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Tracheostomies
32
Contraindications to Percutaneous
2.4
Relative Contraindications
Children under 12 years of age ■
Anatomic abnormalities of the trachea, including tracheomalacia ■
Palpable pulses over tracheotomy site ■
Active infection over tracheotomy site ■
Thyroid mass or goiter over tracheotomy site ■
Obese neck or nonpalpable laryngotracheal landmarks ■
PEEP greater than 15 cm H ■
Platelet count less than 40,000/mm
■
Bleeding time greater than 10 minutes ■
Contraindications
Prothrombin time or partial thromboplastin time greater than 1.5 times control ■
Limited ability to extend the neck, especially in the unstable spine ■
History of difficult intubation ■
Absolute Contraindication
Need for urgent surgical airway ■
Dilatational Tracheotomy
O
2
3
surveillance for any potential immediate complications, as well as confirmation of proper positioning of the tracheostomy tube. Although some controversy
regarding PDT may still linger, numerous large series have been reported with
comparable rates of complications.
The criteria for PDT are more stringent than for surgical tracheotomy
(Couch & Bhatti, 2002; see Table 2.4). The laryngotracheal framework should
be easily palpable through the skin. It is critically important that the patient’s
neck easily extends and that the patient can be easily reintubated in case of
accidental decannulation. Obese patients, children, and those with abnormal
coagulation are not candidates for this procedure. Clinicians performing PDT
should be well trained in the technique, prepared to convert to an open surgical
tracheotomy if needed, and ready to manage any immediate complications.
For this procedure, the patient is positioned and draped as for standard,
open tracheotomy. A skin incision is made and the pretracheal tissue cleared
with minimal blunt dissection. The endotracheal tube is withdrawn until the
cuff is just at the level of the glottis. The endoscopist can place the tip of the
bronchoscope such that the light from its tip is visible through the surgical
wound, thus highlighting the target area. The operator then enters the tracheal
lumen below the second tracheal ring with a needle introducer (Figure 2.7A–B).
A guide wire is then inserted through the needle (Figure 2.8A–B). The track
extending from the skin to the tracheal lumen is then serially dilated over a
guide wire (Figure 2.9A–B). A tracheostomy tube is then introduced under direct bronchoscopic view over the dilator (Figure 2.10A–B). Proper placement is
2.7
Percutaneous tracheotomy procedure. (A) Insertion of needle between second and third
tracheal rings. (B) Bronchoscopic view of needle insertion into trachea. (Bronchoscopic
image provided courtesy of Alberto de Hoyos, MD.)
B
2.8
(A) Guide wire is placed through needle introducer. (B) Bronchoscopic view of guide wire
through needle. (Bronchoscopic image provided courtesy of Alberto de Hoyos, MD.)
A
B
2.9
(A) Insertion of dilator over guide wire. (B) Bronchoscopic view of dilator over guide wire.
(Bronchoscopic image provided courtesy of Alberto de Hoyos, MD.)
A
B
2.10
(A) Insertion of tracheostomy tube over dilator. (B) Bronchoscopic view of tracheostomy
placed over dilator. (Bronchoscopic image provided courtesy of Alberto de Hoyos, MD.)
A
B
Chapter 2 Tracheotomy Procedure
then confirmed by viewing the tracheobronchial tree through the tracheostomy
tube, and the tube is secured into place with sutures and ties.
Pediatric Tracheotomy
As in adult tracheotomy, identifiable landmarks—including hyoid bone, thyroid
notch, cricoid cartilage, thyroid isthmus, and sternal notch—are identified, and
a skin incision is marked accordingly. It should be noted that these laryngotracheal landmarks are located relatively superiorly within the neck in the pediatric age group. Dissection then proceeds as in adults. Particular attention should
be paid to avoid straying laterally due to the presence of the pulmonary apices
within the cervical compartment in the younger age groups, which increases
the risk of pleural puncture and resultant pneumothorax.
At the level of the trachea, the incision is generally made vertically through
two or three tracheal rings, usually within the second to fifth tracheal rings. As
in adults, an incision too close to the cricoid should be avoided, as it is associated with higher rates of subglottic stenosis.
Nylon traction sutures are placed in the trachea on either side of the incision line before the incision is made. These sutures serve to place traction on
the tracheal rings during cannulation of the airway and are crucial in locating
the tracheal window in cases of accidental tracheal displacement in the early
postoperative period (Parnes & Myers, 1976). The vertical transtracheal incision
should be long enough to easily allow passage of the tracheostomy tube in order
to prevent undue damage to the integrity of the cartilage framework. Too small
an incision or a horizontal intercartilaginous incision may lead to the collapse
of the suprastomal tracheal ring as the curved tube exerts backward pressure
on the ring above the incision.
After the tracheostomy tube is placed, it is secured in a similar fashion to
adults. The traction sutures are tied loosely and taped to the skin of the anterior
chest wall. Tape labels are used to clearly identify the right and left traction
sutures so they are not reversed when used to recannulate the trachea, which
would have the counterproductive effect of approximating the edges of the tracheal window.
The position of the tracheostomy tube with respect to the carina and tracheal wall can be determined via either passing a pediatric flexible endoscope
through the tube or obtaining a postoperative chest radiograph. The tip of the
tracheostomy tube should be 5 to 20 mm from the carina. The tube should not
be so short that the lumen faces posteriorly or is at risk for exiting the tracheal
window and entering a false pretracheal passage. Certain patients, such as
obese children or those with metabolic storage diseases, may have excessively
long tracts between the skin and trachea, requiring custom tracheotomy tubes
with extra long proximal, extratracheal portions.
37
Postoperative Care
Postoperative care of the tracheostomy patient is considerably facilitated if
there has been preoperative teaching, which helps both children and adults
adapt to a new way of breathing. Family counseling is also important in order to
Tracheostomies
38
optimize postoperative patient support for those able to be discharged. Highly
skilled nursing care is crucial for success in this area.
tensive care setting in order to continuously monitor vital signs. Indeed, subtle
changes in the patient’s behavior, pulse, blood pressure, or respiratory rate may
herald an obstruction of the tracheotomy tube with dried blood or secretions,
which requires immediate attention. Tracheal suctioning must be performed as
frequently as needed—often more frequently than would be possible outside of
an ICU setting. The humidification of inhaled air is important for the mucociliary
transport of secretions and to prevent the obstruction of the airway with dried secretions. The inner cannula must be removed frequently for cleaning and to avoid
the accumulation of obstructing crusts. The tracheostomy tube is rarely changed
before the third postoperative day to allow the tract to mature and to avoid tissue
collapse that would seal off the airway. Tube replacement within the first 72 hours
postoperatively should be done in the same conditions as the original procedure
and requires adequate headlights, suction, cricoid hook, and assistance. Tube replacement is sometimes necessary if the cuff of the tracheotomy tube fails in a
patient continuing to need positive-pressure ventilation after the procedure.
Summary
In the initial postoperative period, the patient is usually placed in an in-
The surgical technique of tracheotomy should be adapted to the situation at
hand, especially for patients with complicated neck anatomy, those with previous tracheotomies, or pediatric patients. Attention to detail during the procedure will help avoid the pitfalls and complications that can plague tracheostomy
patients during the postoperative period. There continues to be controversy between open and percutaneous dilatational tracheostomy, but both have long
track records, and application of one versus the other depends on the established practice patterns of individual clinicians.
Irrespective of the quality of intervention at the time of the procedure, longterm success and the prevention of complications depends on meticulous care
during the postoperative period.
Key Points
Open surgical tracheotomy can be performed in the operating room or ■
the ICU, with bedside tracheotomies having the advantage of decreased
patient transport risk, operating room cost, and schedule burden.
■
Percutaneous dilatational tracheotomy has become an important alternative approach and is best performed under bronchoscopic guidance to
identify immediate complications and confirm tube placement.
■
After the procedure, patients require continuous monitoring of vital signs
and are usually placed in an ICU.
Acknowledgment
Bronchoscopic images of percutaneous dilatational tracheotomy were provided
by Alberto de Hoyos, MD.
Chapter 2 Tracheotomy Procedure
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Types of
Tracheostomy
Tubes and
Related
Appliances
Linda L. Morris
3
Each tracheostomy tube has a variety of features, and there are many different
tracheostomy tubes to choose from. There are several manufacturers, and all
offer different features, materials, lengths, inner and outer diameters, and so
forth. Some have a single cannula, while others have dual cannulas—that is,
both inner and outer cannulas. Some have low-pressure cuffs, and a few have
high-pressure cuffs. Still others are cuffless. The choices are abundant.
Early tracheostomy tubes were composed of metal, either silver or stainless
steel. Most modern tracheostomy tubes are composed of medical-grade plastics
such as polyvinyl chloride, polyurethane, silicone, or a combination. Although
metal tubes are still in use today, softer materials are much more widespread.
Plastic tubes have the advantages of being cheaper, lighter, easier to modify
for special needs, and, depending on the material, more pliable. These softer
materials have allowed for cuffs at the distal end of the tube. Metal tracheostomy tubes have the advantage of thinner walls, but they usually cannot be connected to a ventilator because they do not have cuffs (Dhand & Johnson, 2006;
St. John & Malen, 2004).
41