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2010 BC Decker Inc ACS Surgery: Principles and Practice

2 HEAD AND NECK 8 TRACHEOSTOMY 1

DOI 10.2310/7800.S02C08

04/10

8 TRACHEOSTOMY

H. David Reines, MD, FACS, and Elizabeth Franco, MD, MPH&TM

History

The word tracheotomy first appeared in Libri Chirgurae 12,

published in 1649, but it was not until Laurence Heruter,

a German surgeon, reintroduced it that it became part of

modern medicine. It was initially performed as a lifesaving

procedure to establish an airway. Alexander the Great is

reported to have used his sword to open the trachea of a

suffocating soldier. The term tracheotomy is defined as a surgi-

cal creation of an opening in the anterior trachea that can be

reversible and temporary, whereas, technically, tracheostomy is

the formation of an opening into the trachea by suturing the

edges of the opening to the skin of the neck. However, over

the years, the two terms have been used interchangeably. For

this document, we use the term tracheostomy to describe the

procedure.

Indications

The indication for a tracheostomy has changed over the

years. Originally, it was conceived as a method to obtain an

airway for obstruction from infections, neoplasm, or trauma.

The most common indications for modern tracheostomy

are prolonged ventilation for respiratory failure and airway

protection following traumatic brain injury with neurologic

dysfunction.

Patients requiring tracheostomy or cricothyroidotomy fall

into four categories:

1. Emergency for airway control, that is, airway obstructionfrom the epiglottis, foreign-body aspiration, laryngeal

trauma, or maxillofacial trauma

2. Semielective for patients requiring prolonged intubation or

mechanical ventilation for respiratory failure or high spinal

cord injury

3. Elective for airway protection, that is, traumatic brain

injury, stroke, sleep apnea, or vocal cord problems

4. Elective for long-term airway access. Permanent tracheos-

tomies are used to maintain airway access when patients

undergo major head or neck dissection for tumors of the

larynx and the base of the tongue.

Patients who arrive with either acute airway compromise

from neck trauma or facial burns should first undergo an

attempt at oral intubation, and if this fails, an emergent surgi-cal airway is required.

Laryngoscopy should be attempted prior to performing

surgical airway. If a patient arrives talking, but there is

evidence of hoarseness with increasing airway compromise,

the surgeon should be prepared for a surgical airway if

oral intubation is unsuccessful. When an attempt at oral

intubation fails and ventilation is a problem, immediate cri-

cothyroidotomy should be performed. A semielective surgical

airway should be undertaken in a patient whose injuries may

result in progressive laryngeal and cervical soft tissue edema

prior to decompensation from respiratory distress. Patients

with a Glasgow Coma Scale (GCS) less than or equal to

8 cannot protect their airway, and intubation should be

performed immediately. If this is not possible, then a surgical

airway should be considered prior to transporting the

patient.

Early Tracheostomy

If the patient is ventilator dependent or has severe headinjury and will need prolonged airway protection, early

tracheostomy should be considered when intracranial pres-

sure is not elevated. Early tracheostomy is defined as occur-

ring at or before 7 days, whereas late tracheostomy occurs

after 7 days. Early tracheostomy has been associated with

decreased incidence of ventilator-associated pneumonia,

decreased days of mechanical ventilation, decreased hospital

stay, decreased intensive care unit (ICU) length of stay,

and increased patient comfort. Although no study has dem-

onstrated a decrease in overall mortality with early tracheos-

tomy, tracheostomy does provide easier access for suctioning

and allows patients to be liberated from the ventilator without

the loss of an airway.

Pertinent Anatomy

The trachea lies relatively superficially in the anterior

neck covered by the strap muscles midline and the platysma.

The first tracheal ring is just below the cricothyroid, whereas

the next three rings may lie beneath the thyroid isthmus. The

sixth through seventh rings lie low in the neck and into

the sternal notch [see Figure 1]. When performing a tracheos-

tomy, knowledge of the normal and potentially abnormal

vasculature is imperative. Care must be taken with a horizon-

tal incision to avoid bleeding from injury to the anterior

jugular vein. Other potential causes of hemorrhage may arise

from injury to a high-riding innominate artery, a medially

placed carotid artery, and the thyroid ima vessels in the

midline. Tumors, hematoma, and edema can cause trachealdeviation from midline. Other anatomic variants should

also be considered. An obese patient may require deeper

dissection, longer instruments, and the use of an extra-long

tracheostomy tube. The length of the neck and the distance

from the jaw to the thyroid cartilage should also be examined.

Patients with a known or potential neck injury or with kypho-

sis must be positioned without extension. Access to the

trachea may be compromised, and plans for dissecting the

thyroid isthmus should be considered.

* The authors and editors gratefully acknowledge the contribu-

tions of the previous author, Ara A. Chalian, MD, FACS, to

the development and writing of this chapter.

Indicates the text is tied to a SCORE learning objective. Please see the

HTML version online at www.acssurgery.com.

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Physiology

When undergoing a tracheostomy, ideally, the patient

should be adequately ventilated and hyperoxygenated in

anticipation of a period of apnea during tracheostomy tube

placement. An oxygen saturation of 100% and a normal

pH and carbon dioxide tension (PCO2) are desirable at thestart of an elective tracheostomy. Use of 100% oxygen during

the procedure will help maintain adequate oxygenation

throughout the procedure. When an emergency cricothyroid-

otomy or tracheostomy is necessary, an attempt should be

made to preoxygenate and ventilate.

Counseling and Informed Consent

The patient, the family, or both should be advised of the

risks and benefits of a tracheostomy. Commonly discussed

issues, including pain, mortality, and the range of possibilities

of early and late complications (see below), should be on

the consent form. A tracheostomy should be proposed as the

best option for the patient requiring prolonged mechanicalventilation or airway protection. Tracheostomy contributes to

patient comfort, allowing improved oral care, oral alimenta-

tion, and speaking as well as the potential for earlier liberation

from the ventilator.

Site of the Procedure

Elective open tracheostomy requires good lighting and

electrocautery. Some may find open tracheostomy in the ICU

more ergonomically difficult than in the operating room

(OR) because the patient is on a hospital bed; however,

finding OR time and transporting the patient may be incon-

venient. Several studies comparing bedside open to percuta-

neous tracheostomies find the techniques to be essentially

equivalent in outcome with the open technique and possibly

lower in cost. Percutaneous tracheostomy is most commonly

performed at the bedside, in the ICU, and does not require

the same lighting or instrumentation and nursing availability

that an open tracheostomy does. A cricothyroidotomy isfrequently performed in the trauma bay, although it may be

executed anywhere and requires the least amount of instru-

mentation. Emergency tracheostomy and cricothyroidotomy

are frequently not performed in the OR.

Anesthesia

Anesthesia can frequently be given as conscious sedation

and/or local anesthesia with epinephrine. Paralysis should be

avoided when possible in a patient with any spontaneous

breathing.

Patient Positioning

Extension of the neck is desirable; however, if the patient

has a known or potential cervical spine injury, operation in

the neutral position is necessary. When possible, the patient

should be placed on an operating table with a shoulder roll

and a foam pad (donut) under the head. When the neck can

be extended, the head rest of the surgical bed can be lowered

and the patient placed in a 30 head elevation position to

decrease venous pressure. Extending the head allows better

palpation of the landmarks. If cervical spine precautions are

necessary, the posterior portion of the cervical collar should

remain in place and the head stabilized by a team member.

Another alternative is to stabilize the neck with bilateral head

rolls with tape over the forehead and chin extending across

the bed.

Operative Techniques

emergent surgical airway

Cricothyroidotomy

Cricothyroidotomy is generally performed for emergent

control of the airway. Inability to secure an airway, especially

with severe facial trauma, requires immediate access to the

trachea. A cricothyroidotomy can be performed rapidly and

does not risk the anatomic problems of a tracheostomy

because the cricothyroid membrane is thin and closest to

the skin directly under the thyroid membrane If a #5 or #6

tracheostomy tube is not available, an endotracheal tube can

be introduced for immediate airway access.

Transtracheal Needle Ventilation and Oxygenation

Transtracheal needle access also can be used in emergency

situations. A large-bore 12- or 14 gauge angiocatheter or a

pulmonary artery catheter introducer sheath is placed through

the cricoid membrane and attached to oxygen tubing with

the capability of providing oxygen at 50 psi. A hole in the

tubing is finger-occluded and intermittently opened to allow

for ventilation. Adequate ventilation can be provided for

Figure 1 Surgical tracheostomy. A transverse cutaneous

incision is made that is approximately 2 to 3 cm long (or as

long as is necessary for adequate exposure). The extent of flap

elevation may be 1 cm or less.

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20 to 30 minutes. This method is best used as a bridge

while awaiting the proper equipment and support for an

orotracheal or surgical airway.

open tracheostomy

Steps

1. Incision of the skin. The patient should be assessed for a

high-riding innominate artery, abnormally placed vessels,

and tracheal deviation. Incision can be made either verti-

cally or horizontally. The horizontal scar heals better

than the vertical scar. However, visualization, especially

if the neck cannot be extended, is frequently easier in a

vertical incision. Damage to the anterior jugular veins like-

wise is less likely with a vertical incision. In an emergency,

a longer vertical incision can facilitate exposure while

avoiding the subplatysmal anterior jugular veins [see

Figure 2]. In general, the incision should be made midway

between the cricoid cartilage and the sternal notch.

The size of the incision is up to the individual surgeon.

However, a minimum of 2 to 2.5 cm is desirable.

Subsequent dissection must be performed perpendicular

to the trachea. A common mistake when dividing the sub-

cutaneous tissue is to deflect in a slightly oblique fashion,

arriving lower in the trachea than anticipated.2. Retracting the strap muscles. The midline raphe is divided

and an assistant with Senn or Army-Navy retractors

or with a self-retraining retractor then retracts the strap

muscles laterally. Undermining should be minimized to

decrease the potential creation of dead-space areas. In

the case of a malignant neoplasm overlying the thyroid

compartment, the anatomic landmarks may be less clear.

In such a case, palpation of the thyroid cartilage and

dissecting caudally are helpful. Care must be taken, espe-

cially in women, to palpate the thyroid and not the hyoid

cartilage [see Figure 3].

3. Dissection of the thyroid gland. The thyroid isthmus fre-

quently lies in the field of dissection. Because its size and

thickness vary greatly and can vary from 5 to 10 mm in

vertical dimension, dissection of this can be undertaken,

and, in many cases, immobilizing the trachea and retract-

ing the isthmus either superiorly or inferiorly to place the

tracheal incision in the second or third tracheal interspace

can be accomplished [see Figure 4]. However, if the isth-

mus is a problem, especially in cases where the neck cannot

be extended, it can be divided and the edges ligated either

with ties or with a Harmonic scalpel. When there is an

isthmus nodule, the isthmus should be removed for diag-

nostic and therapeutic purposes. Recurrent laryngeal

nerves should not be directly in the operative field and are

rarely at risk as long as one stays in the midline anterior on

the trachea. If significant deviation of the trachea is noted,

the nerves may be injured. Because the blood supply to the

trachea is laterally based, one should not encounter them.

However, a thyroid ima vessel is frequently noted in the

lower portion of the isthmus, and this may need to beligated prior to dissection.

4. Incision of the trachea. Tracheostomy should be performed

with a sharp blade. The pretracheal tissues may be

coagulated with a bipolar electrocautery. The opening of

the airway may bring volatile gasses into the operative

field; therefore, monopolar electrocautery should be

avoided if volatile gasses are in use. Several types of

incisions are possible:

Figure 2 Surgical tracheostomy. Retractors are placed, the

skin is retracted, and the strap muscles are visualized in the

midline. The muscles are divided along the raphe and then

retracted laterally.

Figure 3 Surgical tracheostomy. With the strap muscles

retracted, the thyroid isthmus is visualized, and the inferior

(or superior) edge of the isthmus is dissected down to the

trachea. The isthmus is then retracted superiorly (or inferi-

orly) or divided to permit visualization of the trachea before

the tracheal incision is made.

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a. Linear incision. This transverse incision is made either

between the second and third rings or the third and

fourth rings. Stay sutures are then placed superiorly

and inferiorly around the tracheal rings [see Figure 5].

b. T-type incision. This incision is a combination of a

vertical incision that crosses the second ring and forms

a T with a transverse incision below the third

tracheal ring. Stay sutures are placed laterally and

allow for controlled opening of the trachea with a

tracheostomy spreader.

c. Tracheal window. Although a tracheal window with

removal of a portion of the third tracheal ring has been

performed, this is more difficult and may not heal as

rapidly as a ring-preserving incision.d. Bjrk flap. A Bjrk flap is an inferiorly based U-shaped

flap that incorporates the ring below and the tracheal

incision [see Figure 4]. A U-type incision is made from

the third tracheal ring through the second tracheal ring,

and the second tracheal ring is then retracted inferiorly

and sutured with a dissolvable suture as high in the

neck as possible to the skin. The theoretical justifica-

tion for this is to keep the tracheal incision close to

the skin edges in the instance of tracheostomy tube

displacement, to ensure ease of airway access. This

flap suture can be released 3 to 5 days after creation

once the tract has been established or after the first

tracheostomy change.

5. Stay sutures. Stay sutures using a 2-0 nonabsorbable sutureon a UR6 needle can be placed either laterally or inferiorly

and superiorly. These help stabilize the tracheostomy

during the procedure. The sutures are then taped to the

chest and labeled so that they will not be inadvertently

removed. Stay sutures may provide access to a fresh

tracheostomy if the tracheostomy tube becomes dislodged

in the immediate postoperative period. These sutures are

left in place until the first tube change.

In adults, a number 8(outside diameter [OD]) or 6(OD)

tube is preferable. If there is significant edema or obesity, the

use of an extra-long tube is desirable. If a tracheostomy tube

is not available, a standard endotracheal tube can be used to

intubate the neck. Remember when trimming the tube tospare the pilot balloon.

percutaneous tracheostomy

Percutaneous tracheostomy was first described over 50

years ago, but the availability of a dilational percutaneous

tracheostomy kit prompted widespread use in the 1990s.

In many centers, this has become the method of choice

for tracheostomy. Although initial contraindications included

morbid obesity, inability to extend the neck as in potential

cervical spine injuries, short neck, enlarged thyroid isthmus,

and previous tracheostomy, these have been disproven with

increasing experience. A benefit of the percutaneous approach

is the ability to perform the procedure at bedside in the

ICU, reducing OR costs and scheduling conflicts. Thepercutaneous approach has been championed for its ease

of performance at the bedside in the ICU; however, several

studies comparing cost and personnel use demonstrate

open bedside tracheostomy to be more cost-effective with

equivalent complications and safety outcomes. The long-term

cosmetic effects of percutaneous tracheostomy appear to be

better than those of the open technique.

The choice between percutaneous and open tracheostomy

remains a decision best left to individual centers.

Figure 4 Surgical tracheostomy. A tracheotomy is made

either between the second and third tracheal rings or between

the third and fourth rings. A Bjrk flap (inset) may be created

by extending the ends of the tracheostomy downward through

the next lower tracheal ring in an inverted U shape.

Figure 5 Surgical tracheostomy. The tracheostomy tube is

inserted into the tracheal opening from the side, with the

faceplate rotated 90 so that the tubes entry into the airway

can be well visualized.

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Operative Technique

Equipment and personnel The personnel necessary

for the procedure are a respiratory therapist, a critical care

nurse, a surgeon, and a bronchoscopist to safely perform a

percutaneous tracheostomy. The equipment required is a

bronchoscope and a percutaneous dilation tracheostomy kit.

Surgical instruments for an open tracheostomy should be

readily available. Maximum sterile barriers are employed,

including sterile gown, gloves, and drapes. All participating

personnel must wear mask and head covers.

Procedure

1. Incision. Once conscious sedation is initiated, the sub-

cutaneous tissue is infiltrated with local anesthetic 1 cm

caudal to the cricoid cartilage. A 1 to 1.5 cm incision is

made either in a horizontal or a vertical fashion. The sub-

cutaneous tissue is then bluntly dissected using a hemostat

to spread the tissue down to the level of the trachea.

2. Bronchoscopy. The bronchoscope is advanced to the tip

of the endotracheal tube. With the surgeon providing

one-finger ballottement at the level of the first or second

tracheal ring, the endotracheal tube is slowly withdrawn

while maintaining the bronchoscope at the tip of the tube

until one-to-one ballottement is appreciated. Every stepof the procedure involving instrumentation of the trachea

is preferably performed under direct bronchoscopic

visualization.

3. Transcutaneous tracheostomy. The introducer needle is

advanced through the incision at the level where one-

to-one ballottement was appreciated. Constant aspiration

of the syringe and direct bronchoscopic visualization

immediately identify the entrance into the trachea. Once

the needle is noted to be in a good position, the guide

wire is introduced again under direct bronchoscopic

visualization.

4. Dilation. Using a modified Seldinger technique, the needle

is removed and a stiff conical dilator is introduced and

removed. The tract is then dilated with the largest conicaldilator to the level marked for the skin. The dilator is

removed and fully introduced three times. The tracheos-

tomy tube is then introduced over the snuggest fitting

dilator. Once the tracheostomy tube is in place, the guide

wire and dilator are removed. Often the endotracheal

tube must be withdrawn a short distance to allow for serial

dilation and introduction of the tracheostomy tube.

5. Confirmation of placement. Once the tracheostomy tube is

in place, the bronchoscope is withdrawn from the endotra-

cheal tube and introduced through the tracheostomy tube

to confirm placement within the trachea. The endotracheal

tube is kept in place until confirmation is complete. The

tracheostomy tube is then secured with sutures from the

faceplate to the skin and tied in place.

Tracheostomy Management

Tracheal sutures are removed on postoperative day 7. If

the patient is on minimal ventilator settings or liberated from

the ventilator, the tracheostomy tube is downsized. Once

the patient is liberated from the ventilator, the tracheostomy

tube cuff is deflated and the patient is placed on humidified

air or oxygen. The humidified air can be delivered via a

tracheostomy collar or tracheostomy tube. A tracheostomy

collar allows more patient freedom and less torque than a T

tube when frequent suctioning is not required. Speech

pathology consultation should be obtained for swallowing

evaluation and speaking valve placement versus capping the

tracheostomy tube. The approach depends on the patients

mental status and suctioning requirements. Once the patient

is tolerating either tracheostomy tube occlusion or a speaking

valve for greater than 24 hours and managing his or her

own secretions, the tracheostomy is removed. In preparationfor decannulation, the patient should be suctioned and a

replacement tracheostomy with a stylet should be available

in case of sudden respiratory decompensation.An occlusive

dressing is left in place for 24 hours. Generally, no further

dressing is required afterward.

Complications

Reported complication rates from tracheostomy range

from 5 to 31%, with an average of nearly 12%. Major com-

plications range from 2 to 6%. Mortality is extremely low

(0.5%).

early complications

Displacement

The most dangerous complication is early accidental

displacement or decannulation. This can occur when moving

the patient to the ICU or recovery room and when patients

are turned for care or x-rays in the ICU in the first 5 to 7 days

after placement. A loosely tied tracheostomy or one placed

in a precarious position can be dislodged, resulting in the

inability to ventilate and oxygenate. If this is suspected, the

patient should immediately be placed supine and an attempt

at ventilation should commence. If the patient cannot be

ventilated, an attempt to replace the tube should be tried

if stay sutures or a Bjrk flap is present. Emergency oral intu-

bation should be performed if the attempt fails. Multiple

attempts to replace the tube can result in a false passage. The

tracheostomy can then later be replaced via the same incision

with the proper light and proper retraction. A new tracheos-

tomy tube should be available in the room or above the bed

for all patients who have had a fresh tracheostomy.

Pneumomediastinum/Pneumothorax

Pneumomediastinum can occur, especially with a low

tracheostomy or if a false passage is created. Pneumothorax

is a rare (< 2%) complication that can occur especially in

children, in whom the cupola of the lung may ride high.

Pneumothorax can also occur in patients who require high

ventilatory pressures or who cough vigorously during the pro-

cedure. A low tracheostomy and deep dissection potentially

increase the risk of pneumothorax.

Bleeding

A small amount of blood via the wound or tracheostomy

immediately following the procedure is not alarming. How-

ever, the persistence of blood around the trachea implies

venous bleeding from either the skin, subcutaneous tissues,

or thyroid gland. In general, this can be controlled with gentle

packing and the use of a bioabsorbable hemostatic agent.

If bleeding continues, the patient should be taken to the OR

if possible and reintubated under ideal light and retraction;

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the tracheostomy should be removed and the bleeding con-

trolled with cautery or sutures if necessary. If hemorrhage

is demonstrated via the tracheostomy tube, early careful

bronchoscopy should be performed to ascertain the site of

bleeding. Significant bleeding from the tracheostomy is

usually a late complication and may be related to a

tracheoinnominate fistula (see below).

Infection

Tracheostomy infections requiring treatment are muchless common than one would imagine, considering the con-

tamination of the bronchial/tracheal tree in many patients

who have been intubated for a period of time. The majority

of infections can be treated with local wound care, although

deep infections from Staphylococcus aureus and Pseudomonas

aerigunosa may require antibiotics and removal of sutures.

Placing tracheostomies through burn eschar presents a

separate problem.

Acute Obstruction

The most common cause for acute obstruction of a trache-

ostomy is dislodgment. If that is not the case, the tracheos-

tomy may have accumulated blood or mucus, which can clog

the airways. To avoid this, humidified oxygen should always

be administered, and gentle careful suctioning should beinitiated by experienced personnel. The inner cannula should

be removed and examined. Occasionally, bronchoscopy will

be necessary to remove and irrigate mucus plugs.

Negative Pressure Pulmonary Edema

A rare complication of upper airway obstruction may occur

after a tracheostomy is performed for airway obstruction.

Patients generating large negative pressure against resistance,

which is suddenly released, can experience a noncardiogenic

pulmonary edema. The patient becomes hypoxic, develops

rales in the lungs, and can demonstrate pink frothy pulmo-

nary edema via the tube. A chest x-ray may demonstrate

bilateral pulmonary edema. This process is usually self-

limited and responds to positive end-expiratory pressure

(PEEP) and positive pressure ventilation.

late complications

Late complications of tracheostomy are often attributable

to the cuff, either from the tracheostomy tube or from the

endotracheal tube in place prior to tracheostomy. Complica-

tions attributable to cuff injuries are less common now than

previously as a result of improvement in technology allowing

for lower-pressure cuffs, but they still occur in patients who

undergo prolonged endotracheal intubation.

Tracheostomy cuff pressures should be measured daily

or more often to prevent tracheal necrosis. X-rays demon-

strating a dilated cuff in the trachea require assessment of the

tube, cuff, and trachea.

Subglottic Tracheal Stenosis

Tracheal stenosis has a reported incidence of 4 to 18%.

Stenosis is associated with a longer hospital stay and pro-

longed time to tracheostomy. Dyspnea and stridor result

when tracheal stenosis is greater than 50% of tracheal diam-

eter. In suspected tracheal stenosis, referral to a specialist for

evaluation either by computed tomography (CT) or rigid

laryngoscopy is essential for diagnosis. Once the diagnosis is

confirmed, treatment may require tracheal reconstruction.

Tracheal Granulation

Tracheal granulation may cause bleeding or occlusion

of the tracheostomy tube if a flap of granulation tissue is

elevated on exhalation. Granulation tissue may mimic tra-

cheal stenosis. This complication is often easily treatable with

removal of the tracheostomy tube. Occasionally, resection of

the granulation tissue is necessary.

Vocal Cord Dysfunction

Vocal cord dysfunction occurs in less than 2%, whereas

voice changes, including hoarseness and weakness, occur in

10 to 20% of patients. In cases of bilateral vocal cord paraly-

sis, a tracheostomy is necessary until the paralysis resolves.

Most complaints of vocal changes are considered minor by

patients.

Tracheoesophageal Fistula

Tracheoesophageal fistula occurs in less than 0.3% of

patients following tracheostomy. It can occur if a puncture

is made into the posterior trachea or a cuff erodes into

the esophagus. The combination of a a tracheostomy tube

and a stiff nasogastric tube in the esophagus increases the risk

of this complication. Symptoms include aspiration and

persistent cuff leak around the tracheostomy. Persistent tra-

cheobronchitis or pneumonia may also be present. A swallow

study with the cuff deflated or CT and panendoscopy

will demonstrate the defect. Definitive therapy is usually

necessary.

Tracheoinnominate Fistula

Tracheoinnominate fistula has a reported incidence of

0.4 to 4.5% and presents initially as sentinel bleeding that

usually develops within the first month following the proce-

dure. Mortality between 50 and 75% has been reported. Risk

factors include a low (below the third ring) tracheostomy,

caudal migration from leverage on the tube, and the presence

of a more cephalad-coursing innominate artery. An attempt

to visualize the site of bleeding should be undertaken. If

hemorrhage is significant, hyperinflate the cuff and try to

compress the vessel against the posterior sternum. If this

is unsuccessful, oral intubation should be performed. The

tracheostomy tube must be removed and replaced with

digital pressure through the tracheostomy to tamponade the

bleeding en route to the OR. Often the upper extremity of

the person responsible for maintaining digital pressure is

prepared into the operative field in preparation for median

sternotomy

Tracheocutaneous Fistula

Rarely, the tracheostomy wound does not completely close

in 24 to 48 hours. Granulation tissue may be treated topicallywith silver nitrate with good success. Occasionally, the

tracheostomy site must be surgically closed in layers for a

nonhealing tracheocutaneous fistula.

Scar

Cosmetic results vary following tracheostomy. Ten to 15%

of patients consider scar revision of the tracheostomy site.

Financial Disclosures: None Reported.

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Additional Reading

American College of Surgeons Committee onTrauma. Airway and ventilatory manage-ment. In: Advanced trauma life support fordoctors, student edition. Chicago, IL: Ameri-can College of Surgeons; 2008. p. 2553.

Clech C, Albert C, Vincent F, et al. Tracheosto-my does not improve the outcome of patients,requiring prolonged mechanical ventilation: apropensity analysis. Crit Care Med 2007;35:1358.

Griffiths J, Barber VS, Morgan L, Young JD.Systematic review and meta-analysis ofstudies of the timing of tracheostomy in adultpatients undergoing artificial ventilation.BMJ 2005;330(7500):124350.

Grover A, Robbins J, Bendick P, et al. Open ver-

sus percutaneous dilatational tracheostomy:

efficacy and cost analysis. Am Surg 2001;67:

297302.

Marx WH, Ciaglia P, Graniero KD. Some

important details in the technique of percuta-

neous dilatational tracheostomy via the

modified Sledinger technique. Chest 1996;

110:7626.

Pratt LW, Ferlito A, Rinaldo A. Tracheostomy.Historical review. Laryngoscope 2008;1188:

1597606.

Silva B, Andriolo R, Saconato H, Atalla A. Early

versus late tracheostomy for critically ill

patients. Cochrane Database and Systematic

Reviews 2009;(4).

Silvester W, Goldsmith D, Uchino S, et al.

Percutaneous versus surgical tracheostomy:

a randomized controlled study with long

term follow up. Crit Care Med 2006;34:

214552.

Acknowledgments

Figures 1 through 5 Thom Graves

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