep (9% vs. 0.7%) and superficial sternal infections (31% vs. 6.5%) were found to be significantly higher among tracheostomy patients, suggesting tracheostomy was an independent predictor for sternal wound infection. The following year, a study of 5095 patients identified 57 patients who required tracheotomy after cardiac surgery. Ten patients developed sternal infection, but the bacteria isolated from these infections were different than those isolated from tracheal secretions. No correlation was found between the time of tracheotomy and the development of these infections. A similar study reviewed more than 2800 patients and identified 252 patients who had postoperative respiratory failure; 108 ultimately received a tracheotomy. The incidence of deep sternal wound infection was higher in patients with respiratory failure (5.1% vs. 1%), but the rate of infection was similar in the tracheotomy and nontracheotomy subgroups (4.6% vs. 5.6%) of respiratory failure patients. Tracheostomy was not identified as a predictor of deep sternal wound infection, implying that the underlying issues related to the patient's pulmonary failure may be a better predictor of sternal infections post cardiac surgery.
Operative Technique
Open Tracheotomy ( Box 7.2 )
Strictly speaking, tracheotomy is the creation of an opening in the anterior tracheal wall. Tracheostomy, on the other hand, is the formalization of a permanent stoma by suturing the edges of the trachea to the skin. Over the years, these terms have come to be used synonymously. Although typically performed in the operating suite, in select patients, tracheotomy can be performed at bedside in the ICU.
Box 7.2
Procedural Steps for Open Tracheotomy
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Administer preoperative antibiotics
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Position patient with neck in extension (unless contraindicated due to cervical trauma)
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Identify the hyoid, thyroid, and cricoid cartilage.
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Plan skin incision
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Vertical incisions begin at the inferior aspect of the cricoid and extend 2–3 cm inferiorly.
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Horizontal incision should be marked at the approximate level of tracheal ring two, 1 cm below the cricoid
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Inject skin with 1% lidocaine with 1 : 100,000 epinephrine, and then prep and drape the surgical site
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Divide skin and subcutaneous tissue
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Divide strap muscles along the midline raphe
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Mobilize and/or divide the thyroid isthmus
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Secure airway with cricoid hook
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Enter the airway sharply and dilate the tracheal opening
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Retract the endotracheal tube to just above the tracheostomy
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Place tracheostomy through the opening in the airway and connect to the ventilator circuit
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Secure the tracheostomy tube with suture and tracheotomy ties
If no contraindication exists, the patient should be positioned with the neck in extension. This elevates the larynx and brings up to 50% of the proximal trachea into the neck. Antibiotics should be given preoperatively for prophylaxis against skin pathogens. Prior to proceeding, the surgeon should palpate and identify the hyoid, thyroid, and cricoid cartilages. A 2- to 3-cm horizontal incision should be marked at the approximate level of tracheal ring two, 1 cm below the cricoid ( Fig. 7.2A ). When performing a tracheotomy to establish an urgent airway or when landmarks are indistinct, a vertical incision is preferred, because the surgeon will be less likely to encounter vascular structures in the midline. The vertical incision is marked from the inferior aspect of the cricoid and extends 2 to 3 cm inferiorly. The planned incision is injected with 1% lidocaine with 1 : 100,000 epinephrine, and then the patient is prepped and draped in a sterile fashion.
Begin by dividing the skin and subcutaneous tissue with a No. 15 blade. The superficial layer of the deep cervical fascia is then divided vertically, taking care to avoid the anterior jugular veins and any crossing branches. The strap muscles should be divided in the midline raphe and reflected laterally (see Fig. 7.2B ). The thyroid isthmus can be mobilized, so as to expose the anterior trachea, or it can be divided. If the isthmus is divided, care should be taken to address any bleeding from the edges of the gland prior to opening the airway. The cricoid hook should then be used to secure the airway superiorly and anteriorly (see Fig. 7.2C ). A Kittner sponge can be used to bluntly clear the remaining pretracheal fascia to allow for clear identification of the tracheal rings.
It is imperative that the surgeon communicate with the anesthesiologist prior to entering the airway. In the intubated patient, it is recommended that the cuff of the endotracheal tube (ETT) be let down temporarily so that it is not perforated when entering the airway. The tracheotomy should be created between the second and third or the third and fourth ring (see Fig. 7.2D ). The airway can be entered in any number of ways to include vertical, horizontal, or H-shaped incisions. The author prefers a horizontal incision between rings two and three with the creation of a Björk flap. This inferiorly based tracheal flap was introduced by Björk in 1960 to help prevent false passage when replacing a dislodged tube. It should be noted that such flaps often result in semipermanent tracheostomas that may require surgical closure after decannulation.
Once in the airway, the ETT is pulled back so that the tip of the tube is just above the opening. If necessary, this allows the tube to be quickly advanced to reestablish ventilation. The tracheostomy tube is then advanced through the opening in the airway, and the tube is connected to the ventilator circuit. Once ventilator return and end-tidal CO 2 are confirmed, the cricoid hook is removed, and the tube is secured in four quadrants with suture in addition to tracheotomy ties.
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