Elsevier

Clinics in Chest Medicine

Volume 24, Issue 3, September 2003, Pages 413-422
Clinics in Chest Medicine

Techniques of surgical tracheostomy

https://doi.org/10.1016/S0272-5231(03)00049-2Get rights and content

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Indications and timing

Despite its long history and frequent use, the indications and timing for tracheostomy remain controversial. As with all surgical procedures, the potential benefits to the patient must be carefully weighted against the risks. The comorbidities and variability of presentation of patients requiring prolonged ventilatory support make establishing a set of rules governing the use of tracheostomies difficult. Aside from those patients requiring permanent tracheostomy following laryngectomy,

Anatomy

Depending on the person's size, the adult trachea ranges from 10 cm to 13 cm in length from the larynx to the carina. With the neck slightly extended, about half the length is above the thoracic inlet; however, the trachea slides easily in the cephalo-caudal direction and there is tremendous variability in tracheal orientation, depending on the position of the neck and the patients body habitus. This becomes important when attempting tracheostomy in the obese patient with a short neck, or in

Standard open tracheostomy technique

Surgical tracheostomy is routinely done under general anesthesia in the operating room. The optimum position is supine with maximal neck extension, facilitated by placement of a towel roll beneath or between the patient's scapulae. History of an unstable cervical spine, spinal stenosis, kyphosis, or severe cervical osteophyte disease may preclude extension of the neck. Appropriate head and neck support must be given and access to the trachea may require division of the thyroid isthmus. In the

Special circumstances

Although it has become popular in some centers, performing tracheostomy in the intensive care unit (ICU) involves some degree of compromise. The patient's bed is softer and wider than the operating table, limiting exposure and increasing the reach for the surgical team. Additionally, the lighting is almost always inadequate unless a headlight is worn. Bedside tracheostomy is recommended only when the risk of transporting the patient outweighs the risk of operating in a compromised environment.

A

Cricothyroidotomy

Though thought by some to be safe in the elective setting [19], cricothyroidotomy is generally reserved for emergency situations when standard means of translaryngeal intubation are impossible or have failed. Cricothyroidotomy is associated with a historically high rate of difficult-to-manage subglottic stenosis [20]. When forced to obtain a surgical airway in an emergency, a cricothyroidotomy is preferable because of the procedure's relative speed and simplicity. It is important, especially in

Percutaneous tracheostomies

Since its introduction by Toy and Weinstein in 1969 [6] and subsequent modification by Ciaglia [7], percutaneous tracheostomies have enjoyed rapidly increasing popularity. Advocates cite the ease of the familiar technique, and the ability to perform the procedure at the bedside, often by nonsurgical practitioners [22]. Briefly, using a modified Seldinger technique with progressive dilation over a guide wire under bronchoscopic guidance, a stoma, preferably between the first and second, or

Tube-free tracheostomy

To avoid the morbidity associated with an indwelling tracheostomy tube expected to remain for months to years, Eliachar developed the long-term, tube-free tracheostomy. Common indications for the procedure include obstructive sleep apnea, bilateral vocal cord paralysis, neuromuscular disorders, irreparable laryngotracheal stenosis, and severe chronic pulmonary disease [25]. The procedure begins with a horizontal omega-shaped skin incision extending beyond the lateral margins of the

Tracheostomy selection

When selecting among the many available tracheostomy tubes, there are several factors to consider. Important issues include tube diameter and length, cuff design, use of an inner cannula, and the presence or absence of a fenestration (Fig. 9). The size of the tracheostomy can refer to its inner diameter, outer diameter, or length. In general the smallest outer diameter tracheostomy that satisfies the requirement for intubation should be used. This principle will minimize the risk of subsequent

Complications

Tracheostomy, often considered to be a simple procedure relegated to the most junior members of the surgical team is, in fact, fraught with potential complications. Though covered at length in another article, a review of surgical complications is pertinent to a discussion of technique. Intraoperative complications are technical in nature and as such are avoidable. Bleeding during the procedure is rare and usually easily controlled by judicious use of electrocautery or suture ligation when

Summary

Tracheostomy has become one of the most commonly performed procedures in the critically ill patient. Variations in technique and expertise have led to a wide range of reported procedural related morbidity and rarely mortality. The lack of prospective, controlled trials, physician bias and patient comorbidities further confound the decisions regarding the timing of tracheostomy. With careful attention to anatomy and technique, the operative complication rate should be less than 1%. In such a

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References (34)

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