Tracheotomy
Dr J A Anderson MD MSc. FRCS(C)
Chief Department of Otolaryngology HNS
St Michael’s Hospital
University of Toronto
POS November 2012
13/04/2015
1
Tracheotomy
 Indications
 Technique

Open and percutaneous
 Complications
 Physiology of a tracheotomy
 Troubleshooting
 Decannulation
Tracheotomy
 Creation of communication between the
trachea and the cervical skin with insertion of
a tube
Indications
 Airway obstruction
 Pulmonary Secretions
 Ventilation
 Prolonged mechanical ventilation


May assist in weaning from mechanical
ventilation
Prevention of glottic stenosis/complication of
prolonged ett
Fixed Airway Obstruction
 Tumours of upper aero digestive tract

Chronic airway obstruction up to 80% lumen
 External compression by tumour

Anaplastic thyroid, massive lymphadenopathy
 Foreign Body
 Glottic Stenosis/tracheal stenosis
 Trauma upper airway
Non-Fixed Airway Obstruction
 Trauma
 Expanding neck hematoma
 Maxillofacial trauma
 Laryngeal fracture
 Inflammatory
 Inhalation injury
 Anaphylaxis
 Epiglottitis
 Ludwig’s Angina/Deep Neck space infection
 Bilateral vocal cord paralysis
Fiberoptic Intubation can be successful
Pulmonary Secretion Clearance
 Aspiration / dysphagia
 COPD
 Bronchiectesis
 Stasis of secretions

Poor cough
 Poor respiratory reserve
Ventilation
 Neuromuscular disorder affecting respiratory
muscles

Reduced respiratory effort
 Limited pulmonary reserve

COPD, Scoliosis, bronchiectesis
 Central respiratory depression

Reduced LOC
 Severe obstructive sleep apnea

Cor pulmonale, failure CPAP
Prolonged Intubation
 7-10 days ett
 Risk Factors for Glottic
Stenosis




Diabetes
Female
Size ETT and # ett
Hemodynamic
instability
 Incidence glottic
stenosis: 5% over 10
days (Whited 1984)
Example 1
Subglottic Stenosis
Example 3
Combined Glottic/Tracheal Stenosis
Prolonged Intubation
 Weaning from ventilator
 Relative indication for tracheotomy
 Modest gains in respiratory function after
tracheotomy may be enough to increase
chance of successful weaning from ventilator
 Trend of patients ventilator requirements

5 day reversibility of common ICU admitting
diagnoses
Tracheotomy
 Decision made patient requires tracheotomy
 Open or percutaneous technique
 75% of tracheotomies done at SMH are done
percutaneously in ICU at bedside
 Variations of open tracheotomy technique
 General principles are the same



External approach through neck soft tissue
Creation of opening in trachea
Placement of tube to maintain airway
Technique
Diagrams from Lore, Surgical
Atlas 1988
Equipment
 Tracheotomy set

Right angles, cricoid hook, trach spreader
 Tracheotomy tube




Shiley most common
Select size (6, 8 most common)
Cuffed non-fenestrated for most ICU patients
Fenestrated if voicing expected (use non-fen
inner cannula during procedure)
Open Tracheotomy
1.
Position the patient




2.
3.
Neck extended
Roll under shoulders
4.
Arms tucked
5.
On OR bed
Palpate landmarks
Transverse incision half
way between cricoid
and sternal notch
Retraction
Divide strap muscles in
midline
Technique
Diagrams from Lore, Surgical
Atlas 1988
Technique cont’d
6.
7.
8.
9.
10.
Thyroid isthmus
Divide or retract
Identify cricoid and upper
tracheal rings using blunt
dissection
Blunt cricoid hook helpful
Retract cricoid in superior
direction
10. Tracheotomy tube cuff
11.
12.
13.
14.
checked and obturator in
Deflate cuff of
endotracheal tube
Horizontal incision between
tracheal rings (below the
second ring)
Suction lumen if necessary
Spread rings apart with
spreader or scissors
Technique 2
DO NOT use cautery on the trachea
FIRE!
Technique 3
Technique
15. Endotracheal tube withdrawn until just above the
16.
17.
18.
19.
20.
open tracheal site
Tracheotomy tube with obturator, pushed into mid
lumen of trachea, then directed inferiorly
Obturator withdrawn and inner cannula placed
Anaesthetic connector tubing passed over and
connected
Cuff inflated
DO NOT LET GO OF THE TUBE
Final
21. Anaesthesia: Check CO2, good breath
sounds
22. Sew in the trach tube shield to skin
23. Loosely approximate incision
24. Trach ties
Contraindications
 Medically well enough for GA
 PEEP < 20 mm Hg
 Uncontrolled coagulopathy
 Airway pathology below tracheotomy site
Percutaneous Tracheotomy







Bedside tracheotomy in ICU patients
An alternative not replacement for open trach
General anaesthesia and paralysis for procedure
Fiberoptic broncoscopic guidance
Ciaglia ‘Blue Rhino” by Cooke $200
Bronchoscopic guidance
Experienced personnel



Anaesthesia
Respiratory therapist
Surgeon
Selection of Patients
 Must be able to
palpate landmarks
adequately
 Cricoid above sternal
notch

Low larynx/cricoid
 High innominate artery
problematic
 PEEP > 20
contraindication
Advantages
 Smaller wound, less
dissection
 ICU setting
 Set uptime 20 minutes
 Procedures time less
than 10 minutes
Percutaneous Tracheotomy
Disadvantages
 Not for everyone
 Must ventilate with ETT in high position

Maybe an air leak during procedure
 Must use Shiley tube
 Experienced personnel
 Contraindications same as open and
 Anatomic limitations
Technique
1.
2.
3.
4.
5.
6.
Identify landmarks
Local anaesthetic
Small incision midline
ETT moved superiorly
until cuff at cords
Bronchoscope with
connector in ETT
Needle in midline into
trachea
Guide wire passed
inferiorly
9. Small calibre dilator
10. Wire sheath and ‘blue
rhino’ dilator pushed
along wire into trachea
11. Trach tube with fitted
introducer passed
over wire into trachea
8.
Video Percutaneous Tracheotomy
Tracheotomy Tubes
Portex and Shiley common brands of trach tubes.
Shiley used as standard tube at St Michael’s Hospital.
Tracheotomy Tubes
Tracheotomy Tubes
Bivona or foam cuff
Tracoe Cuffless
Speaking valve
Complications: Intraoperative
 Bleeding 2.8%*
 Recurrent laryngeal nerve injury
 Tracheoesophageal fistula
 Pneumothorax: rare
 False passage


Anterior dissection most common
Incidence <1%
*Kost et al 1994
Odd Things That Can Happen
 Trach tube place upside down
 No CO2 tracing despite surgeon positive tube is in the
airway
 Cut the pilot tube of the cuff while cutting the sutures
 Trach tube coughed across table after correct
placement
 Difficulty with air leak

Cuff leak/tube too short or not large enough /position
tube
 Blocked tube secondary to secretions/blood
Tracheotomy: Early Complications
 Bleeding


Minor common
Major tracheoinnominate fistula (<0.2%)*
 Obstruction of tube (2.5%)*
 Dislodgement (1.4%)*
 Pneumothorax (1 - 2.5%)*
 Wound Infection

Local care, antibiotics (staph/pseudomonas)
Late Complications



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Tracheal stenosis
Tracheal chondritis
Subglottis stenosis- high tracheotomy
Tracheomalacia
Tracheoesophageal fistula
Failure of stoma closure when decannulated
 Overall complication rate 15-30% in ICU patients
 largely minor with no long term morbidity
Tracheoinnominate Fistula
 More than 10 days post tracheotomy (as
early as 5 days)
 Sentinel bleed
 Angiogram/CTA for diagnosis
 Surgical exploration
 Interventional radiology-stent
 Associated with low tracheotomy placement,
wound infection or aberrant artery
Late Complications/Stoma
Minor amount of bleeding common due to granulation tissue /dry mucosa
Stoma and Inferior View Vocal Folds
Physiology of Tracheotomy
 Neck breathing
 Bypass upper airway and nasal function
 Loss of humidification/heat airflow
 Dryness, thick secretions
 Voicing possible with speaking valve
 Loss of smell /reduced taste
 Loss glottic closure function for cough
Physiology of Tracheotomy
Respiration
Advantages
 Lower work of breathing (30%) c/w normal
airway
 Facilitates secretion clearance

Aspiration or thick secretions
 Less dead space (100 mL)
 Reduced airway resistance
 Assists in patient independence from
mechanical ventilation
 Patient comfort (better than ett)
 Epstein 2005 Respiratory Care
Physiology of Tracheotomy
Respiration
Disadvantages
 Tube diameter and shape

increases turbulent airflow, secretions adhere inside tube
 Loss of humidification/heat function of upper airway
 Ciliary function affected
 Biofilm colonization
 Diminish cough/loss glottic closure
 Reduce laryngeal elevation during swallow
 Patient comfort (better no tube at all)
Dysphagia
 Common issue in neurological impaired pt
 Tube required for secretion management
particularly in patient with florid aspirate
 Tube presence associated with limitation of
the cephalad excursion of larynx during
swallow and can contribute to
dysphagia/aspiration
 Endoscopic / fluoroscopic assessment
Speech Therapy assessment!
Postoperative Tracheotomy Care




Humidification via trach mask/Instill saline
Clear secretions, prevent crust
Inner cannula cleaning tid at least
If non-ventilated, change cuffed tube to noncuffed at 5-7 days
 Ties changed 2 people if possible
 Most hospital have nursing/RT protocol
 Teach everyone trach care including patient,
family
Inner Cannula Care
 Frequently done tid or more
 Saline and hydrogen peroxide (1:1) and trach
brush
 Rinse with sterile water/saline and reinsert
 Spare inner cannula and store in clean
covered container
 Ties should be one finger tight and square
knot
Respiratory Therapy Protocol SMH
Troubleshooting Dislodgement
 Causes
 Ties too loose
 Cough
 cuff deflated
 tube too short/wrong size for patient
Clinical signs
 Difficulty in ventilating patient
 Increased airway pressure
 Suction catheter obstructed
 Non Ventilated Patient



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Poor cough
Sudden voice change
Stridor, SOB
Suction catheter blocked
What to do: Dislodgement
 Extend neck
 Remove inner cannula
 Use obturator to redirect tracheotomy tube
into lumen
 If patient in distress and does not have fixed
obstruction above, pull out trach tube
 Ventilate with mask/intubate
 Use flex bronchoscope or replace/OR
Troubleshooting Tube Obstructed
 Mucous plug or blood clot most likely
 Granulation tissue, particularly fenestrated
tubes
 Remove inner cannula, suction, instill saline
 Bronchoscopy
 If no other recourse, pull out trach tube and if
necessary, replace new tube with obturator
 Intubate/ventilate from above
Troubleshooting: Bleeding
Bleeding around trach stoma
 Minor bleeding immediately
post-op
 Moderate bleeding/venous
oozing often related to thyroid
 Examine wound
 Pack, surgicel, if not
controlled, take back to OR
Bleeding from within lumen






Often related to suctioning
Broncoscopy exam
Dry mucosa
Granulation tissue
Coagulopathy
Rare innominate fistula
Decannulation
Goal is to ensure patient can tolerate increased
airway resistance/work of breathing and
secretion clearance
 30% increase WOB transition from trach
breathing to upper airway breathing
Decannulation
 Indication for tracheotomy has
resolved/improved
 Patient able to cope with secretions
 Upper airway patent - examined if necessary
 Appropriate vocal cord function
 Good respiratory reserve/overall respiratory
status
 Gag reflex present (5-10% no gag)
Decannulation
 Stable clinical condition


Hemodynamic stability
Absence of fever, sepsis infection
 Adequate swallowing

Gag reflex, bedside swallowing assessment,
video fluoscopy
 Maximum expiratory pressure > 40 cm H2O
Ceriana et al 2003
Decannulation Protocol
 Downsize tube to either 4 or 6 Shiley
 Cuffless fenestrated tube
 Gradually increase corking/cap of trach
 Corked 24-48 hours before decannulation
 Remove tracheostomy tube
 Occlusive dressing for stoma
 Persistent patent stoma
 Occasionally requires local flap to close
 Outpatient procedure under local, infection common
Difficult to Decannulate
 Granulation tissue

Fenestra obstructed
 Tracheal mucosal edema/supraglottic edema

NG, aspiration
 Laryngeal pathology

Glottic stenosis, cord paralysis
 Pulmonary secretions
 Increase airway resistance not tolerated
Tracheotomy: Summary
 Safe method of airway management
 Open versus percutaneous technique
available
 Complications largely minor
 Mortality rare from procedure directly

0.3%* in last 30 years (grouped data)
Summary
 Advantages/risks of a tracheotomy for that
individual patient must outweigh the
disadvantages/risks without one.





Indication for Tracheotomy
Medical comorbidities
Respiratory /deglutition function
Ability to cope with secretions
Trial of corking/decannulation
Cricothyroidotomy
 Open versus percutaneous technique
 Prep and position as for trach
 Identify landmarks
 Local anaesthetic
 Incision over cricothyroid membrane
 Placement of small tracheotomy tube, ETT or
large bore needle with attachment for
ventilation
Cricothyroidotomy
Advantages
 Quick c/w open trach
 No laryngeal injury
 Failure of intubation
attempts in emergency
situation
Disadvantages
 Can cause laryngeal
injury
 Must be sure of
landmarks
 Small tube required
Cricothyroidotomy