Tracheotomy and Upper Airway Obstruction

Chapter 15 Tracheotomy and Upper Airway Obstruction



John E. Heffner, MD




1 What are the different techniques for a surgical airway?




image A standard surgical tracheotomy is an open surgical procedure that allows insertion of a tracheostomy tube into the trachea between cartilaginous rings.


image A percutaneous dilatational tracheotomy refers to various procedures that have in common either a modified Seldinger technique for placing a modified tracheostomy tube or a forceps technique to cannulate and dilate tracheal tissue between cartilaginous rings.


image A cricothyroidotomy is a technique for placement of an airway into the trachea through the cricothyroid space. A cricothyroidotomy can be performed as a surgical procedure through an incision, as a percutaneous procedure by a Seldinger technique, or as a needle cricothyroidotomy for emergency airway access.


image A minitracheotomy allows percutaneous placement of a 7 F cannula through the tracheal rings to allow suctioning for patients with difficulty clearing airway secretions.



2 How is a percutaneous tracheotomy performed?


Most intensivists perform a percutaneous tracheotomy by the Ciaglia technique, which inserts a needle into the trachea under bronchoscopic guidance. A guidewire placed through the needle allows insertion of a Teflon introducer dilator followed by a single curved dilator that increases in caliber from the tip to base where it matches the dimensions of a tracheostomy tube. After stomal dilatation, a tracheostomy tube loaded onto an introducer is inserted over the guidewire. Percutaneous tracheotomy can also be performed with insertion of a balloon catheter between tracheal rings that dilates a stoma tract after balloon inflation. Also, a specialized guidewire dilating forceps (called a GWDF technique) has a groove that allows loading of a guidewire onto forceps and dilates the trachea, threads the wire, and inserts a tracheostomy tube over the wire by a Seldinger technique. In the United States the Ciaglia technique with a curved, graduated dilator is the most commonly performed percutaneous procedure for tracheotomy.



3 What are the indications for a tracheotomy?


The four indications for tracheotomy are as follows:



image Maintenance of an airway for patients with upper airway obstruction


image Airway access for suctioning retained secretions


image Prevention of aspiration for patients with glottic dysfunction


image Airway support for patients who require long-term mechanical ventilation



4 What are the relative advantages of percutaneous versus surgical tracheotomy?


Both techniques provide effective and safe access to the trachea for critically ill patients. No high-quality prospective randomized trials have provided evidence that one procedure is better than the other. However, many studies suggest that percutaneous tracheotomy has advantages of shorter procedure time, ease of performing the procedure in the intensive care unit (ICU), decreased cost by avoiding use of an operating room (OR), provision of a tighter stoma that decreases stomal bleeding and improves tube stability, and lower risk of stomal infections. Performance of the procedure in the patient’s ICU room also expedites an earlier tracheostomy by avoiding the need to schedule OR time. Some surgeons, however, perform standard surgical tracheotomies in the ICU, thereby diminishing the cost benefits of percutaneous tracheotomy by avoiding use of the OR. When a standard surgical tracheotomy is done in the ICU, the ICU room must have adequate lighting and otherwise simulate the OR environment and resources.



5 Is emergency tracheotomy the surgical procedure of choice in patients with apnea and acute upper airway obstruction when intubation fails?


No. Tracheotomy is acceptably safe when performed electively in an OR environment under controlled clinical conditions. Risks of surgical complications increase fivefold, however, when tracheotomy is applied in an emergency situation. An emergency cricothyroidotomy provides the greatest likelihood of successful airway placement with the lowest risks for complications in patients with acute upper airway obstruction who cannot undergo translaryngeal intubation. Advantages of a cricothyroidotomy in this setting derive from the superficial location of the cricothyroid membrane that allows rapid and reliable insertion of an airway.



6 Can a percutaneous tracheotomy be safely performed in a patient receiving mechanical ventilation who requires positive end-expiratory pressure (PEEP)?


Percutaneous tracheotomy can be performed successfully in patients with severe respiratory failure who require high levels of PEEP. In one reported series the procedure was performed under bronchoscopic guidance for patients with mean PEEP levels of 16.6 cm H2O (range, 12-20 cm H2O), and no deterioration of arterial oxygen was found at 1 and 24 hours after the procedure compared with patients with lower PEEP levels (mean, 7.6 cm H2O; range, 5.4-9.8 cm H2O).



7 How is a cricothyroidotomy performed?


The cricothyroid membrane is located approximately 2 to 3 cm below the thyroid notch. The membrane, which is typically 1 cm in height, lies below the vocal cords but within the subglottic larynx. For a surgical cricothyroidotomy, a scalpel is used to incise the overlying skin and stab the membrane. The resultant opening into the airway is enlarged with a spreader, allowing placement of a tracheostomy tube. For a percutaneous cricothyroidotomy, commercially available instruments designed for emergency situations allow puncture of the membrane and introduction of an airway cannula in one maneuver.



8 Why do all patients not undergo a cricothyroidotomy rather than a tracheotomy?


For long-term airway access, cricothyroidotomy has a higher incidence of delayed airway damage; therefore most intensivists limit its use to 3 to 7 days after emergency insertion. If a patient remains ventilator dependent after this time, recommendations exist to convert a patient with a cricothyroidotomy to a tracheotomy. No studies exist to support this recommendation, however, with some studies reporting more airway injury in patients who undergo conversion.



9 What are the complications of tracheotomy?


Tracheotomy complications are categorized as intraoperative, early postoperative, and late postoperative. The most common complications during each of these periods are listed in Box 15-1.



Box 15-1 Complications of Tracheotomy



Intraoperative Complications




Cardiorespiratory arrest


Cardiopulmonary arrest


Hemorrhage


Pneumothorax and pneumomediastinum


Recurrent laryngeal nerve injury


Tracheoesophageal fistula


Tracheal ring fracture and herniation



Early Postoperative Complications




Hemorrhage


Subcutaneous emphysema


Inadvertent decannulation


Wound infection


Pneumonia


Tube obstruction

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Jul 6, 2016 | Posted by in CRITICAL CARE | Comments Off on Tracheotomy and Upper Airway Obstruction

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