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33. Ledgerwood LG, Salgado MD, Black H, Yoneda K, Sievers A, Belafsky PC. Tracheotomy
tubes with suction above the cuff reduce the rate of ventilator-associated pneumonia in intensive care unit patients. Ann Otol Rhinol Laryngol. 2013;122(1):3–8.
34. Smiths Medical. Tracheostomy products. https://www.smiths-medical.com/products/tracheos-
tomy. Accessed
J.M. de AlmeidaVital et al.
Tracheostomy: Conventional Technique
AdilisSteppleda Fonte Neto, TerencePiresde Farias,
JulianaMariade AlmeidaVital, JoseGabrielMirandada Paixão,
JulianaFernandesde Oliveira, andPauloJosede
CavalcantiSiebra
Introduction
Tracheostomy, a term derived from two Greek words meaning “to cut the trachea,”
is a procedure known for approximately 3500years.
The literature concerning its early history is quite scarce and open to various
subjective interpretations, which hinder understanding of the technique. Most articles reference the procedure alone or, at most, its indications [1].
A.S. da Fonte Neto, M.D. (*)
Department of Head and Neck Surgery, Integral Medicine Institute of Pernambuco (Instituto
de Medicina Integral de Pernambuco-IMIP), Recife, PE, Brazil
Pernambuco Cancer Hospital (Hospital de Câncer de Pernambuco), Recife, PE, Brazil
Department of Head and Neck Surgery, Brazilian Head and Neck Surgery Society (Sociedade
Brasileira de Cirurgia de Cabeça e Pescoço), São Paulo, SP, Brazil
e-mail: adilisdafonte@gmail.com
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher.
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University,
Rio de Janeiro, RJ, Brazil
J.M. de AlmeidaVital, M.D.
Head and Neck Department, Irmandade Santa Casa de São Paulo, São Paulo, SP, Brazil
Head and Neck Surgeon, Private Practice, Sao Paulo, SP, Brazil
e-mail: jujuliana.a@gmail.com
J.G.M. da Paixão, M.D. • J.F. de Oliveira, M.D. • P.J. de CavalcantiSiebra
Department of Head and Neck Surgery, Brazilian National Cancer Institute (Instituto
Nacional de Câncer– INCA/MS), Rio de Janeiro, RJ, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_4
47
48
A.S. da Fonte Neto et al.
Information about the procedure is included in two of the world’s three oldest
medical references. The sacred book of Hinduism, written between 2000 and
1000BC, mentions the convergence of the tracheal rings without ligatures after
tracheostomy as apparently not warranting great concern [2]. Since that time, surgical closure of the tracheostomy was considered unnecessary, a principle adopted in
the current era. The Ebers Papyrus, an Egyptian text from 1550BC, refers to caution
in the approach to the neck and diligence concerning the blood vessels, which still
guide the hemostatic precautions adopted with current techniques. In their third
medical book, the Chinese did not reference the procedure because the body was
considered sacred and surgery deemed unnecessary.
Circa 100BC, Asclepiades of Bithynia, a surgeon from a Roman province in
northern Asia Minor, was the rst to perform the procedure electively, in an infectious disease case. The procedure was later condemned because it was believed that
the cartilage would not close [3].
With the fall of the Roman Empire and the beginning of the Byzantine Empire,
one of the most prominent surgeons of that era emerged, Paul of Aegina (AD625–
690). He was born on the island of Aegina and practiced medicine in Alexandria. He
wrote a series of seven books titled The Medical Compendium in Seven Books,
which merged information from the ancient Greek and Roman empires. The chapter
referring to the head and neck was the rst to describe the technique of tracheostomy, fundamentally unchanged since this time, and its indications might be accurate here. According to Paul of Aegina, the patient should be placed in the supine
position with the head extended for better exposure of the trachea. Next, a transverse excision of the membrane between the tracheal rings would be performed
with a subsequent forceful expulsion of air or an inability to vocalize. Later, the skin
would be sutured but not the cartilage [4].
New reports of the procedure and technical developments were possible only
after the end of the Barbarian invasions, at the start of the High Middle Ages.
Initially, due to much fear and skepticism, the procedure was discouraged.
Major technical advances occurred during the sixteenth century. In 1546, Musa
Brassarolo Ferrara described the surgical technique. Notwithstanding its additional
indications, his technique resembled that described by Paul of Aegina. In 1590,
Sanatorius introduced the concept of cannula changing and leaving a cannula in
place for 3days. At that time, the preparation of a tracheocutaneous stula was
already an emerging concern.
In the seventeenth century, experiments performed by Robert Hooke on an animal
model and inspired by the studies of Vesalius (1543) demonstrated the possibility of
mechanical ventilation using cannulae with endotracheal balloons. At the University
of Padua, using a vertical incision in the trachea, Fabricius ab Aquapendente and his
pupil Casserius developed straight cannulae with rings and curved cannulae that
enabled the patient to remain tracheostomized for a long period [1, 4].
The procedure was established during the eighteenth century despite extensive
discussion and contrary opinions, such as those regarding its safety and extended
indications. An important milestone in the nineteenth century was the publication in
1830 of a book by McKenzie, titled Diseases of the Pharynx, Larynx and Trachea,
Tracheostomy: Conventional Technique
49
which discussed the appropriate time for the surgical approach. A literature review
by Dr. Max Schuller in 1880 showed that great disagreement persisted at that time
about the technique—for example, regarding the level chosen for the incision and
the optimal opening of the trachea, anesthesia, and technique in children and adults.
An important development at the end of the nineteenth century and the beginning of
the twentieth century was the possibility of airway control by orotracheal intubation.
This advance allowed reduced comorbidities resulting from complex types of respiratory failure and consequently contributed to surgical technique improvement [24].
A 1909 publication in Laryngoscope by the author Chevalier Jackson, followed
by other publications in 1921, set forth the technical fundamentals used today. He
proposed a long and low incision in the fourth/fth ring, which avoided dissection
of the cricoid and thyroid cartilages and aimed to reduce stenosis. Jackson also
proposed the dissection and sectioning of the tracheal isthmus for better exposure
along with the development of various instruments for laryngotomy, bronchoscopy,
and tracheostomy [18].
Currently, the surgical technique remains similar to that developed over
3000years of history. More objective indications; technically improved scalpels,
suture materials, and hemostatics; and the development of specic cannulae have
contributed to a noteworthy reduction in morbidity.
Legislation
In Brazil, several opinions, consultations, and resolutions guide the Regional and
Federal Medical Councils, standardization of the procedure and its good practice,
and expertise and responsibilities.
The most common guidelines for proper procedural performance are discussed
subsequently.
Who Is Qualified toPerform theProcedure?
In principle, any physician may perform the procedure, whether a clinician or surgeon, as long as they judge themselves capable and are willing to assume responsibility. Prudence demands that such individuals be professionals whose residency
programs are standardized by the Ministry of Health and specialty societies and
have included adequate training.
General surgeons, head and neck surgeons, oncological surgeons, pediatric surgeons,
thoracic surgeons, and intensivists are specialists qualied for this purpose [5–7].
In cases of emergency care for craniofacial trauma for which an oromaxillofacial
surgeon is available, the on-duty clinician or surgeon is responsible for securing the
airway, whether by tracheostomy or another method, before referring the patient to
the specialist [8].
In emergencies, physicians must be prepared to perform cricothyroidotomy or
perhaps tracheostomy if it is within their capability.
50
In cases of elective tracheostomy, it is prudent for the surgical team to perform
the procedure [5].
A.S. da Fonte Neto et al.
What Is aSuitable Location fortheProcedure?
Bedside tracheostomy should be discouraged and should be performed only when
patient transport to the operating room generates greater risks than those of the
intensive care setting. Nonetheless, adequate technical conditions such as lighting
and surgical instruments and a multidisciplinary team cannot be disregarded [6].
Elective tracheostomy should be performed primarily in the operating room with the
participation of a multidisciplinary team to provide adequate health care support [9].
Emergency tracheostomies may be performed outside the operating room and
within the emergency care environment, respecting the need to support well-dened
cases. These procedures should be performed in an isolated environment that provides the technical support required to ensure good practice.
Is Informed Consent Necessary?
In urgent cases, performing a tracheostomy without any prior authorization is
acceptable because the objective of this procedure is to safeguard the patient’s life
and health. Thus, its immediate performance is indisputable and unavoidable, as is
any other procedure performed without informed consent.
In elective cases, prior authorization from the patient or legal representative is
necessary whereby the risks and benets of this procedure are clearly explained.
In cases of patients with unknown identities for whom no legal guardian is identied, the legal department of the institution must request the procedure judicially.
The technical/clinical director is not responsible to authorize any type of invasive
procedure [10].
Surgical Technique
No major changes to the conventional surgical tracheostomy technique have ensued
since it was proposed by Brassarolo in 1546 and later described and rened by
Chevalier Jackson in 1909. The anatomical knowledge held by the Egyptians,
Greeks, and Persians was expanded, described, and studied in the Renaissance era,
which makes the technique a widespread and consolidated procedure.
In the early twentieth century, Chevalier Jackson summarized the tracheostomy
technique according to the following important aspects [18]:
1. Preservation of the cough reex
2. Careful tissue dissection with minimal bleeding
3. Posttracheostomy care
Tracheostomy: Conventional Technique
51
4. Technique following aseptic principles
5. Trendelenburg position to decrease airway infection and bleeding
6. Appropriate size and length of the cannulae
Substantial advances have clearly ensued in terms of indications, damage control,
reduction of complications, and development of minimally invasive techniques.
However, some myths related to the procedure warrant examination. First, some
medical professionals believe that tracheostomy is a low-risk secondary procedure
without complications. Although mortality has decreased considerably, as recently
as the early twentieth century it was 10–15% [18].
Thus, although the procedure is well established and has quite precise indications,
the fact that some complications and sequelae exist that may be fatal for the patient
must be claried for the medical professional, patient, and patient’s family members.
The informed consent form must be completed properly and must not represent an
institutional formality. Although this suggestion may appear innocuous, it may
potentially confer heightened signicance should court proceedings ensue.
The purpose of this chapter is not to discuss indications and contraindications for
the procedure, which will be discussed and detailed in other chapters. Next, the
conventional technique of tracheostomy will be addressed and the procedure
claried.
The following checklist must be followed before procedural execution.
Training oftheMultidisciplinary Team
Less-informed professionals may believe that the simple presence of a surgeon, or
one assisted by a nursing technician or other professional, makes the surgery achievable with risks inherent in the procedure. The assumption of impeccable surgical
skills may represent the most critical error in such surgery.
The team should always be multidisciplinary [22, 23, 25]; its needs depend on
the situation and are determined by the reason the procedure was indicated.
In elective tracheostomy on stable patients able to undergo the procedure under
local anesthesia, the team will be composed of the surgeon, a qualied medical
assistant, a scrub nurse, and a circulating nurse.
In hemodynamically unstable patients with an inadequate ventilation pattern or
those from intensive care units (ICUs) or similar units, the presence of an anesthesiologist is necessary and prudent because simultaneous maintenance of vital functions and judicious performance of the procedure by the same person are not
possible.
For patients undergoing tracheostomy in the ICU, the intensivist may sedate the
patient to perform the procedure. In this situation, the presence of a respiratory
physiotherapist is crucial to assist in the patient’s full adaptation to the respirator.
In emergency tracheostomy, the team should be tailored according to the situation. The crucial consideration is to open the airway as rapidly as possible and with
the least damage.
52
A.S. da Fonte Neto et al.
In all cases, nursing teams and technicians who are trained in the procedure are
necessary, and they should be available at the exact time of the intervention. The
success of the procedure depends on the ability of this team to respond appropriately and effectively.
Surgical Instruments
Because of high demand and low resources in Brazil’s Unied Health System
(Sistema Único de Saúde (SUS)), practitioners must perform the procedure without
minimal conditions being met; they thereby assume unnecessary risks and, in the
worst cases, cause harm to patients.
The following surgical instruments are required for tracheostomy in any situation: surgical mask, surgical cap, sterile surgical gowns and drapes, electrosurgical
knife, cold scalpel, dissecting forceps with and without teeth, hemostatic curved
forceps, straight and curved scissors, Farabeuf retractors, 10cc and 20cc syringes,
lidocaine with and without a vasoconstrictor, suction catheter, gauze and bandages,
eld forceps, 2–0/3–0 surgical cotton yarn, 3–0/4–0 nylon thread, 3–0/4–0 Prolene,
tracheostomy cannulae, and xation tape. The choice of the cannula to be used
depends on various factors and needs. Generally, for patients undergoing tracheostomy in the ICU and on mechanical ventilation regardless of the need for endexpiratory pressure, a polyethylene cannula with a balloon is required, which
ensures full adaptation to the respirator. In cases in which the patient does not
require ventilatory support, the best option is a simpler cannula, such as a metal
cannula or a polyethylene cannula with or without a cuff (with or without risk of
bronchial aspiration, respectively), with or without fenestration (with or without
vocal potential, respectively) and with a subcannula. The availability of at least two
cannulae that may be used and are chosen in advance is essential. Regarding size,
the use of the largest possible cannula is always recommended because it guarantees
the best ventilatory ow and allows better cleaning and less bronchoaspiration. For
adults, metal cannulae sizes 5 and6 and cuffed polyethylene cannulae sizes 7.5, 8,
and8.5 are commonly used (for the latter, the endotracheal tube that is used may
provide guidance regarding the size of the tracheostomy tube). In special cases, the
need for long cannulae due to unusual anatomical conditions should be considered
initially and assessed in advance. This decision cannot be untimely, and the cannula
must be accessible before the procedure begins (Fig.1).
Location
Like any other surgical procedure, tracheostomy is associated with indications, contraindications, surgical techniques, and complications. It is not an inconsequential
or second-tier procedure. Rather, unusual technical situations that may lead to early
or late complications may exist and should not be overlooked.
Tracheostomy: Conventional Technique
Fig. 1 Surgical
instruments mounted on a
Mayo table with
instruments and cannulae
53
For these reasons, as dened in advance according to technical recommendations, the tracheostomy should be performed in a large room, wherein a multidisciplinary team may circulate. The procedure should follow all of the principles of
asepsis, including those pertaining to the gas supplies (oxygen, nitrogen, and nitrous
oxide), anesthesiology equipment, and technical arsenal for intravenous and inhaled
general anesthesia. Also required are laryngoscopy, nasal endoscopy, and bronchoscopy equipment; an electrosurgical knife; appropriate tables and surgical lighting; a
support table; and surgical aspirators. The room may be part of the operating center
or adapted for operation in emergencies (Fig.2).
Tracheostomy performance in the intensive care unit has always been subject to
criticism [19]. The management of critically ill patients—including, among other
factors, adequate transportation to the operating room for the procedure—has
prompted many discussions about technical deterioration and the consequent percentage increase in complications. In their review, Futran etal. found no differences
in the incidence of early and/or late complications between groups undergoing tracheostomy at the bedside or in the operating room. However, tracheostomy at the
bedside was associated with lower cost and greater convenience in terms of the
surgeon’s time and was independent of the operating room schedule. Furthermore,
less movement of critically ill patients was required, which avoided potential complications or less movement of critically ill patients, an activity associated with
potential complications, was required—if either retains the intended meaning [20].
Regardless, the aforementioned minimum necessary conditions must be provided in
that environment to avoid the risks associated with negligence or carelessness.
In extrahospital environments in which control of the appropriate parameters is
typically not possible, providing a large site for the exclusive use of the rescue team
is vital. An oxygen supply must always be considered. Correct patient mobilization
must be followed to avoid exacerbation of the underlying pathology. The use of a
preassembled kit is suggested. Finally, the most suitable technique for the specic
condition should be chosen.
54
Fig. 2 Adequate
monitoring is essential
when performing the
procedure in the operating
room under an aseptic
technique
A.S. da Fonte Neto et al.
General Conditions
Once tracheostomy is indicated (as discussed in specic chapters), the doctor
responsible for performing the surgery must formulate an overview of the patient
from a practical perspective, foreseeing difculties and complications.
Although the procedure is widely practiced and has a low major complication rate, it may nonetheless lead to considerable morbidity in the short term,
medium term, and long term; thus, tracheostomy encompasses great technical
responsibility.
A careful analysis of each case is therefore needed from the outset. No type of
pressure or inadvertent act may be permitted. The indication must be questioned
whenever necessary. The patient’s clinical condition must be meticulously evaluated (drug dependence, mechanical ventilation, oxygen therapy, degree of respiratory discomfort, associated comorbidities, prescription drugs, etc.). The conditions
at the hospital where the procedure will be performed (location, instrumentation,
and multidisciplinary team) must be evaluated. Adherence to these steps will allow
the establishment of minimum safety measures and aid in minimizing mortality
associated risks.
Tracheostomy: Conventional Technique
55
Positioning
The patient’s positioning clearly dictates the success of the procedure. This step
must not be considered a poor use of time nor assigned to the medical assistant or
nursing staff. The purpose of this step is to ensure optimized accessibility to the
laryngotracheal complex.
In most cases, the patient is placed supine on a rigid surface, properly monitored
(physical pressure curves, electrocardiographic tracings, oximetry) with peripheral or
central venous access, oxygen supplementation as necessary, and anesthesiology assistance. A bolster, which should also be hard, is then placed between the rigid surface and
the shoulders, ensuring anteriorization of the laryngotracheal complex. The head is
hyperextended and supported on a comfortable cushion [17, 19, 21, 26] (Figs.3 and 4).
Frequently encountered or unexpected situations may occur. For ICU patients
who require bedside tracheostomy, the following considerations must be addressed:
1. When the cushion used does not have sufcient rigidity to maintain the patient’s
position, one option is to increase the size of the bolster used below the shoulders
or to support the entire chest/neck and head on a rigid surface.
Fig. 3 Proper positioning
with mild cervical
hyperexion, facilitating
exposure with tracheal
anteriorization
Fig. 4 Positioning in
surgical practice. The
bolster used under the
shoulders should be
sufciently rm to
maintain hyperexion.
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