Chapter 49. Percutaneous Tracheostomy for the Intensivist

Percutaneous dilatational tracheostomy (PDT) is one of the most commonly performed ICU procedures. For clinicians performing PDT, knowledge of the pertinent anatomy, the ideal population for PDT, techniques of the percutaneous method, potential complications, and postprocedural tracheostomy care are crucial to assure excellent patient care. As this book is directed to the EM intensivist, this chapter will focus on PDT for the nonsurgeon.

Within the specialty of critical care and the field of medicine as a whole, there is an ever-growing body of literature to support or refute treatment modalities, procedures, and management decisions. In the evaluation of any literature, knowing the limitations, evaluating the methodology, and understanding the difficulty of performing prospective studies must be taken into account before being too dogmatic about an approach to a clinical issue of procedural or managerial significance.

The airway is divided into the upper and lower airways. The upper airway consists of the nasopharynx, oropharynx, and laryngopharynx. The lower airway begins at the vocal cords and consists of the larynx (which includes the cricoid cartilage [the only complete cartilaginous ring in the trachea] and cricoid membrane) and the elements of the tracheobronchial tree. The adult trachea is 12 cm in length and the external diameter of the trachea in the coronal plane is 2.3 cm.1 The trachea has a series of 20 “U”-shaped cartilaginous rings; each tracheal ring is 4 mm wide and separated by a 2-mm membranous segment.2 The female trachea is smaller in diameter and length. The general shape of the trachea is ovoid with posterior flattening; yet as one ages, the trachea becomes narrower and deeper (laterally narrower and deeper anterior–posteriorly). The trachea is approximately 18–32 mm deep from the skin, and the posterior wall of the trachea is 40–56 mm deep from skin.3

On bronchoscopic evaluation of the trachea, the cartilaginous rings are seen anteriorly and the longitudinal folds of dense elastic fibers are present posteriorly. Distally, the carina can be seen branching into the right and left main bronchi.

Paramount to performing PDT is the assessment of externally pertinent anatomy (Figures 49-1 and 49-2). Identifying the patient with a short neck, assessing the landmarks in the obese patient, and evaluating potential vascular contraindications must be completed prior to deciding on PDT. In addition, issues of previous tracheal surgery and cervical spine injury are important anatomic considerations.

The short neck is defined as patients with less than 3 cm from the sternal notch to the thyroid apophysis (the vocal cords are located posterior to the thyroid apophyseal cartilage).4 This shortened area between the vocal cords and sternal notch may make the procedure more complex with less area in which to work, and potentially increases the risk. Body mass index (BMI) and a resultant thick neck have been evaluated as a possible contraindication for PDT. Byhahn et al evaluated patients with BMI ≥27.5 kg/m2 in 73 obese patients and had a 9.6% serious complication rate.5 They found obese patients had a 2.7-fold increased risk for perioperative complications, and a 4.9-fold increased risk for serious complications. Contradicting the data of Byhahn et al, Heyrosa et al performed tracheostomy on 143 patients with BMI>35 (89 PDT and 53 Open Tracheostomy) and concluded PDT in obese patients was as safe as open tracheostomy at their institution. Both open tracheostomy and PDT had 6.5% complication rates.6 Mansharamani et al also challenged the BMI dogma and evaluated PDT in obese patients.7 The mean weight was 132 ± 40.8 kg (range 76.8–206 kg), and the mean BMI was 45.9 ± 12.4 kg/m2 (range 28.1–61.8 kg/m2). Caution with these data is warranted. There were only 13 patients in this series; 3 required extra long 8-mm internal diameter tracheostomy tube and another required a 9-mm tube. Two patients had complications: cuff leak with need for tracheostomy replacement on day 2 and paratracheal insertion that was readily identified and corrected. Interestingly, no study has looked at neck size in particular, only the surrogate of BMI. Given the conflicting data, remembering that PDT is an elective procedure and should have equal or less morbidity than the open procedure is paramount. Therefore, if a patient has poorly identifiable anatomy, it may be wise to consider open tracheostomy.

Because bleeding is the most commonly reported complication in percutaneous tracheostomy, vascular abnormalities overlying the percutaneous route must be evaluated.8 The assessment of this can be based on anatomic understanding of potential vasculature in the area, visual assessment of large pretracheal veins, and ultrasonographic evaluation.

Common sources of bleeding include the thyroid gland, aberrant anterior jugular veins, and unnamed venous vasculature. Visual assessment of large vessels overlying the insertion site should occur, but the addition of ultrasound to this assessment has been proposed and early literature supports ultrasound evaluation prior to incision. In a series of 72 PDT performed with preprocedural ultrasound, the puncture site was actually changed based on the ultrasound findings in 24% of the patients. None of the cases was complicated by bleeding or posterior tracheal injury.9,10

Additional anatomic considerations that must be considered are previous tracheostomy and cervical spine injury. Several small case series conclude that prior tracheostomy is not a contraindication to PDT.11–13 Cervical spine injury is another potential anatomic contraindication to the procedure. In patients with cervical spine fracture, there are two separate risks. Initial risks are in the displacement of the fracture due to the force exerted and positioning for PDT. Mayberry et al performed PDT on patients with cleared and noncleared cervical spines.14 Thirteen patients had cervical spine fractures, five had halo or operative stabilization, and seven were managed only with a collar prior to the procedure. Neck extension for the procedure was not utilized. There were no spinal cord injuries associated with PDT in this population, and, although not statistically significant, the complication rate was actually lower in noncleared group when compared with the cleared group. The group of seven with nonstabilized neck injuries had a 100% success rate. Ben Nun et al evaluated 38 patients with cervical spine fracture and, utilizing the modified Griggs procedure, had no PDT-related neurologic deterioration.15 The second risk is in the postoperative patient who undergoes anterior cervical spine surgery. Without distinction of open tracheostomy versus PDT, Berney et al evaluated whether tracheostomy within 4 days of anterior cervical surgery increased infection rates.16 Their data reported no increase in cross-contamination of wounds. O'Keeffe et al, in a smaller study with 6- to 10-day interval between surgical fixation and tracheostomy, found no cross-infection.17 These small studies suggest the safety of performing tracheostomy in patients with cervical spine fractures and in patients within 7 days of anterior spinal fixation surgery. The authors would like to impress on the reader that, despite these data, the critical care clinician should consider which PDT procedure should be used and have a discussion with the spine service to identify the degree of instability.

TBI patients are a subset of critically ill patients who frequently require tracheostomy. These patients have a lower tolerance for hypoxia and hypercarbia, both of which can occur during bronchoscopy and PDT.18–20 As hypoxia and hypercarbia may increase intracranial pressure (ICP), thereby decreasing cerebral perfusion pressure (CPP), there are concerns about PDT in TBI patients. Milanchi et al, using paralytics and the Ciaglia method, found no statistically significant change in CPP and ICP during PDT. One quarter of their patients had ICP readings greater than 20 during the 48-hour study period indicating that at least a portion of patients may have had some cerebral compliance issues that could have been exacerbated. The study of Milanchi et al (n = 52 had ICP monitoring) agreed with those of Borm and Gleixner (n = 14 had ICP monitoring), Escarment et al (n = 35 unclear how many had ICP monitoring), and Imperiale et al (n = 65 had ICP monitoring; “PercuTwist” method) but differed from that of Stocchetti et al (n = 30 with ICP monitoring; 10 PDT, 10 surgical tracheostomy, and 10 Fantoni method,) who had a statistically significant increase in ICP during all three techniques, yet the greatest frequency in ICP increases occurred in patients with PDT.19,21–24

Conclusions that can be reached from these papers are that tracheostomy and PDT in particular are acceptable in TBI patient without intracranial hypertension. If a patient has increased ICPs and there is a consensus that cerebral compliance is tenuous, waiting until a period of stability would seem a sensible plan. Outside of loss of airway, there is no emergent indication for tracheostomy, and allowing brain pressures to stabilize may incur less cerebral morbidity.

As mentioned previously, bleeding is the most frequent complication of PDT and therefore evaluation of coagulation studies and withholding anticoagulation would seem to be intrinsic to a successful, low-risk procedure. This too has been challenged. Beiderlinden et al in 2007 evaluated 415 patients.25 A total of 137 patients had coagulation abnormalities. Fifty-eight patients had a platelet count less than 50,000/mm3, 75 had a PTT >50 seconds, and 19 patients had a PT >50% of normal values. Twenty-seven patients had two abnormal values. When the authors divided these patients into acute and chronic bleeding, they found no significant difference in coagulation variables between the acute bleeding group (defined as occurring during and immediately after the procedure) and the group without any acute bleeding complications. In evaluating chronic bleeding (defined as persisting for more than 24 hours after tube placement), Beiderlinden et al found that a PTT greater than 50 seconds predicted a 4-fold increase in chronic bleeding and platelet count <50,000/mm3 predicted a 5-fold increase in chronic bleeding. In patients with two or more coagulation variable abnormalities, there was a substantial increase in bleeding (OR = 9.5). In addition, 189 patients had prophylactic low-dose heparin and normal coagulation variables. There was no statistically significant increase in bleeding when compared with the group without heparinization and normal coagulation studies (P = 0.55). In the study of Beiderlinden et al, thrombocytopenia was the strongest single risk factor for chronic bleeding. In contrast, Kluge et al found that platelet counts less than 50,000/mm3 were safe.26 The study of Kluge et al is confounded by the infusion of platelets just prior to the procedure; therefore, whether these patients truly had low platelets is unknown. In the study of Beiderlinden et al, the thrombocytopenic patients were not treated and as a result definitely had platelets less than 50,000/mm3.

As with many aspects of medicine, the proceduralist's training and past complications will flavor their threshold for proceeding in certain situations. Performing invasive procedures in coagulopathic or heparinized patients is one such situation. Although the study of Beiderlinden et al is well done and provides interesting data, the question that must be asked is whether missing a single dose of heparin or infusion of plasma or platelets to correct a marginal coagulopathy portends an increased risk of complications such as venous thromboembolism, transfusion reactions, or immunomodulation. Critical care lacks an actuarial chart, and, for that reason, until more prospective data are secured, these decisions will be very practitioner dependent.

The decision to perform tracheostomy is rooted in improving pulmonary function. Since these patients, at best, have some degree of pulmonary dysfunction and may have high levels of ongoing oxygenation and ventilation support, previous recommendations for performing tracheostomy suggested only performing the procedure in the setting of low FiO2 and low positive end-expiratory pressure (PEEP). The PDT procedure inflicts periods of derecruitment (as does the open tracheostomy) and obstruction of the airway unique to PDT. Although in experienced hands these periods are brief, they are not without risk in the unstable patient. Patients who cannot tolerate hypercarbia, hypoxia, or brief loss of airway for cardiovascular reasons are better served by open procedure or delaying the procedure for a period of greater stability.

Excluding the periprocedural risks of performing tracheostomy on patients with respiratory failure, benefits of tracheostomy on the pulmonary function cannot be ignored. Tracheostomy tubes improve patient comfort and decrease sedative requirements. They can reduce dead space by up to 50% (150 mL) and the decreased length can ease work of breathing leading to facilitation of ventilator weaning.27

As stated above, choosing to perform tracheostomy on an unstable patient may be fraught with risks but a tracheostomy can lessen ventilator days, reduce ventilator-acquired pneumonia incidence, shorten ICU stays, and prevent subglottic stenosis, all of which must be weighed in the risk/benefit analysis. To appropriately perform this analysis, the indications to perform tracheostomy need to be reviewed and the data surrounding the timing of tracheostomy must be evaluated.

Indications for tracheostomy in critical care are different than indications for anatomic considerations such as upper airway obstruction due to trauma, malignancy, vocal cord paralysis, or congenital abnormalities. Critical care indications do have crossover with anatomic reasons as many of our patients are from this latter population, but intensivists would not perform those tracheostomies. This section will focus on the benefits of tracheostomy in the avoidance of laryngeal injury from prolonged translaryngeal intubation and shortening the period until liberation from mechanical ventilation.

Prolonged intubation is one of the well-known indications for tracheostomy and is cited as an indication by the American Academy of Otolaryngology.28 This recommendation is due to laryngeal injury rates as high as 94%29 and chronic injury occurring in up to 19% of patients.30 The long-term sequelae of intubation include stenosis, granulomas, and ulcerations causing chronic hoarseness and, rarely, upper airway obstruction due to stenosis. Tracheal stenosis occurs at the endotracheal tube cuff site in one third of the reported postintubation cases. Loss of regional blood flow from high cuff pressures on the tracheal wall creates the ischemic region that leads to scarring. This ischemic injury begins within the first few hours of intubation, and healing of the damaged region by secondary intention can result in densely fibrotic circumferential stenosis over a period of 3 weeks to 6 months. Large-volume, low-pressure cuffs have markedly reduced the occurrence of cuff injury. Tracheal capillary pressure is between 20 and 30 mm Hg, and perfusion impairment occurs at 22 mm Hg and is completely compromised at 37 mm Hg. The recommended cuff pressures are between 10 and 18 mm Hg (15–25 cm H2O) at all times, and twice-daily evaluation of cuff pressures to limit the occurrence of this devastating sequelae of intubation must be assured.31 Post-tracheostomy tracheal stenosis is also a well-described occurrence. Unlike stenosis secondary to intubation, this can occur due to abnormal wound healing with overgrowth of granulation tissue around the stoma site. It can also occur from granulation at the tip of the tracheotomy tube, or from collapse of the anterior tracheal wall above the tracheotomy stoma. The excess granulation tissue can result from cartilage injury during the procedure or due to unsupported weight of ventilator tubing creating mechanical strain and ischemia on the cartilaginous ring. Wound infection is an additional cause of post-tracheostomy stenosis.32

The most debated indication for tracheostomy is timing: early versus late, and whether early tracheostomy will shorten ventilator days and ICU stay, and decrease pneumonia rates. In 1989 vague guidelines were published, stating that patients with greater than 21 days anticipated intubation should have tracheostomy and less than 10 days should have translaryngeal intubation.33 Between 10 and 21 days, there were no specific recommendations. Since then, multiple studies have attempted to identify whether early tracheostomy may prevent morbidity (see Table 49-1). When evaluating the data, it is important to realize that the definition of early and late tracheostomy can vary widely. Although there are a number of differences between the studies, it seems that duration of mechanical ventilation is statistically shortened with early tracheostomy34 and in one study early tracheostomy had shorter weaning times.35 Length of stay (LOS) in the ICU and/or hospital was also significantly shortened with early tracheostomy in multiple studies. Pneumonia occurrence was found to be reduced by 80% in study of Rumbak et al and by 36% in Moller's study. Bourderka found no difference in pneumonia rates but did find a delay in the development of pneumonia in the early tracheostomy group. Sugerman and Hsu were not able to identify a decreased pneumonia rate.35,36

Although each of these studies has its limitations due to number of subjects, length of time in the early and late groups, and heterogeneity of population, it is important to realize that in certain populations there are expert recommendations for early tracheostomy. Per Eastern Association for the Surgery of Trauma (EAST) guidelines, a Level II recommendation is that patients with severe head injury will benefit from early tracheostomy by shortened ventilator days and ICU LOS.38 The guidelines further state that early tracheostomy may decrease the total days of mechanical ventilation and ICU LOS in trauma patients without head injuries and may decrease the rate of pneumonia in trauma patients. Their Level III recommendation is that early tracheostomy be considered in all trauma patients anticipated to require mechanical ventilation for >7 days.38 As the data cited are limited, prospective large studies are needed to continue the improvement on the 1989 recommendations and move critical care practitioners closer to guidelines such as those from EAST that offer narrower parameters within which to make decisions.

Bronchoscopy is a useful adjunct in performing PDT for a number of reasons. Most importantly, any iatrogenic injuries sustained during the procedure can be immediately identified. Inadvertent puncture of the membranous (posterior) portion of the trachea is one such injury that can be avoided. Additionally, a true midline location and directionality for the placement of the wire can be confirmed by direct visualization. Last, appropriate placement of the tracheostomy device itself can be visually confirmed. One pitfall of bronchoscopic guidance is that it requires the endotracheal tube tip to be withdrawn to the level of the subglottic larynx. This can create a major cuff leak (since the cuff is no longer past the cords in the trachea) and occasionally loss of airway requiring reintubation. For reasons of patient safety and risk management, most would argue that bronchoscopic guidance and having intubation supplies nearby have become the standard of care.

The basis for almost all percutaneous procedures performed is the modified Seldinger technique, which was originally utilized for percutaneous nephrostomy tube placement. As a general principle, a needle is used to gain access to a lumen, and through this needle a guidewire is placed into the lumen. The technique for PDT is no different.

Ciaglia Sequential Dilators

The first step is assessment of anatomic landmarks.39 The sternal notch, cricoid, and thyroid cartilage are the key landmarks to be identified. Once the skin has been prepped with chlorhexidine solution and the neck draped with sterile towels, the appropriately sized tracheostomy appliance is inspected and the balloon's integrity tested. Beginning at the cricoid cartilage, after infiltration of local anesthetic, a 1- to 2-cm vertical or horizontal incision is carried caudally using #15 scalpel. Blunt dissection using a hemostat is performed through the strap muscles, until the pretracheal space is entered. This is the authors' technique, but many intensivists do not use blunt dissection and perform PDT as purely percutaneous. At this time, the fiberoptic bronchoscope should be inserted. Under direct visualization, after deflation of the ETT cuff, the tube should be withdrawn so that the light from the bronchoscope is visible in the incision site at the level of the second and third or first and second tracheal rings. It is important to remember that in patients who are difficult to oxygenate, this maneuver will likely result in desaturation, and ventilator adjustments will need to be made accordingly.

Utilizing a saline-filled syringe with an 18-gauge catheter over needle, the trachea is pierced below the cricoid cartilage through the incision. Under direct bronchoscopic guidance, the needle should be visualized passing between either the second and third or first and second tracheal rings. Aspiration of the syringe will confirm intratracheal placement by the presence of air bubbles. Bronchoscopy will ensure that the needle does not pierce the posterior wall of the trachea and is anterior midline in position. Removing the syringe and 18-gauge needle, the catheter is advanced caudally; the flexible guidewire provided in the kit is then visualized by the bronchoscope and passed. The catheter is removed, and the dilators are passed over the wire into the trachea, under direct visualization, from smallest to largest. The largest dilator used is just smaller than the inner diameter of the tracheostomy appliance, instead of a cannula, and is actually placed inside the tracheostomy tube's lumen. Once the tracheostomy tube is completely inserted, the dilator and guidewire are removed, the cuff is inflated, the tracheostomy is connected to the ventilator circuit, and the appliance is sutured into place and secured with tracheostomy ties. At this point, when the new airway has been confirmed, the endotracheal tube is removed completely as well as the bronchoscope.

Blue Rhino™

The Blue Rhino™, or Ciaglia one-step technique, for PDT has rapidly become the most commonly utilized technique for PDT in the United States. All steps are identical to the sequential dilator technique up to and including placement of the flexible guidewire. The outside of the Blue Rhino™ dilator is hydrophilic and becomes very slippery when wet. Over the wire, a 14 French introducer sheath is placed, and over the sheath/wire combination, the Blue Rhino™ dilator is placed. This dilator has positioning marks, and is curvilinear. Curvilinear pressure is applied toward the mediastinum, creating an appropriately sized tracheostomy opening in a single pass. After this, a curvilinear dilator is placed within the tracheostomy tube; it is placed over the catheter/wire complex, and then the dilator is removed with the wire. As with the previous technique, we recommend bronchoscopic guidance. After this, the tracheostomy tube is secured in a standard fashion. Cook Medical provides an outstanding video of their Blue Rhino PDT at their Web site (http://www.cookmedical.com/cc/educationResource.do?id=Educational_Video).

Griggs

The Griggs technique was developed as an alternative to the sequential dilator technique in 1990.40 The technique does not differ until after the insertion of the guidewire, at which point the operator utilizes a sharp-tipped tracheal spreader, which has been designed to slip over the guidewire. These tracheal spreaders are used to create both the soft tissue tract through the skin and the tracheal opening through which the tracheostomy tube will pass. Following this, a tracheostomy tube with an introducing sheath is passed over the wire, the wire and sheath are removed, and the device is secured into place.

Percutwist™

Another technique, the PercuTwist™, which utilizes “controlled rotating dilatation,” was described by Frova and Quintel in 2002.41 A limited number of studies exist that evaluate the efficacy and safety of this technique, although one study, which compared Griggs, Ciaglia, and PercuTwist head-to-head, suggests that the PercuTwist™ is not only safe but also significantly faster to perform than the other techniques with a comparable rate of complications.42 As with all of the previously mentioned techniques, the trachea is punctured with a needle between the cricoid and first tracheal ring under direct bronchoscopic guidance, and a flexible guidewire is passed through the needle toward the carina. A smaller (8–10 mm) skin incision is made, and the PercuTwist hydrophilically coated dilator screw is inserted over the guidewire after being lubricated with water. The clockwise rotation of the screw is stopped after the maximum diameter of the screw has been visualized within the tracheal lumen. After this, the tracheostomy tube, with an introducer sheath through its lumen, is passed over the guidewire, and secured into place. At this point, the wire and introducer sheath are removed.

An alternative exists to entering the trachea from the outside. Fantoni and Ripamonti have developed a retrograde percutaneous translaryngeal tracheostomy (TLT), colloquially known as the Fantoni procedure. This is the least commonly described technique in the literature, and the authors do not have any experience with this technique at our institution. The trachea is punctured at the usual site; however, the guidewire is passed cephalad and removed through the mouth, and then attached to the dilator/tracheostomy tube complex. This particular dilator has a sharp metal tip; by pulling on the guidewire with one hand, and providing countertraction with the other, the metal tip easily punctures the skin, opening the trachea from the inside out. The device is pulled until it is perpendicular to the skin and rotated 180° so that when it is readvanced into the trachea, it will be directed toward the carina. The cannula is removed so that only the tracheostomy tube remains, which is then secured into place. The major advantage of this technique, as described in the literature, is that it has been safely used in children and infants.43 One possible disadvantage is that stomal metastases of head and neck cancers have been reported, as the device must pass through the oropharynx and vocal cords. It is, therefore, not a true percutaneous technique.44 In a recent comparison of Blue Rhino and TLT, complications were not correlated with choice of technique, but the Blue Rhino™ was found to be cheaper and faster due to its simplicity.

Complications of percutaneous tracheostomy must be taken in the context of a comparison to surgical tracheostomy. In a large meta-analysis performed by Delaney et al, PDT was found to have a reduced incidence of infection, and subgroup analysis suggested that there were less periprocedural and long-term complications as compared with open tracheostomy.45 Both procedures have complications that the practicing ICU clinician must be aware of; yet the addition of bronchoscopy to the PDT has decreased risks and has become part of the standard of care as mentioned previously.

During the procedure, there are multiple risks including loss of airway, hemorrhage, injury to trachea and paratracheal structures, and cardiac arrest. Loss of airway can be a complication that is anticipatable and easily dealt with when proper equipment and personnel who can intubate are readily available. Hemorrhage can be limited by utilizing the data listed for coagulation studies and understanding potential vascular interference via knowledge, clinical exam, and potentially ultrasound. Tracheal, laryngeal, and paratracheal injuries can best be avoided by understanding the anatomy and utilizing proper technique, with particular focus on midline entry into the trachea, adequate preparation of the skin, and proper technique in applying dilatational pressure in the correct plane. Cardiac arrest that occurs during the procedure may be a result of loss of airway during the procedure, or the patient being insufficiently stable to undergo the procedure. As mentioned previously, there are no critical care indications for tracheostomy that cannot wait.

Immediately after the procedure, subcutaneous emphysema (SE), pneumomediastinum (PM), pneumothorax (PTX), tube obstruction, infection, and hemorrhage can occur. SE may be a result of too tight a closure around the tracheostomy tube or prolonged duration of procedure after the point of tracheal perforation and before placement of the tube. This highlights why taking a “time-out” to assure all important tubes and equipment are in the room prior to incision is important. PTX or PM can occur when there is injury to the pleural domes. This rare complication may lead to tension PTX and therefore supports the need for postprocedure chest radiograph. Tube obstruction can have a number causes including mucous plugging and abrasion of the inner lining of the trachea. The authors have had an instance of PDT in which the friable tissue lining the trachea became a flap that partially obstructed the trachea. That flap caused high peak pressures, and was readily identified and relieved on postprocedural bronchoscopy. The solution to this problem continues to be technique and patient selection.

Infectious complications such as wound infections can be limited by both the PDT technique (as opposed to open surgical tracheostomy) and proper technique including chlorhexidine scrub, wearing mask, hat, and sterile gloves. Post-PDT cellulitis can be managed with antibiotics and increasing the size of the incision around the tracheostomy tube. Close postprocedural evaluation of any surgical intervention should be maintained, and evaluating all tubes, drains, and line sites daily is part of providing good critical care.

Delayed hemorrhage can occur and may be related to vasoconstrictor properties of injected anesthesia that has worn off or, rarely, from the potentially lethal erosion of major thoracic vasculature (0.4% of all tracheostomies), specifically the innominate artery (brachiocephalic artery). Briefly, tracheoinnominate (TI) fistula must be rapidly identified and evaluated if there is any chance to prevent the mortality from this complication.

TI fistula will present most frequently (70% of the time) during the first 3 weeks but can arise as early as 30 hours and as late as several years after the tracheostomy.46–48 Approximately 50% of patients present with a massive hemorrhage, whereas the other half may report a small “herald” bleed49 or a pulsating tube.48 The most frequent site of fistula formation is at the level of the endotracheal cuff, but one third result from pressure necrosis from the angle or the tip of the cannula. Other predisposing factors include the presence of an anomalous innominate artery, infection, and the use of steroids. Overinflation of the tracheostomy is the first maneuver that should be attempted in the face of a bedside massive hemorrhage. This technique can be successful in 85% of the cases.49 Otherwise, a cuffed endotracheal tube should be inserted under direct laryngoscopy into the glottis and beyond the TI fistula. Finger pressure, directed anteriorly, as the artery is anterior to the trachea, is then applied on the innominate artery through the stomal opening after removal of the tracheostomy tube. For those patients presenting with sentinel bleed, preparation should be made for transfer to the operating room and emergency chest exploration. A diagnostic flexible bronchoscopy might be attempted first, but a rigid bronchoscopy is recommended for a better visualization and superior ability to suction blood clots. The rigid bronchoscope also allows the operator to stop the bleeding by applying the tube firmly against the innominate artery. The postoperative death rate is relatively high, as only 25% of those who survive the surgery are discharged alive.

Delayed complications that manifest can be less dramatic than loss of airway or TI fistula but must be respected as a serious cause of morbidity and mortality. As mentioned previously, tracheal stenosis, granulation tissue, and laryngeal injury can develop from prolonged intubation or tracheostomy and may or may not be primarily preventable. Although tracheoesophageal fistula is a complication, it can be prevented by avoiding trauma to the posterior wall of the trachea during the procedure and abstaining from prolonged large-bore feeding tubes in the esophagus. This rare complication can be initially managed by the intensivist by placing an ETT or new tracheostomy tube distal to the defect yet not too deep to be main-stemmed. Once the airway has been stabilized, a thoracic surgery consult for surgical or nonsurgical management decisions must be undertaken.50

Accidental decannulation (dislodgment) in the first few days after surgery is an emergency. Since the tracheostomy site does not mature until approximately 5–7 days postprocedure, these patients should go to the operating room for replacement or an attempt to secure the airway from the translaryngeal route should be made. Attempting to replace a new tracheostomy tube into an unmatured site runs the risk of paratracheal placement, loss of airway, and death. If the patient has a disruption between the upper and lower airways (i.e., post-tumor resection), making mask ventilation and translaryngeal intubation impossible, ventilating through the stoma may be the only choice. This increases the chance of altering the anatomy with subcutaneous air and making the operative replacement significantly more difficult. To prevent accidental tracheal decannulation, make sure the tube is properly secured, minimize manipulation of the tube and traction on the tube from oxygen or ventilator tubing, and instruct the patient to move cautiously until the tract is healed.

Knowing how to properly care for a patient with a tracheostomy is vital because inappropriate or inadequate care may lead to complications and even death. Although details vary depending on the type of tracheostomy tube, tracheostomy care includes cleaning or changing the inner cannula, changing the dressing and tracheostomy tube holder, and suctioning if needed. Most tracheostomy tubes have disposable inner cannulas, which are replaced and secured using aseptic technique. Thoroughly assess the skin around the tracheostomy for evidence of skin breakdown related to the tracheostomy tube, tube securement device, or mucus and secretions. The area around the tracheostomy tube should be cleaned with a noncytotoxic cleanser. If you see skin breakdown, consult a wound team for a plan of care. Absorbing secretions helps prevent maceration and skin breakdown. Place a prepackaged, sterile tracheostomy dressing under the tube flanges. Always use a manufactured, one-layer split sponge rather than cutting a gauze pad. Never place anything with loose fibers around the stoma or tracheostomy tube because they can cause irritation, and the loose fibers could be aspirated.51 Maintaining humidification is another key to avoiding potential issues. Normally, the nasopharynx humidifies inhaled air. Because the tracheostomy tube bypasses the upper airway, you need to provide adequate humidity to keep the airway moist. In hospitalized patients, this can be accomplished by a heat and moisture exchanger (HME) on a mechanical ventilator or a T-piece or tracheostomy mask.

Weaning the tracheostomy patient off ventilatory support is the first step for reaching the goal of decannulation. When the patient no longer requires ventilatory support, aerosol tracheostomy collar trials (TCT) should be initiated, and the cuff must be deflated for TCT. The patient should slowly be weaned down on the oxygen requirement as tolerated. If the patient has a cuffed tube, the tube should be downsized with a cuffless tracheostomy tube. When the patient is able to ventilate and oxygenate adequately, capping trials should be initiated. If the capping trials are tolerated without any issues for 24 hours, decannulation can be performed. The stoma should be bandaged until closure. The decannulated patient should be followed by the team for 24 hours postdecannulation.

The authors would like to extend their appreciation to Natahnee Winder, who assisted with proofreading and collecting data for this chapter.