Tracheostomy care and management of tracheostomy complications are tremendously important to the Emergency Physician. Rapid assessment and understanding of tracheostomies and their potential complications can be lifesaving in the critically ill and tracheostomy dependent patient.
Tracheostomies have been performed since ancient times but have been perfected in the last few centuries. A Greek physician named Asclepiades of Bismuth was the first credited with performing a successful tracheostomy in 100 BC.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 20th century, perfected the tracheostomy technique and reduced the operative mortality from 25% to below 1%.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 will be 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 26-4). The surface of the tracheal mucosa is covered in respiratory epithelium. This epithelium is responsible for tracheal secretion, mucociliary “elevator” movement of secretions and debris, and humidification. The remaining part of the upper respiratory tract, which is bypassed by the tracheostomy, plays a major role in warming and humidifying inspired air.
The term tracheostomy and tracheotomy are widely interchanged in current parlance. Tracheotomy refers to the actual incision through the skin to the trachea, which is then kept open by a tracheotomy tube. A tracheostomy refers to the procedure in which the tracheal opening is sutured to the skin incision. This creates a more permanent orifice. The term tracheostomy will be used for the remaining sections of this chapter.
A tracheostomy is created by an incision at the level of the second or third tracheal rings. After the subcutaneous tissue is dissected and anatomic structures identified, 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 into the trachea. The trachea is secured to the overlying skin and the tube is secured in place. Further details can be found in Chapter 26.
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 27-1). The size of the tracheostomy tube is usually defined by its inner diameter. The outer cannula is the more permanent fixture in ...