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
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.