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 in 100 BC with performing a successful tracheostomy.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. Trousseau reported successful tracheostomies in more than 2000 cases of upper airway obstruction secondary to diphtheria in the 1800s.2 Chevalier Jackson perfected the tracheostomy technique and reduced the operative mortality from 25% to less than 1% in the 20th century.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 or its placement. Tracheostomy care will be divided into routine care and emergent care.
ANATOMY AND PATHOPHYSIOLOGY
The trachea is a fibromuscular tube with approximately 16 to 20 cartilaginous arches extending from the cricoid cartilage to the division at the carina into right and left mainstem bronchi (Figure 33-4). 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 bypassed by the tracheostomy plays a major role in warming and humidifying inspired air.
The terms 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. An incision is made into the trachea after the subcutaneous tissue is dissected and anatomic structures identified. 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 33.
Tracheostomy tubes vary in their composition, angles, and types and the presence or absence of a cuff (Tables 34-1, 34-2, and 34-3). The basic tube consists of an outer cannula and an inner cannula (Figure 34-1). The size ...