Laryngology Semina
Tracheostomy & Tracheotomy
2004-10-27
R3 林正民
Historical review
2nd & 3rd centuries A.D.: Galen and Aretaeus. The first detailed reports of tracheotomy
1546: Antonio Muso Brasovolo. The 1st reported successful tracheotomy
1766: Caron. Remove a bean from a 7-year-old boy with tracheotomy
Early 1900s: Bretonnear & Trousear. Tracheotomy for patients with diphtheria
1700s: Moreau:1st tracheotomy in recumbent position.
(Prior to Moreau: Sitting position with neck hyperextension)
1909: Jackson C: Standard surgical principles of the tracheostomy—till now
1955: Shelden: 1st attempt percutaneous tracheostomy, fatality
1969: Toye & Weinstein: single tapered dilator
1985: Ciaglia et al: Percutaneous dilational tracheostomy (PDT)
1990: Grigg et al: PDT and guidewire dilating forceps (GWDF)
Tracheotomy vs. Tracheostomy
Anatomy of Trachea
Tracheal diameter: 3mm (1-y-o) and increase with age. 2.0-2.5 cm (Adult).
Flattened shape: Ant.—cartilageous rings, Post.—muscular membranous portion.
20 to 22 rings, with 2.1 rings per cm of trahea.
Indications
1) Respiratory obstruction 2) Secretory retention 3) Resipratory insufficiency.
Timing for intubation conversion to tracheotomy
Post-intubational tracheal stenosis (Whited RE, 1984)
< 5 days— No long-term laryngotracheal complications.
6 ~ 10 days— 5% chronic airway stenosis, vocal cords to cuff level.
11 ~ 24 days— 10 % laryngeal functional disturbance.
12 % chronic laryngotracheal stenosis.
Medical Directors of Respiratory Care (Switzerland) (Plummer et al, 1989)
a. Translaryngeal intubation preferred up to 10 days.
b. Tracheostomy preferred when artificial airway is needed longer than 3 wks.
Methods: Techniques, location, anesthesia
1. Cricothyroidotomy
1976, Brantigan and Grow
4% significant subglottic tracheal stensosis; 15% voice dysfunction
2. Minitracheostomy
14-gauge needle cricothyroidotomy with jet ventilation
3. Standard tracheotomy
 Emergency vs. Orderly tracheotomy
 Tracheal wall incision:
a. Vertical b. Transverse c. Cruciate d. H type incision e. Horizontal H
f. Björk flap g. Fenestation, window-type excision


Tracheostomy in pediatric model: (Fry TL et al, 1985)
Vertical incisionwas superior to horizontal H incision and Björk flap.
Kremer B. (2002): recommend Björk flap to reduce danger of accidental
decannulation and tracheostomal collapse while cannula exchange

Tracheal incision
Byrant LR (1978): No significant difference between window-type excision,
transverse incision, and vertical incision with stoma stenosis. (Table )
Natvig KN (1981): Etiology of tracheal stenosismultifarious (Fig )
4. Terminal tracheostomy: cervical or mediastinal
5. Percutaneous tracheotomy
 Currently, 25% of tracheostomy in ICU at USA.

Needle (1st~ 3rd tracheal ring)Wire Dilator  Tracheostomy tube (fig)
Multiple serial dilation, ex Ciaglia Cook kit: (8 or 11 F38 F)
Single-step dilation, ex Blue Rhino percutaneous tracheostomy kit
Advantages of PDT over surgical tracheotomy—
Smaller skin incision, less dissection and tissue trauma, fewer infection, decreasing
risk and cost to OR, less time (11.7 vs 26.9min).
Disadvantages —
Higher perioperative complication (10% vs 3%)
•Perioperative death (0.44% vs 0.03%)
•Serious cardiorespiratory events (0.33% vs 0.06%)
Contraindications to PDT
Absolute—Emergent airway access, infants, infection at insertion site, high
PEEP or oxygenation requirements
Relative—Anatomic abnormalities (deviated trachea, enlarged superficial veins,
etc.), enlarged thyroid or other neck mass, coagulopathy, previous
neck surgery, obesity.
Complications of Tracheostomy
Intraoperative
Early (< 7 days)
Late (> 7days)
Bleeding
Tracheal laceration
Tracheoesophageal fistula
Tube malposition
Recurrent laryngeal n injury
Bledding
Persistent abscess or
cellulites, tracheitis
Subcutaneous emphysema
Pneumomediastinum
Tracheoimmominate artery
fistula
Tracheoesophageal fistula
Tracheal stenosis
Tracheal malacia
Pneumothorax
Pneumomediastinum
Cardiopulmonary arrest
Tube malposition
Tube obstruction
Persistent Tracheocutaneuous
fistula
Reference
1. William W. Montgomery. Surgery of the larynx, trachea, esophagus, and neck. 2002.
2. Whited RE. A study of endotracheal tube injury to the subglottis. Laryngoscope. 1985
Oct;95(10):1216-9.
3. Plummer Al, Gracey DR. Consensus conference on artificial airways in patients receiving
mechanical ventilation. Chest. 1989 Jul;96(1):178-80.
4. Burkey B, Esclamado R, Morganroth M. The role of cricothyroidotomy in airway management.
Clin Chest Med. 1991 Sep;12(3):561-71.
5. Fry TL, Jones RO, Fischer ND. Comparisons of tracheostomy incisions in a pediatric model. Ann
Otol Rhinol Laryngol. 1985 Sep-Oct;94(5 Pt 1):450-3.
6. Kremer B, Botos-Kremer AI, Eckel HE., et al. Indications, complications, and surgical techniques
for pediatric tracheostomies. J Pediatr Surg. 2002 Nov;37(11):1556-62.
7. Marc S, Rovner. Percutaneous dilatational tracheotomy. Clin Pulm Med 2001;8(2):78-87.
8. Dulguerov P et al: Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999;
27: 1617-1625