Tracheostomy: indications and complications

Tracheostomy

1. Description of the problem

History of tracheostomy

Tracheotomy is one of the oldest documented surgical procedures performed, with records of its performance by the ancient Egyptians and Hindus. The first appearance in the medical literature of the tracheostomy procedure is found in the medical text Epitome written by Paul of Aegina (625-690 BC).

The next substantial evidence of its use does not occur until the 16th century, when the Italian surgeon Antonia Musa Brasavola is credited with reintroducing the procedure. This was followed by the first reported percutaneous tracheostomy approach in 1626, when Sanctorio Sanctorius described his use of a “ripping needle” to introduce a silver cannula into the tracheal lumen, followed by removal of the needle.

The diphtheria epidemic of 1833 led to widespread use and acceptance of tracheotomy as a surgical procedure; however, its high operative mortality led to its limited use otherwise. Further acceptance occurred during the polio epidemic in the 1930s in which it was advocated as an effective means for bronchopulmonary toilet and long-term mechanical ventilatory support.

In 1967, Toye and Weinstein first used the Seldinger technique to safely introduce a cannula into the tracheal lumen. The technique was further refined by Pasquale Ciaglia in 1985 in what has now become one of the most popular techniques for percutaneous dilatational tracheostomy (PDT).

Tracheotomy timing

Tracheotomy has often been advocated as part of the long-term ventilator weaning process and has also found its way into evidence-based guidelines for weaning. In 2001, the American College of Chest Physicians guidelines for weaning and discontinuing ventilatory supports encourages early tracheostomy after patient stabilization if the patient needs prolonged mechanical ventilation more than 3 weeks after intubation.

Data looking at early versus late tracheostomy appears to favor early tracheostomy. In a randomized controlled trial by Rumbak et al, comparing early (less than 48 hours) versus late (14-16 days) tracheotomy in patients with respiratory failure, the early group had a significant decrease in mortality, pneumonia and ventilator days.

Terragni et al randomized 419 patients to receive early (6-8 days) vs late (after 13-15 days) tracheotomy with a primary endpoint of incidence of ventilator-associated pneumonia and secondary endpoints of ventilator-free days, ICU-free days and 28-day survival.

There was a trend toward a decrease in ventilator-associated pneumonia and ICU days but no survival benefit. Other systematic reviews have found decreased ventilator days, ICU length of stay and incidence of ventilator-associated pneumonia.

To date, there are not enough well-designed studies to allow for a clear consensus or guidelines in regard to the timing of tracheostomy. Unfortunately, survival data for patients receiving early versus late tracheostomy is conflicting. However, the impact of other factors in ICU care of these patients is evident. Improved patient comfort, decreased need for sedatives, increased ability to communicate with enhanced nursing care have all been shown to be improved by tracheostomy placement.

Selection of patients who should undergo tracheostomy placement is a complex medical decision and as such needs to be individualized for each patient.

Evaluation for tracheotomy

Tracheal anatomy

Basic airway anatomy as well as a thorough understanding of the surrounding vasculature and vital structures is required for safe and effective performance. The trachea is an unpaired centrally located superficially in the mid-neck, plunging dorsally as it enters the mediastinum. The average length of the adult trachea is 11cm (range 10 to 13 cm). Along the course of the trachea there are 18 to 22 C-shaped semicartilaginous rings.

There are several structures that lie anterior to the trachea that should be identified prior to tracheotomy. The thyroid isthmus is located between second and third tracheal rings, the innominate artery most often crosses the anterior trachea in an oblique fashion distal or inferior to the third tracheal ring and the aortic arch crosses above the carina. The recurrent laryngeal nerves lie in close proximity to the trachea within the tracheoesophageal groove.

The blood supply to the cervical trachea enters posteriolaterally from the inferior thyroid artery. As a result, when performing a tracheostomy, dissection along the anterolateral plane is often the safest way to avoid vascular injury. With the more recent widespread availability of ultrasound in intensive care units (ICUs), some providers now place an ultrasound probe in the intended area of dissection to confirm the absence of any significant vasculature.

The cricoid cartilage in the larynx has the only complete cartilaginous ring and has a membranous attachment to the first tracheal ring. The posterior wall of the trachea or membranous trachea is composed of a flexible sheet of fibroelastic tissue between the ends of the tracheal rings. The rigidity of the anterior two thirds of the trachea with the flexibility of the poster one third allow for a great range of flexibility and stability to withstand the forces of forced expiration and coughing, but also allow for continuous airway patency.

Indications for percutaneous tracheotomy

• Enhancement of patient comfort during prolonged weaning efforts

• Mechanical ventilation estimated or anticipated to be longer than 7 days

• Failed extubation

• Relief of upper airway obstruction

• Secretion management

• Need for bedside procedure secondary to increased risk of patient transfer to operating room

Contraindications for percutaneous tracheotomy

Absolute

• Absence of informed consent

• Active site infection

• Uncorrectable bleeding diathesis

• Operator inexperience

Relative

• Difficult airway

• Morbid obesity

• High ventilatory/positive end-expiratory pressure (PEEP) requirements

• History of neck surgery

• Emergent procedure

As with all procedures, the first major contraindication is the performance of the procedure by an inexperienced provider without appropriate supervision or guidance. Neck anatomy should be carefully examined for abnormal vasculature, which can increase the risk of vessel injury or fistula formation. If these anatomic variants are identified, patients should be referred for open surgical tracheostomy to allow dissection and isolation of the surrounding vasculature.

Although the overall risks during PDT are small, preoperative ultrasound assessment offers the potential to further reduce these rare complications.

Special situations

Cervical spine injury

Although cervical spine injury has traditionally been considered a contraindication to percutaneous dilational tracheostomy, more recent data have called this practice into question. Thirty-eight consecutive PDT procedures were safely and successfully performed on patients with documented cervical spine fractures.

Recent neck or mediastinal surgery has also previously been considered a relative contraindication, but several recent studies have demonstrated successful percutaneous tracheostomy placement in this population as well.

Repeat tracheotomy

Initially, the percutaneous approach was thought to be contraindicated in those patients requiring repeat tracheotomy. Meyer et al first reviewed 14 consecutive patients with a previous tracheotomy between 8 days and 10 years before undergoing their repeat procedure. All patients underwent a percutaneous approach, making the incision at the site of the initial scar, with no evidence of periprocedural complications.

A similar study by Yilmaz et al described 12 consecutive patients undergoing repeat tracheotomy via the percutaneous approach. All 12 were successful with no one requiring conversion to a surgical tracheostomy. These reports suggest that prior tracheostomy should not be used as definitive exclusion criteria for PDT.

Tracheotomy in the obese patient

Morbid obesity has also been considered a contraindication to bedside PDT; however, in experienced hands it appears safe and effective. Obesity can make the percutaneous approach more challenging with distortion of anatomic landmarks, increased depth of predilatation dissection and limited availability of customized tubes.

A retrospective review of 1062 tracheotomies was performed at a single institution over 4 years by Heyrosa et al demonstrating the safe performance of PDT in 89 patients with a BMI > 35. There were no complication differences between percutaneous versus surgical approarch in this cohort of morbidly obese patients. Other, smaller studies have essentially demonstrated these same findings.

Extra planning is critical in this patient population and the operator should have multiple tracheostomy tubes available to ensure the most appropriate sizing and fit.

3. Diagnosis

Tracheal stenosis in PDT

Clinically significant tracheal stenosis has been shown to occur after both endotracheal intubation and tracheostomy placement with an estimated incidence of 1.8%. This iatrogenic stenosis appears to often occur around the level of the tracheal stoma or the tube cuff. In an autopsy study of 21 patients undergoing either surgical tracheotomy or PDT, laryngotracheal specimens were collected. Though PDT was associated with a higher incidence of cartilage fractures at the introduction site, none of the patients in either group developed clinically significant tracheal stenosis.

Surgical versus percutaneous tracheotomy

Elective tracheostomy in the ICU performed at the bedside using the PDT technique offers several advantages over surgical tracheotomy (ST). In general, there are limited complications of bedside PDT in the ICU, which either compare or are less than those associated with surgical tracheotomy performed either in the operating room or at the bedside. Most studies have shown there is no significant difference in bleeding risk between PDT and ST.

Using the PDT approach there are less clinically significant wound infections observed most likely due to the limited tissue manipulation when compared to ST. A randomized controlled trial with long-term follow-up by Silvester showed no difference in short- or long-term complications between the groups. In a recent study by Seder et al, clinical outcomes of PDT performed by neurointensivists versus ST were compared retrospectively with no significant difference in complications and a significant cost savings in the PDT arm.

In a large study, Moe et.al found an overall procedure related-mortality rate of only 0.4%. Major hemorrhage and pneumothorax occurred in 0.6%, wound infection in 0.8%, paratracheal insertion in 0% to 6%, accidental decannulation in 0% to 2%, and minor hemorrhage in up to 3% with no significant difference in surgical approach. In a meta-analysis by Freeman et al, 115 patients undergoing PDT and 121 ST found no significant difference in the overall operative complication rate.

Although most studies quote a time advantage favoring PDT, it is likely the majority of time savings is due to decreased patient preparation time. Although this is no clinical significance from a procedural standpoint, it does factor into cost savings and operating time budgetary considerations.

The question as to whether performing tracheotomy at the bedside will limit the risk of patient transportation has also been studied. Massick et al randomized 100 patients to PDT or ST performed at the bedside in the ICU and compared the results to an additional 64 patients who had ST performed in the OR. The incidence of postoperative complications did not differ between the bedside and OR groups.

PDT in this study was associated with a small reduction in operative bleeding, and postoperative complications were significantly less common in the PDT group. The study also confirmed the reduced procedural time of PDT compared with ST (20.1 minutes vs 41.7 minutes), and also found that PDT charges were significantly less ($1,569 vs $3,172), though the majority of this savings was due to the lack of OR charges associated with PDT.

Use of bronchoscopy during percutaneous tracheotomy

The use of bronchoscopic visualization during PDT has been proposed as a method to reduce the complication rates during PDT. These benefits include ensuring midline placement of the needle and guide wire, safe withdrawal of the endotracheal tube and avoidance of paratracheal placement or injury to the posterior tracheal wall. Potential complications associated with the use of bronchoscopy during PDT include hypercapnia and damage to the bronchoscope from the introducer needle.

To date there are no randomized trials comparing the use of the bronchoscope during PDT. A study using bronchoscopic visualization during PDT in obese critically ill patients showed no difference in the procedure performed in standard patients with bronchoscopic visualization suggesting a safety benefit in this subset population. We suggest the use of bronchoscopy during PDT for the reasons above but further studies are needed to better define its role in PDT.

Operative evaluation and technique

Preoperative evaluation

The use of the PDT technique has allowed for increasing numbers of tracheostomy procedures to be performed in the ICU. However, it remains critical that all patients being considered for tracheotomy undergo the same pre- and perioperative evaluation and treatment. Centers should attempt to institute a program standardizing practice throughout the institution and thus limit complications. At a minimum, centers performing bedside PDT should have a checklist available for the preprocedure assessment of patients. Many of these initiatives can be accomplished with a mutlidisciplinary approach involving otolaryngology, anesthesiology, general surgery, and interventional pulmonology, along with the help of other advanced practitioners (nurse practitioners, physician assistants, etc). Although a bedside procedure, a careful history and physical examination are required to help prevent complications. PDT appears to remain relatively safe in coagulopathic patients. We often recommend PT/PTT less than 1.5. In uremic patients, we administer DDAVP prior to our incision. There have been no randomized studies reviewing the bleeding risk of patients on clopidogrel, but given the presumed risk in the setting of an elective procedure, if there are no contraindications to holding clopidogrel, we suggest holding 5 to 7 days prior to the procedure. Although there are no trials reviewing the bleeding risk of aspirin, anecdotally, there does not seem to be an increased risk and as such we do not hold aspirin prior to PDT.

Operative technique

Once the decision is made to proceed with PDT, we employ a multidisciplinary model. A detailed preoperative assessment is made by a nurse practitioner on the tracheostomy team followed by a review of data and assessment by the anesthesiologist and operating surgeon. The anesthesiologist is positioned at the head of the bed with a free-flowing IV and airway management tools. Once consent is confirmed and a time out is performed, the patient is sedated and paralyzed by the anesthesiologist. An ICU nurse is charged with monitoring of vital signs, and a respiratory therapist preoxygenates the patient with a FiO2 of 1.0 and controls the ventilator during the procedure with a back-up rate as the patient will be paralyzed. A bronchoscopy is then performed with a therapeutic aspiration of any retained secretions prior to the start of the procedure. Hyperextension of the neck is then achieved by placing a rolled towel under the patient’s shoulders, which maximally increases the distance between the tracheal rings and brings the larynx and trachea to a more superior position. The skin is then prepped with chlorhexidine, and a sterile field is created with a fenestrated drape. Anatomic landmarks are identified that include the thyroid cartilage, the cricothyroid membrane, the cricoid cartilage and the tracheal rings as well as a palpation or ultrasound assessment for overlying vasculature. The preferred entry site is between the first and second, or second and third tracheal rings. Studies recommend avoidance of the cricothyroid membrane to decrease the incidence of tracheal stenosis. We utilize the Blue Rhino Percutaneous Tracheotomy kit at our institution, and the following directions will be as such; however, the other available tracheostomy kits are somewhat similar. The skin at the entry site should be infiltrated with up to 5cc of 1.5% lidocaine with epinephrine. The epinephrine allows preferential vasoconstriction of the surrounding tissue to limit bleeding during the procedure. A 1.5 cm vertical incision is made through the skin and subcutaneous fascia and the soft tissue is bluntly dissected. Our standardized approach includes withdrawing the endotracheal tube to a position just inferior to the vocal cords under direct laryngoscopy and/or bronchoscopic visualization by the anesthesiologist. After bronchoscopic confirmation that the endotracheal tube lies superior to the stomal insertion site and transillumination is verified through the incision site, the tracheal rings are re-palpated and the seldinger needle is introduced into the midline trachea. The needle should be visualized to enter the trachea in the midline and avoid puncture of the posterior wall of the trachea. The insertion angle of the introducer needle should remain perpendicular to the trachea and aspiration of air as well as direct bronchoscopic visualization confirms the proper location of the needle in the lumen of the trachea.A J-tipped guide wire is then advanced in the direction of the carina under vision and the needle is removed. The tract is initially dilated with a 14-French dilator. This small dilator is then removed with the J wire remaining in place. A single tapered dilator loaded on a stiffening catheter is then utilized to dilate the stoma. The dilator is removed, leaving the stiffening catheter and J wire in place, and the tracheostomy tube is then inserted on a separate obturator and the cuff is inflated. Proper placement is confirmed again by direct visualization both above and through the tracheostomy tube. Adequate tidal volumes and absence of a cuff leak are also confirmed at the completion of the procedure in order to confirm that a properly sized and functioning tracheostomy is in place. After confirmation that the tracheostomy tube is in correct position and functioning correctly the endotracheal tube is removed by the anesthesiologist. The tracheostomy tube is secured with suture or staples and a cloth tie such that one finger can be placed between the strap and the skin. It is crucial during this step that one operator or assistant always hold the tracheostomy tube as it is being secured to avoid accidental decannulation. If decannulation occurs at any time before a mature tracheotomy tract has developed, intubation with an endotracheal tube placed distal to the tracheal stoma should be performed. Only then should the tracheal stoma be re-examined and in a controlled manner though be given to replacing the tracheostomy tube. Postoperatively, given the use of bronchoscopic guidance and visual confirmation, we do not perform a routine chest radiograph. A study by Kumar et al prospectively reviewed 345 PDT procedures with a postoperative chest radiograph and found that it did not reveal any unexpected radiographic abnormalities.

Complications

Acute

• Aspiration pneumonia

• Tracheal ring rupture or herniation

• False lumen insertion

• Unplanned extubation

• Pneumothorax

• Pneumomediastinum

• Tracheal wall laceration

• Bleeding

• Local site or deep Infection

• Cardiac arrest

Delayed

• Tracheoinnominate artery fistula

• Tracheoesophageal or tracheoinnominate artery fistula

• Mucus impaction

• Cellulitis

• Ventilator-associated pneumonia

• Aspiration (inadequate cuff pressures)

• Mucosal wall ischemia/necrosis (related to high cuff pressure)

• Granulation tissue formation

• Tracheomalacia

• Tracheal stenosis

Pathophysiology

PDT kits

There are several PDT kits available in today’s market. The operator should be well versed in the available techniques used to obtain tracheal access but in general it is recommended that operators obtain competence using one technique initially based on their level of training. Currently the Ciaglia Blue Rhino kit remains one of the most widely used PDT kits in North America. The Blue Rhino used a tapered dilator with a hydrophilic coating to allow single step dilation.

Other kits include the Portex^® UniPerc^TM kit, which is designed in a similar fashion to the Blue Rhino, the Ciaglia Blue Dolphin, which utilizes a balloon dilatational technique, the Portex^® Griggs forceps technique kit and the Rusch Percutwist approach, which uses a screw-like device to initiate the stoma. The PDT procedure is described in more detail below for the Blue Rhino, Blue Dolphin and the UniPerc^TM kits.

The two most popular kits for PDT are the Ciaglia Blue Rhino Percutaneous Tracheotomy Introducer Tray and the Portex^® UniPerc^TM Kit. Both kits use a seldinger technique followed by a single dilator for stomal entry and tracheostomy tube placement. The desired tracheostomy tube must be obtained separately or can be ordered with the introducer kit. Obese patients may require a tracheostomy tube with extra horizontal length, which can be achieved by either technique.

The Blue Dolphin also uses a modified seldinger technique, but the dilation is performed in a single-step fashion with the tracheostomy tube preloaded, potentially reducing procedure time. Although available on the market, the Portex^® Griggs forcep technique kit and the Rusch Percutwist approach have been largely replaced by the other techniques described above secondary to ease of the procedure as well as potential concerns for higher complication rates.

Special considerations for nursing and allied health professionals.

Credentialing

PDT is a relatively simple procedure and has an excellent track record of safety. It is commonly performed bedside in the ICU by nonsurgeons. The operator should be appropriately trained in advanced airway management including emergent airway techniques. Formal training prior to performing PDT is essential, and should begin with hands-on instruction by an expert, and supervision by an experienced operator is encouraged, especially when performing the first several cases.

Although complications are rare, a multidisciplinary team is strongly encouraged when embarking on starting a PDT program to aid in the necessary communication and collaboration between subspecialists if and when complications occur. The most recent guidelines published by the American College of Chest Physicians suggest that 20 supervised procedures, followed by at least 10 per year are required to perform and maintain competency in PDT.

What's the evidence?

Heffner, JE. “Tracheotomy application and timing”. Clin Chest Med. vol. 24. 2003. pp. 389-98. (Review article on appropriate selection and timing of tracheostomy candidates.)

Mansharamani, NG, Koziel, H, Garland, R. “Safety of bedside percutaneous dilational tracheostomy in obese patients in the ICU”. Chest. vol. 117. 2000. pp. 1426-9. (Study demonstrating the safety of performing tracheostomy in those obese patients that most would have considered as candidates for open surgical tracheostomies based on neck anatomy and obesity.)

Meyer, M, Critchlow, J, Mansharamani, N. “Repeat bedside percutaneous dilational tracheostomy is a safe procedure”. Crit Care Med. vol. 30. 2002. pp. 986-8. (Small study demonstrating the safety of repeat PDT in those patients with previous tracheostomy.)

Zagli, G, Linden, M, Spina, R. “Early tracheostomy in intensive care unit: a retrospective study of 506 cases of video-guided Ciaglia Blue Rhino tracheostomies”. J Trauma. vol. 68. 2010. pp. 367-72. (Large retrospective review of patients undergoing early or late tracheostomy. No difference was found in overall hospital stay or mortality between groups, however, the early tracheostomy group spent less time on the ventilator and less time in the ICU.)

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