Chapter 16

All Emergency Physicians should be familiar with tracheostomy care and the management of tracheostomy complications. Rapid assessment and understanding of tracheostomies and their potential complications can be lifesaving in the critically ill and tracheostomy-dependent patient.

Although tracheostomies have been performed since ancient times, they were perfected only during the past century. A Greek physician named Asclepiades of Bismuth has been credited with performing the first successful tracheostomy in 100 B.C.1 Two of the four physicians summoned to President George Washington’s deathbed were said to have argued for tracheostomy as his only means of survival. In the 1800s, Trousseau reported successful tracheostomies in more than 2000 cases of upper airway obstruction secondary to diphtheria.2 Chevalier Jackson, in the twentieth century, perfected the tracheostomy technique and reduced the operative mortality from 25 percent to below 1 percent.3 This is roughly what it remains today.

The important aspects of tracheostomy care include the assessment of respiratory distress in the tracheostomy patient, proper suctioning techniques, and assessment and evaluation of possible complications arising from the tracheostomy itself or its placement. For the purposes of this chapter, tracheostomy care is divided into routine care and emergent care.

The trachea is a fibromuscular tube with approximately 18 to 20 cartilaginous arches extending from the cricoid cartilage to the division into right and left mainstem bronchi (Figure 15-4). The surface of the tracheal mucosa is covered with respiratory epithelium. This epithelium is responsible for the formation of secretions, mucociliary “elevator” movement of secretions and debris, and humidification. Of note, the remaining part of the upper respiratory tract (which is bypassed by the tracheostomy) plays a major role in the warming and humidification of inspired air.

The terms tracheostomy and tracheotomy are widely interchanged in current parlance. Tracheotomy refers to the actual incision through the skin and the trachea, which is then kept open by a tracheotomy tube. Tracheostomy refers to the procedure whereby the tracheal opening is actually sutured to the skin incision. This creates a more permanent orifice. The term tracheostomy is used in the remaining sections of this chapter.

A tracheostomy is created by an incision at the level of the second and third tracheal rings. After the subcutaneous tissue is divided, an incision is made into the trachea. A hook is inserted into the incision and used to stabilize the trachea while a tube is placed in its lumen. The trachea is secured to the overlying skin and the tube is secured in place. Further details can be found in Chapter 15.

Tracheostomy tubes vary in their composition, angles, and types and the presence or absence of a cuff. The basic tube consists of an outer cannula and an inner cannula (Figure 16-1). The size of the tracheostomy tube is usually defined by its inner diameter. The outer cannula is the more permanent fixture in ...

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