Control of the airway is the first priority in the resuscitation of a critically ill patient and must be accomplished before any other intervention can proceed. Emergency Physicians are equipped with multiple nonsurgical techniques and devices to secure an airway including orotracheal intubation, nasotracheal intubation, and laryngeal mask airways. Unfortunately, there are cases in which these methods become impossible or are contraindicated. In these instances, a surgical airway must be obtained and can be accomplished by performing a cricothyroidotomy or tracheostomy. Cricothyroidotomy is described in Chapter 32. This chapter will focus on the indications, technique, and complications for a tracheostomy.
A tracheotomy is the surgical creation of an opening into the trachea, while a tracheostomy refers to the more permanent procedure of bringing the tracheal mucosa into contact with the skin of the neck.1-3 The most traditional role for a tracheostomy is as an elective procedure done in patients with the need for a prolonged artificial airway. The role of a tracheostomy for emergent airway access has diminished as newer, safer, and equally effective techniques have evolved.
Familiarity with the methods to perform a tracheostomy is still valuable. Knowledge of proper techniques, possible indications, limitations, and likely complications will guide one’s judgment in critical moments when it most counts. Understanding the procedure for a tracheostomy will allow Emergency Physicians to properly care for a problem or complication when a patient with a tracheostomy tube presents to the Emergency Department.
ANATOMY AND PATHOPHYSIOLOGY
A surgical approach to the airway relies upon a sound knowledge of the anatomy of the neck and a safe approach to the trachea. A careful review of this anatomy illustrates how critical it is to remain in the midline in order to avoid morbidity and mortality. External landmarks are useful in identifying the significant structures of the airway (Figure 33-1).4,5 The laryngeal prominence is a useful guide to the thyroid cartilage. The cricoid cartilage can be identified as a ring just inferior to the thyroid cartilage. In the absence of edema or a hematoma, a finger marched down the midline from the cricoid cartilage can palpate and identify the cartilaginous rings of the trachea. In an emergent situation, these external landmarks may be all a physician has to guide the establishment of a surgical airway.
Lateral view of the topographic anatomy of the neck.
The neck is a complex three-dimensional structure with numerous vital structures coursing through a small space (Figures 33-2, 33-3, 33-4, 33-5, 33-6). The cervical portion of the airway is anterior, superficial, and midline. It is covered by skin, subcutaneous tissue, and numerous muscles (Figure 33-2). The basic cartilaginous framework of the airway begins superiorly ...