Overview
Definition:
An open tracheostomy is a surgical procedure that creates a direct opening into the trachea (windpipe) through the neck
This opening, or stoma, allows for the insertion of a tracheostomy tube, bypassing the upper airway to facilitate breathing
It is typically performed electively or emergently when the upper airway is obstructed, or when prolonged mechanical ventilation is anticipated.
Epidemiology:
Tracheostomy rates vary significantly based on patient population, hospital setting, and indications
In critical care settings, it is a common procedure for patients requiring extended mechanical ventilation, with incidence rates reported between 4% to 22% of ICU admissions
Elective tracheostomies are performed for a variety of congenital and acquired conditions affecting the airway.
Clinical Significance:
Open tracheostomy is a life-saving intervention in cases of severe upper airway obstruction or the need for long-term mechanical ventilation
It provides a secure and stable airway, facilitates secretion management, reduces the risk of ventilator-associated pneumonia compared to prolonged endotracheal intubation, and can improve patient comfort and communication
Understanding its indications, techniques, and potential complications is crucial for surgical and critical care physicians.
Indications
Absolute Indications:
Acute or chronic upper airway obstruction secondary to trauma, tumor, infection (e.g., epiglottitis, severe laryngitis), congenital anomalies, or foreign body
Complete or near-complete obstruction of the glottis or supraglottic larynx.
Relative Indications:
Need for prolonged mechanical ventilation (typically > 7-10 days) as an alternative to tracheostomy tube, severe tracheobronchial secretions that cannot be managed by endotracheal suctioning, facilitation of weaning from mechanical ventilation, improved patient comfort and mobility, and to prevent laryngeal injury associated with prolonged endotracheal intubation.
Contraindications:
Absolute contraindications are rare but include complete tracheal transection distal to the intended stoma site and inability to identify landmarks due to severe neck swelling or deformity
Relative contraindications include coagulopathy, morbid obesity, and severe cervical spine instability that may preclude safe positioning.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination to identify airway anatomy, potential difficulties, and comorbidities
Assessment of coagulation status is essential
Discuss risks, benefits, and alternatives with the patient and/or family.
Informed Consent:
Detailed discussion of the procedure, potential complications (bleeding, infection, pneumothorax, vocal cord injury, stomal stenosis), and post-procedure care
Obtain written informed consent.
Equipment Preparation:
Ensure availability of appropriate tracheostomy kit, tracheostomy tubes of various sizes, tracheostomy ties or Velcro holders, suction apparatus, humidification, light source, and emergency airway equipment (e.g., bronchoscope, endotracheal tubes, cricothyroidotomy kit).
Anesthesia Considerations:
General anesthesia with endotracheal intubation is typically preferred for elective procedures to ensure airway control and immobility
Local anesthesia with sedation may be used in select emergent or awake cases, but carries higher risks
Secure the endotracheal tube in a position that allows for tracheostomy tube insertion.otracheal intubation is typically preferred for elective procedures to ensure airway control and immobility
Local anesthesia with sedation may be used in select emergent or awake cases, but carries higher risks
Secure the endotracheal tube in a position that allows for tracheostomy tube insertion.
Procedure Steps
Patient Positioning:
Supine position with the neck hyperextended using a shoulder roll or sandbag to bring the trachea anteriorly and improve visualization of landmarks
Ensure adequate head support.
Landmark Identification:
Palpate the cricoid cartilage, which is the most inferior part of the larynx and a reliable landmark
The tracheostomy stoma is typically created 1-2 cm inferior to the cricoid cartilage, between the second and fourth tracheal rings.
Skin Incision:
A transverse or vertical skin incision is made in the midline of the neck over the identified landmark
Vertical incisions offer better exposure in obese patients or those with anterior neck masses, but may be associated with more scar tissue
Transverse incisions are often cosmetically preferred.
Dissection To Trachea:
Dissect sharply through subcutaneous tissue and strap muscles in the midline, retracting the thyroid isthmus if encountered superiorly or dividing it if necessary
Carefully identify and protect the recurrent laryngeal nerves and surrounding vascular structures
Use of a pre-tracheal fascial flap can help secure the stoma and prevent subcutaneous emphysema.
Tracheal Entry And Tube Insertion:
Once the trachea is identified, a vertical or cruciate incision is made into the tracheal lumen, typically between the second and fourth rings
Avoid entering too high (risk to vocal cords) or too low (risk to carina)
Immediately insert the appropriately sized tracheostomy tube, advancing it into the tracheal lumen
Secure the tube with sutures to the skin and/or a tracheostomy tie or Velcro holder.
Confirmation And Securing:
Confirm correct placement by observing bilateral chest rise, auscultating breath sounds, and checking for end-tidal CO2
If intubated, the endotracheal tube can be withdrawn below the stoma site or removed once the tracheostomy tube is securely in place and functional
Inflate the cuff and secure the tube to prevent dislodgement.
Postoperative Care
Immediate Monitoring:
Continuous monitoring of vital signs, oxygen saturation, and respiratory status
Assess for bleeding, subcutaneous emphysema, pneumothorax, and airway patency
Suctioning of secretions is essential.
Tracheostomy Tube Care:
Regular cleaning of the inner cannula (if present), stoma site care to prevent infection and skin breakdown, and regular humidification of inspired air
Humidification is critical to prevent mucus plugging.
Airway Suctioning:
Perform suctioning as needed, using sterile technique
Suction only when indicated by signs of airway compromise or secretions
Over-suctioning can cause mucosal trauma and hypoxia.
Patient Education And Rehabilitation:
Educate the patient and family on tracheostomy care, suctioning, emergency procedures, and communication strategies
Speech therapy may be initiated for swallowing evaluation and communication device recommendations
Nutritional support is also important.
Complications
Early Complications:
Bleeding (most common, can be severe if anterior jugular veins or thyroid vessels are injured)
Pneumothorax or hemothorax due to inadvertent pleural entry
Surgical emphysema (air dissecting into subcutaneous tissues) due to poor seal or tracheal entry
Tube obstruction by blood clots or mucus
Accidental dislodgement of the tracheostomy tube
Vocal cord injury or granuloma formation
Injury to adjacent structures (esophagus, recurrent laryngeal nerve).
Late Complications:
Tracheal stenosis at the stoma site or cuff site
Tracheomalacia (weakening of tracheal cartilage)
Tracheoesophageal fistula
Tracheocutaneous fistula (persistent opening after decannulation)
Granuloma formation at the stoma or vocal cords
Persistent tracheostomy dependence
Difficulty with decannulation
Increased risk of aspiration.
Prevention Strategies:
Meticulous surgical technique to identify and protect vital structures
Accurate landmark identification
Proper tracheostomy tube size and type selection
Securing the tube adequately
Aggressive suctioning and humidification post-operatively
Regular stoma care
Prompt recognition and management of any signs of complication
Use of a pre-tracheal fascial flap can reduce emphysema risk.
Key Points
Exam Focus:
High-yield indications for open tracheostomy in adults (airway obstruction, prolonged ventilation)
Critical landmarks (cricoid cartilage, tracheal rings)
Most common early and late complications
Principles of post-operative airway management and stoma care
Distinction between open and percutaneous tracheostomy.
Clinical Pearls:
Always have a tracheostomy tube one size smaller and a Trousseau dilator readily available at the bedside for at least the first 72 hours post-procedure
Hyperextend the neck significantly to expose the trachea
Identify the thyroid isthmus and decide whether to retract or divide it early
Confirm tube placement with capnography
Adequate humidification is paramount for preventing tube occlusion.
Common Mistakes:
Failure to adequately hyperextend the neck
Inadequate landmark identification leading to incorrect stoma site
Injury to adjacent structures (e.g., recurrent laryngeal nerve, esophagus)
Poorly secured tube leading to dislodgement
Inadequate suctioning and humidification causing tube blockage
Ignoring signs of subcutaneous emphysema or pneumothorax.