7

7
Tracheotomy
Shannon M. Kraft, Joshua S. Schindler

KEY POINTS American history involves George Washington, who awoke one
morning in 1799 with a severe sore throat. His physicians, James
• Although described in numerous historic texts, Craik, Gustavus Brown, and Elisha Dick, were called to the
tracheotomy did not become a routine surgical president’s Virginia home. Dick, the junior member of the group,
procedure until the late 19th to early 20th century. suggested that Washington should have a tracheotomy to relieve
the obstruction,8 but the elder physicians disagreed with his
• Indications for tracheotomy include relief of airway assessment and treated Washington for “inflammatory quinsy” in
obstruction, access for head and neck surgery, accordance with the practice of the era—blood-letting. The
pulmonary toilet, and need for prolonged mechanical president’s airway obstructed, and he died shortly thereafter
ventilation. from complications of what we currently believe to have been
• Tracheotomy decreases the risk of laryngeal trauma epiglottitis.9,10
from translaryngeal intubation and promotes an earlier Attitudes toward tracheotomy began to change in the mid-19th
return to oral feeding and communication. century, when outbreaks of diphtheria in Europe resulted in
• Early tracheotomy (<10 days) does not decrease the numerous deaths from airway obstruction. French surgeons Pierre
incidence of ventilator-associated pneumonia compared Bretonneau and Armand Trousseau advocated for a more aggressive
with late tracheotomy (>10 days). use of tracheotomy for airway management. Trousseau11 published
his experience in 1869, noting that he had “performed the operation
• Early tracheotomy is associated with reduced duration in more than 200 cases of diphtheria, and … had the satisfaction
of sedation, length of intensive care unit stay, and of knowing one-fourth of these operations were successful.”
long-term mortality among ventilated patients. In time, surgeons began to realize potential indications for
• Proper tube selection depends upon the individual tracheotomy beyond management of acute airway obstruction.
patient’s anatomy and ventilatory requirements. Friedrich Trendelenburg presented a paper in 1871, in which he
• Multidisciplinary teams and protocols for tracheostomy described using tracheotomy to provide general anesthesia.12 In
care decrease morbidity, promote earlier decannulation, the years that followed, and prior to the advent of orotracheal
and improve the quality of life in tracheostomy patients. intubation, elective tracheotomy was used to provide airway control
during some surgical procedures. Chevalier Jackson’s13,14 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 manage-
HISTORY OF TRACHEOTOMY ment of many of the upper airway infections that previously
The history of tracheotomy is long and storied, its origins rooted necessitated a surgical airway. In 1921, Rowbotham and Magill15
in legend (Fig. 7.1). The earliest accounts of a procedure resembling published their work on endotracheal intubation based on their
tracheotomy are found in Egyptian tablets dating back to 3600 experience with patients who sustained facial injuries during World
BCE.1 In the Greek and Roman era, physicians and poets alike War I. Intubation soon became the preferred method for admin-
recorded accounts of opening the airway to relieve obstruction. istering anesthetic during surgical procedures, replacing ether or
Hippocrates was vehemently opposed to the procedure, citing chloroform administered by a mask,16 and tracheotomy fell by
potential risk to the carotid artery.2 The poet Homerus of the wayside, reserved for those patients who could not be intubated
Byzantium regaled the court with stories of Alexander the Great, transorally or transnasally.
who saved a fellow warrior choking on a bone by opening the In the first half of the 20th century, recurrent outbreaks of
soldier’s airway with his sword.3 However, it was not until 340 poliomyelitis in the United States resulted in the paralysis of tens
CE that a firsthand account of the surgery was recorded. The of thousands of patients.17 The polio epidemic shaped the evolution
physician Antyllus of Rome described making an incision at tracheal of tracheotomy in two ways. Airway protection and secretion
rings three and four and pulling the cartilage apart with hooks to management were compromised by pharyngeal weakness in those
allow a patient to breathe more easily.4 most severely affected by the disease. Although most could be
For much of the next 1500 years, tracheotomy was frowned treated with postural drainage, tracheotomy was occasionally
upon as a “semi-slaughter and a scandal of surgery.”5 The procedure necessary for pulmonary toilet.18 In addition to pharyngeal weakness,
was largely abandoned until the Renaissance, when anatomists many patients suffered from respiratory failure as a result of paralysis
and physicians revived interest in the surgery. In 1543, Andreas of the diaphragm or disruption of medullary respiratory centers.
Vesalius, best known for his work De Humani Corporis Fabrica, A negative-pressure ventilator, colloquially referred to as the “iron
placed a reed into the trachea of a pig and demonstrated lung lung,” was the primary means of assisting ventilation early on in
ventilation by blowing into the cannula intermittently.6 Antonio the epidemic. In the 1950s, positive pressure ventilation machines
Musa Brassavola is credited with providing the first documented were developed from technology devised for World War II pilots.9
successful tracheotomy; he performed the procedure on a patient The combination of tracheotomy with positive pressure ventilation
in 1546 to relieve airway obstruction resulting from a peritonsillar facilitated long-term ventilation in patients with bulbar polio,19
abscess.7 The patient reportedly made a full recovery. which reduced mortality in the acute phase from approximately
Despite a growing understanding of respiratory tract anatomy 90% to 25% by some accounts.20
and physiology, tracheotomy was slow to be recognized as a Tracheotomy continues to be a useful tool in the management
legitimate surgery. Fear and avoidance of the procedure often had of acute airway obstruction, for the administration of general
dire consequences. One of the most striking examples of this in anesthesia in select head and neck oncologic and oromaxillofacial
81
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 CHAPTER 7 Tracheotomy 81.e1

Abstract Keywords
7
Although described in numerous historic texts, tracheotomy did tracheotomy
not become a routine surgical procedure until the late 19th century. percutaneous tracheostomy
Indications for tracheotomy include relief of airway obstruction, tracheostomy complications
access for head and neck surgery, pulmonary toilet, and need for tracheostomy care
prolonged mechanical ventilation. Tracheotomy decreases the risk
of laryngeal trauma from translaryngeal intubation and promotes
an earlier return to oral feeding and communication. Performed
early (before 10 days), tracheotomy is associated with reduced
duration of sedation, length of intensive care unit stay, and long-
term mortality among ventilated patients. Proper tube selection
depends upon the individual patient’s anatomy and ventilatory
requirements. Multidisciplinary teams and protocols for trache-
ostomy care decrease morbidity, promote earlier decannulation,
and improve the quality of life in tracheostomy patients.

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82 PART II General Otolaryngology

c3600 BCE 1st record of

tracheotomy in ancient Egypt1

c.2000–1000 BCE References to

tracheotomy in Rig Veda and
the Ebers Papyrus4
c400 BCE Alexander the
great performs tracheotomy
340 CE 1st witnessed account with his sword2
of tracheotomy—
Antyllus of Rome4
100 BCE Asclepiades
reportedly conducts elective
tracheotomy4

1543 CE Andreas Vesalius

demonstrates ventilation6
1546 CE 1st documented
1590 CE Sanctorius successful tracheotomy–
devises first tracheostomy Antonio Musa Brassavola7
tube55

1871 CE Trendelenburg 1869 CE Trousseau11 publishes

describes using tracheotomy his experience on tracheotomy
for general anesthesia12 for diphtheria

1909–1923 CE Chevalier Jackson13,14

standardizes techniques for performing
and post-tracheotomy care 1921 CE Rowbotham and Magill15
published their work on
1929 CE Continued endotracheal intubation
developments in negative
pressure ventilation—
Iron lung

1940¢s–1950¢s CE Peak
1950s CE Positive-pressure of the polio epidemic
ventilation machines
developed20

1969 CE 1st described

percutaneous
tracheotomy39

1985 CE Dilational percutaneous

technique introduced40
Fig. 7.1 A timeline of the history of tracheotomy.

surgeries, and for pulmonary toilet (Box 7.1). However, advances

in critical care in the last half of the 20th century have made
TIMING OF TRACHEOTOMY
prolonged mechanical ventilation the leading indication for tra- There are several clear advantages to tracheotomy over orotracheal
cheotomy in the current era.7,20,21 Almost two-thirds of tracheos- intubation. Evidence of laryngeal edema, granuloma formation,
tomies are performed on intubated patients in the intensive care and ulceration can be seen within days of intubation. By virtue
unit (ICU),20,22 and tracheotomy is currently one of the most of bypassing the larynx, tracheotomy results in reduced laryngeal
commonly performed operations in the critically ill patient.23 damage from local trauma to the posterior commissure and reduces

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 CHAPTER 7 Tracheotomy 83

sedation (WMD 5.07 days), and reduced long-term mortality (odds

BOX 7.1 Indications for Tracheotomy ratio [OR] 0.83). There was no demonstrable difference in the 7
risk of acquiring VAP.
Prolonged mechanical ventilation
• Respiratory disease
• Neuromuscular disease Trauma Patients
• Depressed mental status (inability to protect airway)
Dunham and colleagues queried databases for the Eastern and
Pulmonary toilet
American Associations for the Surgery of Trauma and Medline,
Surgical access
searching for studies that compared early tracheotomy (3 to 8
• Head and neck cancer reconstruction
days) to late tracheotomy (>7 days) in the trauma population.30
• Extensive maxillofacial fractures
No survival benefit to performing early tracheotomy was dem-
Airway obstruction
onstrated. The incidence of developing VAP was the same between
• Epiglottitis/supraglottitis
groups (relative risk [RR] 1.00, 95% confidence interval). The
• Craniofacial abnormalities
number of days spent on mechanical ventilation and the length
• Tumor
of ICU stay were similar between groups, although a trend was
• Bilateral vocal cord paralysis
noted toward decreased ICU time and decreased ventilator
• Angioedema
requirements in patients with severe brain injuries.
• Foreign body
• Blunt/penetrating neck trauma
Stroke Patients
The Stroke-Related Early Tracheostomy Versus Prolonged
Orotracheal Intubation in Neurocritical Care Trial (SETPOINT)31
the risk of laryngeal stenosis.24 Anecdotally, patients report that was a prospective trial in which neurosurgical ICU patients who
having a tracheostomy is more comfortable than translaryngeal suffered from intracerebral hemorrhage, subarachnoid hemorrhage,
intubation, which likely accounts for reports of decreased sedation or ischemic stroke with expectations for prolonged intubation
requirements after tracheotomy.25 Other advantages include the were randomized to receive tracheotomy at either 3 days or 7 to
potential for early return to oral nutrition and communication, 14 days after intubation. Thirty patients were assigned to each
both of which are impeded by translaryngeal intubation. group, and researchers found no difference in the primary end
Initially, guidelines regarding the timing of tracheotomy were point (ICU length of stay) between the early group (17 days) and
quite broad. In 1989 the American College of Chest Physicians the standard group (18 days). The overall use of sedatives and
released a consensus statement in which translaryngeal intubation narcotics for the early group (42% and 64%, respectively) was
was recommended if fewer than 10 days of ventilation were significantly lower than in the standard group (62% and 75%,
anticipated. If the need for mechanical ventilation was expected respectively). A subsequent prospective study in subarachnoid
to exceed 21 days, tracheotomy was recommended.26 Since then, hemorrhage patients demonstrated a significant decrease in the
a great deal of interest has been shown in earlier transition to use of analgesics, as well as vasopressors used to counteract the
tracheotomy as a means to reduce the incidence of ventilator- effects of the analgesics on mean cerebral perfusion pressure, within
associated pneumonia (VAP), the duration of mechanical ventilation, 24 hours of tracheotomy.32
and the length of stay in the ICU.27 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
Cardiothoracic Patients
support the appropriate timing of tracheotomy in different popula- Tracheotomy in patients after cardiac surgery is controversial
tions of patients, based on their respective medical needs. largely due to concerns for sternal wound infection from con-
taminated tracheal secretions. A review of 228 adult patients who
had either early (<10 days) or late tracheotomy (14 to 28 days)
Critical Care/Intensive Care Unit Patients after coronary artery bypass or valve surgery demonstrated
In an attempt to resolve some of the questions regarding the ideal decreased mortality (21% vs. 40%) and decreased length of ICU
timing of tracheotomy among ICU patients, the Intensive Care stay (mean difference, 7.2 days), respectively. Interestingly, the
Society of the United Kingdom completed a large, multicenter, rate of sternal wound infection was found to be less in the early
prospective randomized trial that involved ventilated patients in tracheotomy group (6% vs. 20%), raising the question as to the
2009. The Tracheostomy Management in Critical Care (TracMan) real risk of infection in this population.33
trial identified 909 patients were who were expected to require Attempts to resolve the wound-infection dilemma have been
intubation for more than 7 days.28 Patients were randomized fraught with conflicting data. A 2008 study looked at 7002 consecu-
to tracheotomy early (day 1 to 4) or late (>10 days). This trial tive cardiothoracic surgery patients, 1.4% of whom ultimately
demonstrated no significant difference in the length of ICU underwent percutaneous tracheostomy. The incidences of deep
stay, length of hospitalization, or incidence of pneumonia. (9% vs. 0.7%) and superficial sternal infections (31% vs. 6.5%)
The only significant difference reported between groups was were found to be significantly higher among tracheostomy patients,
a reduction of sedation requirement by 2.6 days in the early suggesting tracheostomy was an independent predictor for sternal
tracheotomy cohort. wound infection.34 The following year, a study of 5095 patients
In 2015, Hosokawa and colleagues conducted a systematic identified 57 patients who required tracheotomy after cardiac
review of randomized controlled trials focusing on the utility of surgery. Ten patients developed sternal infection, but the bacteria
early tracheotomy.29 Timing of tracheotomy was defined a priori isolated from these infections were different than those isolated
as very early (<4 days), early (>4 days but before 10 days), or late from tracheal secretions. No correlation was found between the
(>10 days). Twelve studies, involving pooled data from 2689 patients, time of tracheotomy and the development of these infections.35
met inclusion criteria for the review. Although the overall length A similar study reviewed more than 2800 patients and identified
of mechanical ventilation was not significantly different between 252 patients who had postoperative respiratory failure; 108 ulti-
groups, patients receiving tracheotomy before 10 days experienced mately received a tracheotomy. The incidence of deep sternal
more ventilator-free days (weighted mean difference [WMD] 2.12 wound infection was higher in patients with respiratory failure
days), shorter ICU stays (WMD 5.14 days), shorter duration of (5.1% vs. 1%), but the rate of infection was similar in the

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84 PART II General Otolaryngology

tracheotomy and nontracheotomy subgroups (4.6% vs. 5.6%) of the gland prior to opening the airway. The cricoid hook should
respiratory failure patients. Tracheostomy was not identified as a then be used to secure the airway superiorly and anteriorly (see
predictor of deep sternal wound infection, implying that the Fig. 7.2C). A Kittner sponge can be used to bluntly clear the
underlying issues related to the patient’s pulmonary failure may remaining pretracheal fascia to allow for clear identification of the
be a better predictor of sternal infections post cardiac surgery.36 tracheal rings.
It is imperative that the surgeon communicate with the
anesthesiologist prior to entering the airway. In the intubated
OPERATIVE TECHNIQUE patient, it is recommended that the cuff of the endotracheal tube
(ETT) be let down temporarily so that it is not perforated when
Open Tracheotomy (Box 7.2) entering the airway. The tracheotomy should be created between
Strictly speaking, tracheotomy is the creation of an opening in the the second and third or the third and fourth ring (see Fig. 7.2D).
anterior tracheal wall. Tracheostomy, on the other hand, is the The airway can be entered in any number of ways to include
formalization of a permanent stoma by suturing the edges of vertical, horizontal, or H-shaped incisions. The author prefers a
the trachea to the skin. Over the years, these terms have come to horizontal incision between rings two and three with the creation
be used synonymously. Although typically performed in the of a Björk flap. This inferiorly based tracheal flap was introduced
operating suite, in select patients, tracheotomy can be performed by Björk37 in 1960 to help prevent false passage when replacing
at bedside in the ICU. a dislodged tube. It should be noted that such flaps often result
If no contraindication exists, the patient should be positioned in semipermanent tracheostomas that may require surgical closure
with the neck in extension. This elevates the larynx and brings after decannulation.
up to 50% of the proximal trachea into the neck. Antibiotics Once in the airway, the ETT is pulled back so that the tip of
should be given preoperatively for prophylaxis against skin the tube is just above the opening. If necessary, this allows the
pathogens. Prior to proceeding, the surgeon should palpate and tube to be quickly advanced to reestablish ventilation. The tra-
identify the hyoid, thyroid, and cricoid cartilages. A 2- to 3-cm cheostomy tube is then advanced through the opening in the
horizontal incision should be marked at the approximate level of airway, and the tube is connected to the ventilator circuit. Once
tracheal ring two, 1 cm below the cricoid (Fig. 7.2A). When ventilator return and end-tidal CO2 are confirmed, the cricoid
performing a tracheotomy to establish an urgent airway or when hook is removed, and the tube is secured in four quadrants with
landmarks are indistinct, a vertical incision is preferred, because suture in addition to tracheotomy ties.
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
Percutaneous Tracheotomy
incision is injected with 1% lidocaine with 1 : 100,000 epinephrine, The challenges of securing operating room time and the burden
and then the patient is prepped and draped in a sterile fashion. of transporting critically ill patients have been the impetus behind
Begin by dividing the skin and subcutaneous tissue with a developing a rapid, safe, and reliable alternative to performing
No. 15 blade. The superficial layer of the deep cervical fascia is open tracheotomy. Toye and Weinstein38 first described percutane-
then divided vertically, taking care to avoid the anterior jugular ous tracheotomy using the Seldinger technique in 1969, but it
veins and any crossing branches. The strap muscles should be was not until Ciaglia introduced the dilational percutaneous
divided in the midline raphe and reflected laterally (see Fig. technique in 1985 that the procedure began to become more
7.2B). The thyroid isthmus can be mobilized, so as to expose the commonplace in the ICU.39
anterior trachea, or it can be divided. If the isthmus is divided, Not surprisingly, the greatest benefits of percutaneous dilational
care should be taken to address any bleeding from the edges of tracheotomy (PDT) are primarily logistical. In 2005, Liao and
colleagues40 reviewed their experience with 368 tracheotomies,
190 open and 178 percutaneous. The average time from consultation
to tracheotomy was 7.4 days in the PDT group compared with
14 days in the open-procedure group. Per the cost analysis for
BOX 7.2 Procedural Steps for Open Tracheotomy their institution, PDT saved more than $400 per procedure, in
addition to minimizing the physiologic stress on already critically
• Administer preoperative antibiotics ill patients. A 2007 review of 339 transports of ICU patients revealed
• Position patient with neck in extension (unless contraindicated that unexpected events occurred in nearly 70% of transports.
due to cervical trauma) Although usually minor events (tangled lines and loss of oximetry
• Identify the hyoid, thyroid, and cricoid cartilage. probes), 8.9% of transports were associated with a serious event
• Plan skin incision such as severe hypotension or increased intracranial pressure.41
• Vertical incisions begin at the inferior aspect of the cricoid The speed with which a PDT can be performed in experienced
and extend 2–3 cm inferiorly. hands also helps to reduce the amount of time the patient is at
• Horizontal incision should be marked at the approximate risk for additional procedure-related stressors. PDT has been
level of tracheal ring two, 1 cm below the cricoid demonstrated to be anywhere between 9.842 and 25.743 minutes
• Inject skin with 1% lidocaine with 1 : 100,000 epinephrine, faster than open surgery.
and then prep and drape the surgical site The surgeon should recognize that not all patients are appropri-
• Divide skin and subcutaneous tissue ate candidates for PDT. The procedure is contraindicated in
• Divide strap muscles along the midline raphe children because the collapsible, mobile trachea of the pediatric
• Mobilize and/or divide the thyroid isthmus airway is difficult to localize and stabilize for safe performance of
• Secure airway with cricoid hook the percutaneous technique. In addition, it is challenging to
• Enter the airway sharply and dilate the tracheal opening adequately ventilate the patient and manage the bronchoscope
• Retract the endotracheal tube to just above the tracheostomy simultaneously through a pediatric ETT.44
• Place tracheostomy through the opening in the airway and Although few absolute contraindications for PDT exist in adults,
connect to the ventilator circuit some conditions certainly favor an open technique.45 Midline neck
• Secure the tracheostomy tube with suture and masses can obscure landmarks and should generally be managed
tracheotomy ties with open surgery. Open tracheotomy is preferred in the setting
of significant coagulation abnormalities because of the improved

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 CHAPTER 7 Tracheotomy 85

Median raphe

Incision
A B

C
D
Fig. 7.2 (A) Favorable position of incision below the inferior border of the cricoid. (B) The midline
raphe of the strap muscles is divided, and the muscles are reflected laterally. (C) The cricoid hook can
be used to immobilize and secure the trachea prior to entering the airway. (D) The airway is entered
between rings two and three or rings three and four. The inferior ring can be secured with a suture to
facilitate easy access, should the patient be accidentally decannulated. (From Cohen JI, Clayman GL,
eds: Atlas of head and neck surgery, Philadelphia, 2011, Elsevier.)

ability to achieve hemostasis, although the ability to correct phenomenon is not unique to the PDT technique but may be an
coagulopathy in an ICU setting makes this less of an issue. A high indication for an open procedure with a Björk flap or similar
level of respiratory support (FiO2 >70% and positive end expiratory technique to mitigate this risk.
pressure >10) favors an open approach because the need for The most commonly used technique for PDT was first described
bronchoscopy during the procedure can make ventilation chal- by Ciaglia and colleagues47 (Box 7.3). In this technique a guidewire
lenging. Finally, patients with cervical spine injuries should have is passed between the first and second or second and third tracheal
an open surgery to prevent unintended movement of the neck rings. Sequential dilation using graduated dilators (Ciaglia Per-
during tracheotomy placement. cutaneous Tracheostomy Introducer Set; Cook Medical, Inc.,
Obese patients deserve special consideration. Although obesity Bloomington, IN) over a guidewire creates a passage through
is not an absolute contraindication to PDT, palpation of laryn- which a tracheostomy tube can be placed. Serial dilation has been
gotracheal landmarks can be difficult in a thick neck. Surgeons replaced by use of a single tapered dilator with a hydrophilic
should carefully consider their familiarity and comfort with PDT coating (Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer
before performing the procedure on obese patients. One review Kit, Cook Medical), which allows for faster dilation and less
identified obesity as an independent risk factor for postprocedure instrumentation.48
complications in PDT. Fifteen percent of patients with a body Although PDT can be performed blindly, it is currently generally
mass index (BMI) greater than 30 kg/m2 experienced complications executed with videobronchoscopic assistance.49 This primarily
compared with 8% of patients with a BMI less than 30 kg/m2. serves to protect the posterior membranous wall of the trachea.50
More specifically, 80% of accidental decannulations occurred in The overall complication rate is higher when bronchoscopic
patients with a BMI greater than 30 kg/m2.46 However, this guidance is not used (16.8%) versus when bronchoscopy is used

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86 PART II General Otolaryngology

TABLE 7.1 Common Tracheostomy Tube Sizes

BOX 7.3 Procedural Steps for Percutaneous
Dilational Tracheotomy ID (mm) OD (mm) Length (mm)
SHILEY DISPOSABLE INNER CANNULA
• Position the patient with neck in extension (unless otherwise Size 4 5.0 9.4 62 (cuff)/65 (no cuff)
contraindicated) Size 6 6.4 10.8 74 (cuff)/76 (no cuff)
• Identify the hyoid, thyroid, and cricoid cartilage Size 8 7.6 12.2 79 (cuff)/81 (no cuff)
• Inject skin with 1% lidocaine with 1 : 100,000 epinephrine, then Size 10 8.9 13.8 79 (cuff)/81 (no cuff)
prep and drape the surgical site PORTEX FLEX DISPOSABLE INNER CANNULA
• Make a 2-cm incision from the inferior border of the cricoid Size 6 6.0 8.5 64
toward the sternal notch Size 7 7.0 9.9 70
• Dissect bluntly with hemostat in midline through subcutaneous Size 8 8.0 11.3 73
tissue Size 9 9.0 12.6 79
• Advance bronchoscope through the endotracheal tube, and Size 10 10.0 14.0 79
then withdraw the tube to the level of the vocal cords SHILEY XLT PROXIMAL EXTENSION
• Once the trachea can be palpated, pass a 22-gauge seeker Size 5 5.0 9.6 20 P, 33 D
needle on a saline-filled syringe between the first and second Size 6 6.0 11.0 23 P, 34 D
or second and third tracheal rings. Size 7 7.0 12.3 27 P, 34 D
• Confirm needle placement via Size 8 8.0 13.3 30 P, 35 D
• Application of negative pressure on the syringe and SHILEY XLT DISTAL EXTENSION
aspiration of air and Size 5 5.0 9.6 5.0 P, 48 D
• Visualization with the bronchoscope Size 6 6.0 11.0 8.0 P, 49 D
• The needle should be between the 10 and 2 o’clock Size 7 7.0 12.3 12 P, 49 D
positions on the anterior tracheal wall Size 8 8.0 13.3 15 P, 50 D
• Withdraw needle, leaving catheter in place PORTEX EXTRA HORIZONTAL LENGTH
• Pass J-wire the needle and into the airway Size 7 7.0 9.7 18
• Use 12-Fr introducer dilator to perform the initial dilation Size 8 8.0 11.0 22
• Load appropriate-sized tracheostomy tube over tapered Size 9 9.0 12.4 28
dilator, and advance into the airway over the guidewire under PORTEX EXTRA VERTICAL LENGTH
bronchoscopic visualization Size 7 7.0 9.7 41.0
• Once in place, remove the guidewire, guiding catheter, and Size 8 8.0 11.0 45.0
loading dilator Size 9 9.0 12.4 48.0
• Secure tracheostomy with suture and ties Size 10 10.0 13.8 52.0
D, Distal; ID, inner diameter; OD, outer diameter; P, proximal.
Modified from Hess DR: Tracheostomy tubes and related appliances.
Resp Care 50(4):497–518, 2005; Adult Tracheostomy, www
.covidien.com; and Portex Tracheostomy Tubes, www.smiths
-medical.com/catalog/portex-tracheostomy-tubes.
(8.3%).46 If the patient does not have significant respiratory
demands, a laryngeal mask airway can be used to improve visualiza-
tion during bronchoscopy.

Alternative Percutaneous Techniques Tracheostomy Tubes

Several modifications have been made to the PDT technique, One of the first attempts to devise a tracheostomy tube involved
although none are currently commercially available in the United a short, straight cannula designed by Sanctorius in 1590. Unfor-
States. One technique uses the Griggs (Portex; Hythe, Kent, UK) tunately, this tube configuration was prone to create fistulae.54 A
guidewire dilating forceps over a guidewire to spread through the curved metal tube was introduced a few years later by Julius
soft tissue of the anterior neck and into the trachea. The tube can Casserius to overcome this issue,55 although it was never widely
then be fed over the guidewire.51 used. Jackson14 is credited with designing a double-lumen metal
The Fantoni Translaryngeal Tracheostomy Set (Mallinckrodt; tube of an anatomically appropriate length and curvature that is
Mirandola, Italy) uses a retrograde method of placing a tracheotomy. the model for the tubes commonly used currently. He even created
A rigid, cuffed tracheoscope replaces the ETT and is used to tubes with longer shafts that allowed tracheal obstructions to be
transilluminate the skin and to allow for passage of a guidewire bypassed.
that is pulled out through the mouth. Control of the airway is Selection of the proper tube depends on a number of factors
temporarily relinquished while the guidewire is secured to a cuffed that include lung mechanics, patient anatomy, and communication
cannula. The cannula is pulled through the mouth, past the larynx, needs.56 Metal tubes composed of silver or steel offer the benefit
and through the anterior tracheal wall. The cuffed end of the of a low profile but lack a 15-mm connector and cuff and therefore
cannula is directed distally down the trachea. Once in place, a are not suitable in patients who require mechanical ventilation.57
flange is fixed to the cannula, and the patient is able to be ventilated Plastic tubes made of silicone or polyvinyl chloride come in a
through the cannula.52 variety of shapes and sizes, with and without cuffs, and most have
The PercuTwist Kit (Rusch-Teleflex Medical; Kernen, Germany) the ability to be connected to ventilator circuits.
uses a single-dilator technique.53 A catheter needle is used to pass Tube configurations are defined by the inner diameter (ID),
a J-tipped guidewire into the airway. The PercuTwist device, which outer diameter, length, and curvature of the appliance (Table 7.1).
resembles a large screw, is introduced over the wire. As it is twisted In dual-cannula systems, the ID refers to the diameter of the inner
in a clockwise fashion, it engages the tracheal wall, pulling it cannula. The ID of single-cannula tube systems is determined by
anteriorly while dilating the opening into the trachea. The device the ID of the tube itself. Ultimately, the ID of the tube determines
is removed, and a 9.0 tube is place with the aid of an insertional airflow. If the ID is too small, resistance through the tube increases
dilator. and impacts the work of breathing. The estimated resistances

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 CHAPTER 7 Tracheotomy 87

through size 4, 6, 8, and 10 Shiley tubes are 11.4, 3.96, 1.75, and TABLE 7.2 Reported Range in Adverse Effects Associated With
0.69 cm H2O/L per second, respectively.58 The smallest diameter Tracheostomy From Randomized Trials Comparing Percutaneous and 7
tube that meets the patient’s needs should be selected. Open Surgical Techniques
It is imperative to select a tube that conforms best to each Incidence (%)
patient’s anatomy to avoid complications from obstruction or
accidental decannulation. Tubes with extra proximal length Complication PDT Open
(horizontal) are designed to accommodate the obese neck or neck INTRAPROCEDURAL
masses that displace the trachea posteriorly. Tubes with extra distal Paratracheal insertion 0–4 0–4
(vertical) length can be used to bypass areas of stenosis or malacia Posterior wall laceration 0–13 NA
distal to the stoma. If prefabricated tubes with extra length do EARLY (<7 DAYS)
not meet a patient’s particular needs, flexible adjustable flange Bleeding
tubes can also be used to customize the length of the tube. Once Minor 10–20 11–80
the ideal length is determined, a custom tube can be constructed Major 0–4 0–7
to fit individual specifications. Pneumothorax <1 0–4
Uncuffed tubes are ideal for patients who do not require Subcutaneous emphysema 0–5 0–11
mechanical ventilation. These tubes can bypass upper airway Airway fire <1 <1
obstruction, allow for pulmonary toilet, and accommodate speech. Accidental decannulation 0–5 0–15
On the other hand, cuffed tubes are designed to facilitate positive Stoma infection 0–10 11–80
Loss of airway 0–8 0–4
pressure ventilation. Most cuffs are designed to be high-volume/
low-pressure cuffs to help mitigate the risk of tracheal stenosis. LATE (>7 DAYS)
Tracheal mucosa capillary perfusion pressure is approximately 25 Tracheal stenosis 7–27 11–63
to 30 mm Hg. Cuff pressures greater than that can result in Tracheomalacia 0–7 0–8
Tracheoesophageal fistula <1 <1
ischemic necrosis, which leads to stenosis. Low-volume/high-
Tracheoarterial fistula <1 <1
pressure (tight-to-shaft [TTS]) and foam cuffs are used less fre- Delayed stoma closure 0–39 10–54
quently. TTS tubes are ideal for patients who need only intermittent
positive pressure; the low profile of the cuff, once deflated, allows PDT, Percutaneous dilational tracheotomy.
for easier speech.57 Of note, silicone TTS tubes should be filled From Delaney A, Bagshaw SM, Nalos M: Percutaneous dilatational
tracheostomy vs surgical tracheostomy in critically ill patients: a
with sterile water during periods that require cuff inflation, because
systematic review and meta-analysis. Crit Care 10:R55, 2006.
air diffuses through the cuff.

COMPLICATIONS
Although a seemingly routine procedure, tracheotomy is not
without risk. A 2006 review revealed the overall complication
Pneumothorax/Pneumomediastinum
rate for tracheotomy to be 3.2%, with procedure-related mortality Pneumothorax and pneumomediastinum are uncommon after
approximating 0.6%. Complication rates were higher in patients tracheotomy. Potential mechanisms include direct injury to the
with upper airway infections, obesity, paralysis, and congestive heart pleura, dissection of air along the trachea, or rupture of an alveolar
failure. Not surprisingly, postprocedure mortality was also higher bleb.61 The incidence of radiographic pneumothorax in one large
in patients with cardiac conditions (>25%) compared with patients study was 4.3%. However, only 3 out of 255 patients required
with trauma (6% vs. 11.5%) or pulmonary infection (5.7%).59 any sort of intervention, and this decision was made solely on
Complications of tracheotomy can be classified as intraprocedural, clinical grounds.62 As such, in the absence of clinical findings,
early (<7 days), or late (>7 days) (Table 7.2). routine chest radiography is not indicated after tracheotomy.

Intraprocedural Complications Early Complications

Airway Fire Infection
The initiation and propagation of fire requires three things: (1) Tracheotomy site infections occur in approximately 6.6% of
a fuel source, (2) an energy source, and (3) an oxidizing agent. patients. The incidence has been shown to be less in PDT compared
Although surgical fires are rare during tracheotomy, all of the with open tracheotomy. Local wound care and antibiotics are
essential elements are present, and tracheotomy is the most common usually adequate to resolve the problem.
procedure being performed at the time of an airway fire. The
drapes, ETT, and alcohol-based antiseptics are all potential fuel
sources. Cautery and oxygen or nitrous oxide provide the activation
Tube Obstruction
energy and oxidizing agents, respectively.60 Care should be taken Tracheotomy bypasses the natural warming and humidification
to keep the concentration of inspired oxygen as low as the patient provided by the nasal passages. The result is desiccation of the
will safely tolerate, ideally less than 40% when electrosurgical tracheal mucosa with decreased mucociliary function,63 which
instruments are in use. The surgeon should discontinue the use increases the risk of tube obstruction by inspissated secretions.
of electrosurgical instruments upon entry into the airway to Frequent suctioning and routine changing of the inner cannula
eliminate the risk of fire. are required initially, but the trachea eventually adapts. In addition,
the tube can be poorly positioned such that the tip abuts the
membranous tracheal wall, which often necessitates a different
Bleeding size or style of tube.
Intraoperatively, most bleeding is secondary to anterior jugular
vein injury or from the bleeding edge of the thyroid. This can
usually be easily controlled, but care should be taken with the use
Pressure Ulcers
of cautery, particularly in the case of patients requiring increased Ulceration of the skin can occur as a result of pressure from the
FiO2 to maintain oxygenation. tracheostomy faceplate. Patients with difficult cervical anatomy

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88 PART II General Otolaryngology

(severe kyphoscoliosis), obese patients, and pediatric patients are “party wall” is increased when a large-bore nasogastric tube
particularly at risk. Up to 29% of pediatric tracheostomy patients is also in place.80 Although stenting to bypass the fistula is an
have wound complications related to their appliance.64 Daily option,81 tracheoesophageal fistula is best managed by interposi-
inspection and use of barriers such as soft foam dressings can tion of viable tissue between the membranous trachea and the
significantly reduce this risk.65 esophagus.82

Accidental Decannulation Tracheocutaneous Fistula

Accidental decannulation has been associated with patients with Of patients who have a tracheotomy tube in place for more than
altered mental status, increased secretions, and nursing shift 4 months, 70% will have a persistent tracheocutaneous fistula as
changes.66 If decannulation occurs prior to the maturation of the a result of epithelialization of the tract.83 A history of radiation
tracheotomy tract, attempts to replace the tube can result in false exposure or the use of a Bjork flap increases the risk of a persistent
passage of the tube into the soft tissues of the neck. Unrecognized, tract after decannulation.84 Fistulae should be closed because of
this can lead to pneumothorax, pneumomediastinum, and respira- the risk of aspiration pneumonia, skin irritation, and difficulties
tory distress. If the tube cannot be successfully placed through with voicing.
the tracheotomy, translaryngeal intubation should be attempted.
Special care should be taken in patients who had PDT, because
the tract can be quite tight. If patients are accidentally decannulated
TRACHEOSTOMY CARE
before 7 days, it is recommended that they be intubated from The use of multidisciplinary teams and protocols for tracheostomy
above rather than by an attempt to replace the percutaneous tube care decreases tracheostomy-related morbidity, promotes earlier
emergently. Once the airway is secure, a percutaneous kit can be decannulation, and generally improves the quality of life of tra-
used to replace the tube in a controlled fashion. cheostomy patients.85–88 However, despite being a commonly
performed procedure, a paucity of peer-reviewed literature exists
regarding tracheostomy care. In 2011 the American Academy of
Late Complications Otolaryngology–Head and Neck Surgery convened a panel of
experts for the purpose of reviewing the available literature and
Tracheal Stenosis developing a consensus statement.89 The goal was to reduce vari-
When cuff pressure exceeds capillary perfusion pressure, the result ances in practice patterns, provide recommendation for standardiza-
is ischemic necrosis and chondritis of the underlying tracheal tion of care, and help to reduce complications (Table 7.3).
cartilages. High-volume, low-pressure cuffs have been designed Whenever possible, the patient and the patient’s caregivers
to mitigate this risk. The tip of a poorly positioned tube can also should be provided education regarding tracheotomy prior to
damage the tracheal mucosa. Such trauma can potentially lead to surgery.90 The panel felt that adult patients with favorable anatomy
tracheal and/or subglottic stenosis. It is unclear whether PDT or who had had an open tracheostomy could have the first trache-
open tracheotomy is more likely to cause stenosis (24% to 58% ostomy tube change by physicians between days 3 and 5, if the
vs. 7% to 63%, respectively),67,68 but the incidence of clinically patient had an open tracheotomy, but that percutaneous trache-
relevant stenosis is low in either case. Stenoses from PDT are ostomy appliances should not be removed or changed until day
unique in that they are characterized by a corkscrew pattern that 10 because of the increased risk for false passage.90,91 Patients
is morphologically distinct. This is thought to be due to disruption should have ready access to a suction machine in the immediate
and fracture of the tracheal rings,69 as well as increased mucosal postoperative period, and as soon as they are physically able, they
trauma caused by the shearing forces of the dilator.70 Using tapered should be instructed on how to clear the tube in the event of
tracheostomy appliances, proper anterior location of the trache- blockage with secretions. With the exception of patients who have
otomy, and use of the smallest possible tracheostomy tube are had recent free-flap reconstruction, tracheostomy ties should be
recommended to help reduce this risk. used to reduce the risk of accidental decannulation. Humidification
should be used for all ventilated patients and in the immediate
postoperative period for patients who do not require mechanical
Tracheoinnominate Fistula ventilation.
Tracheoinnominate fistula occurs in approximately 0.7% of patients For patients who require mechanical ventilation, the panel
in both acute (<2 weeks)71 and chronic (>2 weeks)72 settings. A recommended that cuff pressure be monitored and that cuffs should
sentinel bleeding event often, but not always, precedes massive be maintained at the lowest pressure that allows for adequate
hemorrhage. Prompt recognition and treatment of the condi- ventilation. Early involvement of the speech-language pathologist
tion are required to prevent asphyxiation and exsanguination. is encouraged to determine whether the patient is an appropriate
Any patient with severe bleeding should undergo tracheobron- candidate for a speaking valve. A speaking valve should not be
choscopy. In 78% of cases, the event occurs between 3 and 4 used unless the cuff has been deflated.
weeks after tracheotomy.73 Risk factors include low placement Prior to discharge, patients and caregivers should be assessed
of the tracheostomy, malnutrition, radiation, steroid usage, and for competency in care for the tracheostomy and emergency
hyperextension of the head. Immediate attention to establishing procedures. Caregivers should be able to identify signs of respiratory
an airway with an ETT that bypasses or tamponades the fistula is distress, and both patients and care providers should be able to
the first priority. Traditionally, definitive treatment is via median demonstrate suctioning and cleaning of the tube, tracheostomy
sternotomy with ligation of the innominate artery.74–76 However, change, and the use of all home equipment. Patients should be
this emergent surgery carries an approximately 50% mortality provided contact information for health care providers and equip-
rate.77 Successful outcomes with endovascular treatment have been ment supply companies. Finally, a written instruction manual should
reported78,79 but carry the concerns of placing a stent in a potentially be provided prior to discharge.
contaminated field.
DECANNULATION
Tracheoesophageal Fistula For many patients, the need for a tracheotomy is temporary. When
Tracheoesophageal fistula occurs in less than 1% of patients who the underlying medical condition has been resolved, the patient
undergo tracheotomy. The risk of fistula formation through the may be evaluated for decannulation. Candidates for decannulation

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 CHAPTER 7 Tracheotomy 89

TABLE 7.3 Key Statements That Achieved Consensus Regarding Tracheostomy Care
7
No. Statement Mean
1 The purpose of this consensus statement is to improve care among pediatric and adult patients with a tracheostomy. 8.56
2 Patient and caregiver education should be provided prior to performing an elective tracheostomy. 8.22
3 A communication assessment should begin prior to the procedure when a nonemergent tracheostomy is planned. 7.67
4 All supplies to replace a tracheostomy tube should be at the bedside or within reach. 8.78
5 An initial tracheostomy tube change should normally be performed by an experienced physician with the assistance of nursing staff, a 8.22
respiratory therapist, and a medical assistant, or with the assistance of another physician.
6 In the absence of aspiration, a tracheostomy tube cuff should be deflated when a patient no longer requires mechanical ventilation. 8.22
7 In children, prior to decannulation, a discussion with family regarding care needs and preparation for decannulation should take place. 8.67
8 Utilization of a defined tracheostomy-care protocol for the patient and caregiver education prior to discharge will improve patient 8.11
outcomes and decrease complications related to the tracheostomy tube.
9 Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain with the patient 8.89
at all times.
10 All patients and their caregivers should be evaluated prior to discharge to assess competency in tracheostomy care procedures. 8.89
11 Prior to discharge, patients and their caregivers should be informed of what to do in an emergency situation. 8.89
12 In an emergency, a dislodged, mature tracheostomy should be replaced with a tube of the same size or a smaller size or with an 8.44
endotracheal tube through the tracheal wound.
13 In an emergency, patients with a dislodged tracheostomy that cannot be reinserted should be intubated (when able to intubate orally) 8.11
if the patient is failing to oxygenate or ventilate, or if there is fear that the airway will be lost without intubation.
From Mitchell RB, Hussey HM, Setzen G, et al: Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg 148(1):6–20, 2013.

should be assessed for level of consciousness, respiratory status The length of the capping trial is patient dependent and can
and ability to cough and swallow.92 Fiberoptic endoscopy is helpful range from overnight to several weeks. Provided the patient can
to confirm that the glottis and subglottis are adequately patent. meet criteria and can tolerate an appropriately long capping trial,
If the patient possesses an adequate level of alertness to protect the tube can be removed. The site should be covered with gauze,
the airway and does not require intubation for any additional and pressure should be applied to the wound during speech and
procedures, an uncuffed tube is placed in the stoma, and the coughing to reduce airflow through the tract. The patient should
tracheostomy appliance is capped. The patient should be able to continue to observe water precautions until the tract is completely
breathe comfortably and should demonstrate the ability to manage closed.89 If the tract does not close spontaneously, it can be closed
and clear secretions. In addition, the patient should be able to under local or general anesthesia.
demonstrate the ability to remove the cap should difficulty in
breathing develop. For a complete list of references, visit ExpertConsult.com.

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 CHAPTER 7 Tracheotomy 89.e1

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