Chapter 26. Tracheostomy

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 25. 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 tracheostomy refers to the more permanent procedure of bringing the tracheal mucosa into contact with the skin of the neck.1,2 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.

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 26-1).3,4 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.

The neck is a complex three-dimensional structure with numerous vital structures coursing through a small space (Figures 26-2, 26-3, 26-4, 26-5, and 26-6). The cervical portion of the airway is anterior, superficial, and midline. It is covered by skin, subcutaneous tissue, and numerous muscles (Figure 26-2). The basic cartilaginous framework of the airway begins superiorly at the hyoid bone and continues inferiorly with the larynx and trachea (Figure 26-3). The external skeleton of the larynx comprises the hyoid bone, thyroid cartilage, and cricoid cartilage.5 The hyoid bone is a U-shaped structure attached to the mandible, tongue, and base of the skull by muscles. It is the most stable portion of the airway. Even in the presence of pathology, the hyoid bone is remarkably constant in position and can be considered a stable landmark.6–8

The larynx is easy to identify externally. The prominent thyroid cartilage forms the laryngeal prominence (Adam's apple) at its inferior pole (Figure 26-3). It is a freely mobile structure that is anchored by muscles and moves with deglutition. Airway manipulation done on an awake patient will need to fix the larynx to avoid involuntary movement of the larynx from reflex swallowing. The thyroid cartilage is attached to the cricoid cartilage via the cricothyroid membrane (Figure 26-3). This is the site for a cricothyroidotomy and can be identified by palpating a slight indentation inferior to the laryngeal prominence. The cricoid is signet ring-shaped and is the only complete cartilaginous ring in the airway. Procedures should avoid damage to the cricoid cartilage, fearing a loss of stability in the airway. The cricotracheal ligament attaches the cricoid cartilage to the trachea.

The trachea is a cartilaginous and membranous tube that is approximately 10 to 11 cm long and 2 to 2.5 cm wide in the average adult. In the pediatric patient, the length and width of the trachea will vary depending on the size and age of the child.9 It extends from the neck into the thorax, where it ends at the carina by dividing into the right and left mainstem bronchi (Figure 26-4). It is made up of 16 to 20 incomplete U-shaped cartilaginous rings anteriorly and laterally. The posterior portion is comprised of a fibromuscular membrane. This membrane attaches the cartilaginous rings to one another and imparts great elasticity in the trachea.2 Full extension of the neck adds significant length to the supraclavicular trachea. This feature should be taken advantage of when performing a tracheostomy.10

The trachea is bordered anteriorly by skin, subcutaneous tissue, platysma muscle, pretracheal fascia, and the thyroid gland (Figure 26-5). The pretracheal fascia is the anterior portion of the deep cervical fascia. It descends from the thyroid and cricoid cartilages and splits to enclose the thyroid gland, trachea, and esophagus. The pretracheal fascia continues downward into the thorax and mediastinum. Anterior to the trachea, it is very thin and inconsequential. Laterally, it is extremely thick and blends with the carotid sheath.

The thyroid gland lies anterior to the second through fourth tracheal rings and is inevitably encountered during a tracheostomy. It is a richly vascular structure (Figure 26-6) that receives its blood supply from the superior thyroid artery (a branch of the external carotid artery) and the inferior thyroid artery (a branch of the thyrocervical trunk). These vessels anastomose into a rich plexus on the anterior surface of the thyroid gland. These major arteries do not usually cross the midline.

Unfortunately, the midline is not always free of blood vessels. An unpaired thyroid ima artery will occasionally be found in the midline to supply the isthmus of the thyroid gland. The anterior thyroid veins often form a vascular arch across the midline and just inferior to the thyroid gland. A hastily performed tracheostomy or one carried out under difficult conditions may encounter significant hemorrhage from transected vessels.

A number of vital structures surround the trachea and are at risk for injury during a tracheostomy. Their positions relative to one another are best appreciated in a cross-sectional view of the neck (Figure 26-5). The deep strap muscles, the sternohyoid and sternothyroid, run adjacent to the trachea and may have to be reflected away for adequate visualization (Figure 26-2). The right and left lobes of the thyroid gland encase the upper trachea (Figures 26-5 & 26-6) with the thyroid isthmus crossing anteriorly from the second to the third tracheal rings.2 Close to the thyroid lobes, the recurrent laryngeal nerves run vertically on both sides of the trachea. These nerves are particularly vulnerable when dissection is extended laterally.11 The common carotid artery, internal jugular vein, and vagus nerve are contained by the carotid sheath and lie adjacent to the thyroid gland. The carotid sheath lies extremely close to the trachea in infants and have been mistaken for the trachea in emergent situations.11 The innominate or brachiocephalic artery crosses left to right immediately anterior to the trachea, while the esophagus lies immediately posterior to the trachea. Erosion of the anterior tracheal wall can occur with prolonged tracheostomy tube placement leading to a tracheoinnominate artery fistula. The parietal pleura can be found on either side of the trachea at the sternal notch and is also at risk of injury during a tracheostomy.

The tracheostomy is an ancient and time-honored technique for securing and maintaining an artificial airway. The American Academy of Otolaryngology—Head and Neck Surgery has proposed specific clinical indicators for the use of a tracheostomy (Table 26-1).12 A number of indications for tracheostomy are widely accepted (Table 26-2).11–18 As mentioned previously, a tracheostomy is generally considered an elective procedure done under nonemergent conditions after the airway has been secured by other techniques.19–23 Its use as an emergency procedure is controversial. Used by battlefield surgeons during wartime, its reputation as a procedure of last resort is not without reason. When performed under emergency circumstances, it is fraught with danger.

A tracheostomy is frequently considered in the treatment of upper airway obstructions including epiglottitis, deep space neck infections, angioedema, airway foreign bodies, multiple lacerations to the floor of the mouth, and complex facial fractures. Although these conditions can create serious and immediate airway compromise, the airway can be managed in most cases with orotracheal intubation. An emergency tracheostomy is not the treatment of choice but rather the choice of last resort.

There are a few clinical settings in which an emergency tracheostomy should be considered: laryngotracheal injury with airway disruption;11,28,29 severe maxillofacial trauma; complete subglottic obstruction; and the need for an airway when all other methods have failed. With the exception of these limited applications, an emergency tracheostomy is discouraged.11,14,32,33

Laryngotracheal Trauma

Most head and neck trauma patients can be managed with nonsurgical airway techniques. There are a number of options available, including orotracheal intubation, nasotracheal intubation, intubation guided by a lighted stylet or “lightwand,” retrograde guidewire intubation, and fiberoptic-assisted intubation. Nasotracheal intubation should be avoided in patients with a potential head injury. If a surgical airway is necessary, a cricothyroidotomy is usually the procedure of choice.

Laryngotracheal injuries are rare but potentially life threatening. When suspected, immediate efforts should focus on getting the patient to the operating room. These injuries can result from either blunt or penetrating injury to the neck. They are often accompanied by edema, hemorrhage, subcutaneous emphysema, and fracture of either the thyroid or cricoid cartilages. In their presence, rapid access to the cricothyroid membrane may be limited, making it difficult to perform a cricothyroidotomy, and tracheostomy should be considered.11,34–36 Blunt injury has been described when the anterior neck forcefully strikes a fixed object such as a rope or a cable. A classic example of this type of injury is forcefully striking the anterior neck against the steering wheel during high-speed motor vehicle accidents.11,35,36 Penetrating injuries to the airway are usually apparent; however, blunt injuries to the trachea require a high index of suspicion.36,37 In a review of 51 patients with blunt injury to the trachea, the most common presenting signs and symptoms included subcutaneous emphysema, respiratory distress, hoarseness or dysphonia, and hemoptysis.36 In this same review, a high rate of endotracheal intubation failure was reported with the conclusion that emergent tracheostomy was the best means of airway control.36 In cases of penetrating trauma to the larynx, physicians may consider obtaining emergent airway control directly through the wound as a temporary measure prior to operative management.9

Laryngotracheal disruption, occurring when the larynx and trachea become separated, is an unusual injury. This is the one injury in which a tracheostomy is the undisputed method for establishing and securing the airway. Patients with laryngotracheal disruption may exhibit varying degrees of respiratory distress, visible bruising over the anterior neck, hoarseness or aphonia, subcutaneous emphysema or blood-streaked sputum. A defect may be palpable in the neck. Soft tissue radiographs of the neck may reveal an interrupted air column. If the airway is disrupted, a “low tracheostomy” between the fourth and fifth tracheal rings should be performed. The severed airway will tend to retract into the thorax, and a low tracheostomy will offer the best chance of securing the dismembered segment. Misguided attempts to visualize the airway, intubate orally, or perform a cricothyroidotomy may further damage the already precarious airway. This is fortunately a rare injury with only a few case reports in the literature.28,29 A tracheostomy performed in this setting is more treacherous than usual. Although a tracheostomy may be the only way to secure the airway, this airway intervention has a better chance of success when performed in the operating room.

Surgical Airways in the Pediatric Patient

Surgical approaches to the airway are more difficult and complicated in pediatric patients, especially newborns and infants. In the child, the larynx is positioned more cephalad than in the adult, allowing relative protection by the mandibular arch.9 It is more anteriorly located and significantly smaller than in adults, as well as more floppy and mobile. The infant's cricothyroid membrane, unlike that of the adult, is extremely narrow and cannot easily be used for access to the airway. For this reason, a surgical cricothyroidotomy should be avoided until a child is greater than 12 years old.9,11 Attempts at creating emergency surgical airways in children are typically acts of desperation. A calm, reasoned approach to the pediatric airway and common respiratory problems is essential. Efforts should first be made to suction the airway clear of secretions, followed by ventilation with a bag-valve-mask device. Direct visualization by laryngoscopy and orotracheal intubation should be attempted before resorting to a surgical airway. If an unstable patient cannot be ventilated, a needle cricothyroidotomy can serve as a temporizing measure until a surgical team can be assembled and better control achieved.9,11

In the pediatric population, laryngotracheal injury is rare.11 Typically, children sustain blunt anterior neck injury as the result of high-speed accidents involving bicycles, falls, and motor vehicles. Additionally, this injury type may be the result of sports-related activity. Clinical signs and symptoms of laryngeal or tracheal trauma mirror that of adults. Airway management in these patients can be achieved with a tracheostomy. However, this may be quite difficult and is only advocated by some authors.9 Attempts to obtain surgical assistance should be sought immediately.

Simply stated, an emergency tracheostomy is contraindicated when other methods can be used to secure the airway. There are a few instances when an immediate surgical airway is necessary. Cricothyroidotomy is the procedure of choice when a surgical approach to the airway is required. Compared to a tracheostomy, a cricothyroidotomy is faster and more direct; it relies predominantly on external landmarks, requires only a single operator, can be done with ambient lighting, and requires a limited amount of equipment.12,24 In contrast, a tracheostomy is a procedure requiring multiple steps. It involves direct visualization to dissect through vascular structures and requires better light than is commonly present at the bedside. It is easier and therefore faster to execute if one has an assistant, proper suctioning equipment, and electrocautery. Without these advantages, the technique is difficult and likely to be complicated. A “timely trach” can be performed within 5 to 10 minutes.12 However, reported times to definitive airway during elective open tracheostomies have ranged from 13.5 to 105 minutes.24–27 Although this time frame may be adequate for urgent situations, it is too slow for the true emergency in a patient who lacks an airway.

A tracheostomy requires an extensive amount of equipment. Appropriate supplies should be sterilized and assembled in a prepackaged tray. A list of required equipment is given in Table 26-3. If such a tray is not available, supplies that are immediately on hand have to suffice. A thoracotomy or a major procedure tray will contain most of the required equipment.

Patient preparation will depend largely on the circumstances dictating the procedure. If the patient is uncooperative, hypoxic, or thrashing about, rapid control will have to be established with a sedative. The ideal agent is one that sedates with minimal hemodynamic consequences, preserves spontaneous respirations, and leaves an intact gag reflex. If the patient is awake and cooperative, calm reassurance may allow the procedure to be performed under local anesthesia. If the patient is unconscious, a local anesthetic is sufficient.

Place a rolled towel under the patient's shoulders and neck if no contraindications exist (Figure 26-7). This detail cannot be emphasized enough. Full neck extension brings the airway anterior and increases the length of the supraclavicular trachea by as much as 2.6 cm.9 It enlarges the surgical field for improved access. Neck extension tends to fix the airway in position and pull it taut. When the neck is in a neutral or flexed position, the trachea lies more posteriorly and is more “floppy.” In this situation, it is easier for the operator to stray off midline. When the neck is flexed, the surgical field may be reduced to a dark hole with poor visibility. In the pediatric patient, a certain degree of extension is helpful, but full extension may occlude the airway.

Prior to beginning the incision, the physician should check the equipment. A tracheostomy tube that is appropriate for the patient's size should be selected. An average male will accommodate a size 7 or 8 Shiley tracheal tube. An average-size female will accommodate a size 6 or 7 Shiley tracheal tube. The cuff of the tracheal tube should be tested prior to use. As an alternative, an endotracheal tube can be used.

Identify the anatomic landmarks required to perform this procedure. Using the nondominant hand, place the thumb on one side and the middle finger on the other side of the patient's trachea (Figure 26-8). Identify the laryngeal prominence (Adam's apple) with the index finger. Slide the index finger caudally to identify the cricothyroid membrane, cricoid cartilage, and tracheal rings.

Clean the neck of any dirt and debris. Even during the resuscitation of an unstable patient, there should be adequate time for the use of aseptic solution as well as sterile technique. Prepare yourself by applying a mask, eye protection, sterile gown, and sterile gloves. Apply a sterile drape to isolate a surgical field. Infiltrate local anesthetic solution along the planned incision line. It was once thought that injection of local anesthetic into the trachea blunts the cough reflex and provides a sense of depth of the airway. A recent review of 97 patients who underwent an awake tracheostomy noted that this could result in cough, agitation, and less beneficial outcomes.38

Once the patient is positioned, prepped, and anesthetized, establishment of the airway should be just 2 to 3 minutes away. The last step in preparation should be the mental decision that no other technique will suffice and the commitment to proceed with confidence.

In the most critical situation, the simplest technique is likely to be the most successful.39 The right-handed operator should stand to the patient's right and fix the airway with their left hand (Figure 26-8). Left-handed operators should adjust their technique based on their preference for handedness. Apply the thumb and third digit of the nondominant hand on the thyroid cartilage while the index finger palpates the cricoid and tracheal rings (Figure 26-8). An awake or lightly anesthetized patient may swallow or gulp during the procedure, thereby moving the landmarks. Fixing the left hand firmly on the upper airway will minimize this distraction.

A vertical incision is preferred in the emergent setting because it allows greater exposure of the cricothyroid membrane and the trachea, and avoids traversing lateral structures.11 Make a 3 or 4 cm vertical midline incision through the skin and subcutaneous tissues beginning just below the cricoid cartilage and extending inferiorly to the supraclavicular notch (Figure 26-9). A larger skin incision causes no harm as long as it remains superficial, to avoid damaging the cricoid cartilage. Extreme care should be taken to ensure that the incision and further dissection remain in the midline.11

Once the skin and subcutaneous tissue have been incised, attention should be directed toward clearing the pretracheal space and defining the tracheal rings. Divide the superficial and deep strap muscles in the midline and retract them away from the trachea (Figure 26-10). Bluntly dissect free and reflect away any blood vessels in front of the trachea. If they impede progress, they can be clamped with hemostats and divided. The thyroid gland lies above the trachea. Bluntly dissect between it and the trachea with a hemostat to mobilize the thyroid gland (Figure 26-11). An alternative option to consider in the emergent setting is to use the nondominant index finger to dissect the pretracheal space bluntly and reflect the thyroid isthmus either superiorly or inferiorly. This minimalist blunt approach lacks finesse but is effective and timely.14

Retract the thyroid gland upward (Figure 26-12). If this becomes difficult, it may be faster to divide the isthmus between two hemostats (Figure 26-13). The divided edges can be oversewn after the tracheostomy tube is in place. Once the thyroid has been divided, the operating field will be cluttered with hemostats and may be partially obstructed. Do not apply traction to the instruments, as this can avulse tissue, leading to bleeding and further obstruction of the surgical field.

When ready to make the tracheal incision, it may be helpful to have an assistant place a tracheal hook under the first tracheal ring and apply traction superiorly and anteriorly (Figure 26-14). Have the assistant hold the tracheal hook in position. This will elevate and immobilize the trachea. The assistant should direct their hands superior to the wound to keep the field unobstructed. If the neck is properly extended, this may be unnecessary. If at any time identification of the trachea becomes difficult, needle aspiration may be used to confirm the presence of an air-filled tube.

Make an incision in the trachea. The preferred tracheotomy is a midline vertical incision extending from the second through the fourth tracheal rings (Figure 26-15A). There are other options, but they are discouraged in the emergent setting because they stray from the midline (Figures 26-15B to 26-15D). Insert a Trousseau dilator or hemostat into the incision. Use the dilator to open and widen the incision. Alternatively, the sides of the tracheal incision can be grasped and held open with Allis forceps (Figure 26-16A).

Lubricate the appropriate size tracheostomy tube liberally. Insert the tracheostomy tube, with its obturator, through the tracheotomy while the incision is held open (Figure 26-16A). Advance the tracheostomy tube and inflate the cuff (Figure 26-16B). Hold the tracheostomy tube in place securely. Remove the obturator and insert the inner cannula. Attach a bag-valve device and begin ventilating the patient.

Since 1969, a number of authors have described a third invasive option for airway control, the percutaneous dilatational tracheostomy. Although techniques vary somewhat, they all rely on an initial puncture of the airway followed by progressive dilatation of a tract. Once a sufficiently large tract is formed, an airway tube is placed. There is now enough evidence to argue that percutaneous tracheostomies are competitive with, and perhaps preferable to, formal open tracheostomies done under elective conditions.25,26,40–52 Several large series of percutaneous tracheostomies are now complete, but significant results are available only for elective tracheostomies done in patients who have already been intubated.41,43,44,49 There are small case studies that have been published regarding the successful use of percutaneous dilatational tracheostomy in an emergency setting. These authors conclude that percutaneous dilatational tracheostomy is an effective airway, providing an alternative to endotracheal intubation. The resultant airway is stable and does not require conversion in the immediate postresuscitation period.53 Furthermore, a recent case series of four patients undergoing percutaneous dilatational tracheostomy in the intensive care setting illustrated the possible benefits of performing the procedure in combination with ultrasound guidance.54 The authors concluded that the use of ultrasound could identify patients unsuitable for the procedure, prevent puncture of aberrant vessels, estimate the distance from the surface of the skin to the trachea, and ensure accurate placement of the needle into the trachea.54 While these studies are promising, larger studies are needed to determine the ultimate role of percutaneous dilatational tracheostomy in the emergency setting.53 Cricothyroidotomy remains the procedure of choice for emergency surgical access to the airway.

Once the airway is established, tracheostomy tube positioning should be confirmed by auscultation, ease of ventilation, and pulse oximetry. Obtain a chest and neck radiograph to confirm tracheostomy tube position and exclude a pneumothorax.

Once the airway has been established, inspect the wound to ensure hemostasis. Any clamped vessels or thyroid tissue should be tied. The skin edges do not need to be closed unless the skin incision was overly zealous. If the skin is reapproximated, close it loosely to avoid the development of subcutaneous emphysema. Secure the tracheostomy tube with umbilical tape wrapped around the neck. Suture the flange of the tracheostomy tube to the skin using 3-0 silk as an additional safeguard (Figure 26-17). If the wound is oozing, place a loose gauze pad between the skin and the tracheostomy.

Special care should be taken to protect the artificial airway. Suction the lumen frequently and as necessary to prevent obstruction from blood or secretions. Administer humidified oxygen through the tube to prevent dried and inspissated secretions from occluding it.

An elective tracheostomy is a relatively basic and common surgical procedure. Despite this, it has an unusually high complication rate. Authors report widely different morbidity rates, perhaps determined in part by the clinical settings if not their own biases. Reported morbidity ranges from 6% to 58%, with procedures done emergently having the highest rates.20,21,23,24 However discomforting these numbers may be, the risk is certainly acceptable in the face of an unstable airway in a dying patient.

Complications from a tracheostomy can be divided into immediate operative complications, postoperative complications, and delayed complications. A summary of reported complications are listed in Table 26-4. It cannot be stressed enough that the best way to avoid complications is to avert the need for a tracheostomy. Under emergent circumstances, a variety of things can and do go wrong. It is best if one has thought about these possibilities, considered alternative strategies for airway management, and sought assistance from surgical colleagues. A more detailed discussion regarding chronic complications is found in Chapter 27 (Tracheostomy Care).

The most common problem with a hastily performed tracheostomy is hemorrhage. Most bleeding can be controlled with the application of direct pressure. An assistant may be invaluable in providing sufficient control until the airway is established. The search for a bleeding source during the procedure will waste valuable time and can usually wait until the airway is established. The best way to avoid this difficulty is strict hemostasis during the procedure and being careful to avoid the transection of any blood vessels. The next most likely problem is inadvertent injury to adjacent structures. This can be avoided by remaining strictly in the midline, positioning the patient properly, and using a tracheal hook. Additional problems that can be encountered include the creation of a false passage. This should not occur if the operator has visualized the trachea and remained in the midline. In pediatric patients, pneumomediastinum is one of the most frequent early complications of tracheostomy.55

The Emergency Physician should be cautious not to adopt methods for tracheostomies learned from elective procedures performed in the operating room under controlled circumstances. The emergent tracheostomy must be carried out with the simplest, fastest, and most straightforward technique possible. Tracheostomies done under elective conditions may use rescue stay sutures and more elaborate tracheal incisions. The added benefits of these features do not offset the additional time required to perform them.

Any physician who cares for patients under emergency circumstances should think through the clinical scenarios in which an emergent tracheostomy may be necessary. Expertise in surgical airway techniques should first be obtained in a laboratory setting. Unless one is poised to respond with a plan of action for the emergent airway and prepared with the necessary surgical skills, such situations create chaos and all too often end in disaster.

A well-trained Emergency Physician must be prepared for any kind of airway emergency and should be skilled in a variety of approaches. Optimal airway management begins with optimal medical management of the patient, including the early identification of possible airway compromise and aggressive preventive treatment. Many airway problems can be averted with anticipatory action. In the armamentarium of airway procedures, a tracheostomy will be (and should be) a rare solution. The physician who is knowledgeable about and comfortable with alternative airway techniques, including surgical access, will be prepared to act decisively yet appropriately upon encountering a challenging airway crisis. While a cricothyroidotomy is the surgical airway procedure of choice, a tracheostomy should be considered for laryngeal injuries with airway disruption, or when all other methods have failed.