A tracheotomy or a tracheostomy is an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather than through the nose and mouth. The term “tracheotomy” refers to the incision into the trachea (windpipe) that forms a temporary or permanent opening, which is called a “tracheostomy,” however; the terms are sometimes used interchangeably.

Reasons for a tracheostomy

A tracheotomy is usually done for one of three reasons:

to bypass an obstructed upper airway;
to clean and remove secretions from the airway;
to more easily, and usually more safely, deliver oxygen to the lungs.

All tracheostomies are performed due to a lack of air getting to the lungs. There are many reasons why sufficient air cannot get to the lungs.
Airway Problems That May Require a Tracheotomy

Tumors, such as cystic hygroma
Laryngectomy
Infection, such as epiglottitis or croup
Subglottic Stenosis
Subglottic Web
Tracheomalacia
Vocal cord paralysis (VCP)
Laryngeal injury or spasms
Congenital abnormalities of the airway
Large tongue or small jaw that blocks airway
Treacher Collins and Pierre Robin Syndromes
Severe neck or mouth injuries
Airway burns from inhalation of corrosive material, smoke or steam
Obstructive sleep apnea
Foreign body obstruction

Lung Problems That May Require a Tracheostomy

Need for prolonged respiratory support, such as Bronchopulmonary Dysplasia (BPD)
Chronic pulmonary disease to reduce anatomic dead space
Chest wall injury
Diaphragm dysfunction

Other Reasons for a Tracheostomy

Neuromuscular diseases paralyzing or weakening chest muscles and diaphragm
Aspiration related to muscle or sensory problems in the throat
Fracture of cervical vertebrae with spinal cord injury
Long-term unconsciousness or coma
Disorders of respiratory control such as congenital central hypoventilation or central apnea
Facial surgery and facial burns
Anaphylaxis (severe allergic reaction)

How a tracheostomy is performed

Surgical Anatomy

The superior thyroid notch, cricoid and suprasternal notch usually can be easily palpated through the skin. The cricothyroid space can be identified by palpating a slight indentation immediately below the inferior edge of the thyroid cartilage. Cricothyroid arteries traverse the superior aspect of this space on each side and anastomose near the midline.
The innominate artery crosses from left to right anterior to the trachea at the superior thoracic inlet. Its pulsations can be palpated and occasionally seen in the suprasternal notch especially in case of a high riding vessel, representing a contraindication for a bedside percutaneous or open tracheostomy.
The isthmus of the thyroid gland lies across the 2nd to 4th tracheal rings and must be dealt with in any procedure at or around the upper trachea.

Indications for PDT

They are the same as a routine open operative tracheostomy with particular attention to contraindications.¹

Contraindications for PDT

Absolute:
Emergent tracheostomy ( i.e., securing emergent airway) in any patient population, infants and children (<15 years)
Relative Surgical Contraindications: Poor neck landmarks, neck mass (e.g. goiter), high innominate or pulsating vessels, previous neck surgery, limited neck extension, severe coagulation (uncorrected)
Relative Anesthetic Contraindications:
High PEEP (>18 cm), high airway pressure (>45 cm), high FiO2 (80%), retrognathic mandible with a limited view of the larynx on laryngoscopy

Preparation for Tracheostomy

Once the decision to perform a tracheostomy has been made, the surgeon must determine if the patient is a good candidate for the surgery and obtain written informed consent. In addition, the range of motion of the neck needs to be assessed. The tracheostomy team, including the surgeons and anesthesiologists need to discuss the entire sequence and alternatives to the procedure. All equipment must be available and functioning properly.

Equipment

A regimented approach to preparation and performance of the procedure has been shown to significantly reduce the incidence of procedural complications⁴.
Our approach includes the following equipment and protocols:

We routinely use Cook Blue Rhino single dilator kit and videobronchoscopy to perform the procedure.
The following must be available:
- An attending anesthesiologist must be present for maintenance of airway, provision of intravenous sedation and performance of bronchoscopy.
- An intubation roll and a cricoid hook.
- Open tracheostomy set.

Technique

Watch a tracheostomy (24 MB Windows Media file)

The technique described here is based on Seldinger’s principle ². The technique we use was first described and later modified by Ciaglia ³. The use of bronchoscopy was first introduced by Marelli et al and has subsequently been adopted by many centers ^{4, 5}.
Positioning

The patient’s neck is extended over a shoulder roll (unless there is a contraindication).
The anesthesiologist stands at the head end of the bed and under direct laryngoscopy positions the endotracheal tube (ETT) so that the cuff is midway at the vocal cord level.

Incision

We routinely inject the skin with 1% lidocaine with 1:100,000 epinephrine solution.
A horizontal or vertical incision centered on the inferior border of the cricoid cartilage may be used. We routinely use a 3-4 cm vertical incision.

Placement of Introducer Needle

A minimal dissection is performed onto the pretracheal tissue in order to push the thyroid isthmus downward.
The larynx is stabilized and pulled cephalad with the operator’s left hand.
A bronchoscopy is then performed and the light reflex is used to select the best site for the introducer needle.
Placing the needle at the inferior edge of the light reflex, the tip of the needle is directed caudad into the tracheal lumen avoiding the posterior tracheal wall at all cost.

Introduction of Guide Wire, Stylet and Initial Tract Dilatation The needle is withdrawn while keeping the cannula in the tracheal lumen. A J-tipped guide wire is then place under vision. The stylet is then placed with the safety ridge directed towards the tip of the wire. The tract is then dilated with the 8 FR dilator.
Dilatation with the Blue Rhino Dilator The Blue Rhino dilator is loaded on the stylet with the tip resting on the safety ridge. The dilator is moved in and out to optimally dilate the tissue between the skin and the tracheal lumen. The Blue Rhino dilator is never advanced beyond the point where 40 FR mark disappears below the skin level.
Placement of the Tracheostomy Tube

A tracheostomy tube is loaded onto the dilator
- Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to the 26 FR dilator
- Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the 28 FR dilator
The dilator is then loaded on the safety ridge of the stylet and placed into the tracheal lumen under direct visualization.

Confirmation of Placement
The bronchoscope is withdrawn from the ETT and introduced via the tracheostomy tube. The placement is confirmed by visualizing the carina.
Securing the Tube
We routinely secure the tube with 2 sutures of 2-0 nylon on each side of the flange. In addition, a tracheostomy tape is used to hold the tube in place. A flexible extension tube is used to connect the tube to the ventilator circuit to avoid undue movement of the tube in the immediate postoperative period.

Postoperative Consideration

A chest X-ray is not routinely required as long as the entire procedure was done under direct visualization and there were no adverse events intraoperatively⁶. The postoperative care is same as for the open procedure.
The tract between the skin and the tracheal lumen takes a little longer (10-14 days) to mature as there is no formal layer by layer dissection involved. We, therefore, perform the first tube change on Day 10-12 postoperatively.

Bedside Percutaneous Dilational Tracheostomy (PDT)

Overview

Watch video of procedure

Percutaneous dilational tracheostomy (PDT), also referred to as bedside tracheostomy, is the placement of a tracheostomy tube without direct surgical visualization of the trachea. This is considered a minimally invasive, bedside procedure that may be easily performed in the intensive care unit or at the patient’s bedside – with continuous monitoring of the patient’s vital signs.
Two critically important preoperative criteria for PDT are:

The ability to hyperextend the neck
Presence of at least 1 cm distance between cricoid cartilage and suprasternal notch ensuring that the patient will be able to be reintubated in case of accidental extubation

Patients should not be considered for this procedure if they are:

Children (younger than 12 years of age)
Obese
Patients with severe coagulopathies

Techniques

There are several different systems and approaches for PDT. Following are brief descriptions:

Ciaglia (method used at Hopkins)
With this technique, there is no sharp dissection involved beyond the skin incision. The patient is positioned and prepped in the same way as for the standard operative tracheostomy. General anesthesia is administered and all steps are done under bronchoscopic vision.

Procedure:
Skin incision is made and the pretracheal tissue is cleared with blunt dissection.
Endotracheal tube is withdrawn enough to place the cuff at the level of the glottis.
Endoscopist places the tip of the bronchoscope such that the light from its tip shines through the surgical wound.
Operator enters the tracheal lumen below the second tracheal ring with an introducer needle.
The tract between the skin and the tracheal lumen is then serially dilated over a guidewire and stylet.
A tracheostomy tube is placed under direct bronchoscopic vision over a dilator.
Placement of the tube is confirmed again by visualizing the tracheobroncial tree through the tube.
Tube is secured to the skin with sutures and the tracheostomy tape.
We routinely use Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer Tray.
Shachner (Rapitrac) systemAfter making a small skin incision, the surgeon passes a dilator tracheotome over the guidewire into the trachea to dilate the tract fully in one step. The tracheotome has a beveled metal core with a hole through its center that accommodates a guidewire. Once inside the trachea, the tracheotome is dilated. A conventional tracheostomy cannula, fitted with a special obturator, is passed through the tracheal opening. The dilator and obturator are then removed.

Translaryngeal tracheostomy (Fantoni’s technique)
Unlike the other techniques, the initial puncture of the trachea is carried out with the needle directed cranially and the tracheal cannula inserted with a pull-through technique along the orotracheal route in a retrograde fashion. The cannula is then rotated downward using a plastic obturator. The main advantage of Fantoni’s tracheostomy is the minimal amount of skin incision required, with practically no bleeding observed. It should be noted that the procedure can only be carried out under endoscopic guidance, and rotating the tracheal cannula downward may pose a problem – demanding that the surgeon have more experience.

Advantages of PDT

Although there is a learning curve to the technique of PDT, it is relatively easy to learn. The learning curve may be overcome by performing a number of supervised procedures. Other advantages include:

Time required for performing bedside PDT is considerably shorter than that for an open tracheostomy
Elimination of scheduling difficulty associated with operating room and anesthesiology teams for critical care patients
PDT expedites the performance of the procedure because critically ill patients who would require intensive monitoring to and from the operating room need not be transported
Cost of performing PDT is roughly half that of performing open surgical tracheostomy due to the savings in operating room charges and anesthesia fees

Complications and Risks of Tracheostomy

As with any surgery, there are some risks associated with tracheotomies. However, serious infections are rare.
Early Complications that may arise during the tracheostomy procedure or soon thereafter include:

Bleeding
Air trapped around the lungs (pneumothorax)
Air trapped in the deeper layers of the chest(pneumomediastinum)
Air trapped underneath the skin around the tracheostomy (subcutaneous emphysema)
Damage to the swallowing tube (esophagus)
Injury to the nerve that moves the vocal cords (recurrent laryngeal nerve)
Tracheostomy tube can be blocked by blood clots, mucus or pressure of the airway walls. Blockages can be prevented by suctioning, humidifying the air, and selecting the appropriate tracheostomy tube.

Many of these early complications can be avoided or dealt with appropriately with our experienced surgeons in a hospital setting.
Over time, other complications may arise from the surgery.
Later Complications that may occur while the tracheostomy tube is in place include:

Accidental removal of the tracheostomy tube (accidental decannulation)
Infection in the trachea and around the tracheostomy tube
Windpipe itself may become damaged for a number of reasons, including pressure from the tube; bacteria that cause infections and form scar tissue; or friction from a tube that moves too much

These complications can usually be prevented or quickly dealt with if the caregiver has proper knowledge of how to care for the tracheostomy site.
Delayed Complications that may result after longer-term presence of a tracheostomy include:

Thinning (erosion) of the trachea from the tube rubbing against it (tracheomalacia)
Development of a small connection from the trachea (windpipe) to the esophagus (swallowing tube) which is called a tracheo-esophageal fistula
Development of bumps (granulation tissue) that may need to be surgically removed before decannulation (removal of trach tube) can occur
Narrowing or collapse of the airway above the site of the tracheostomy, possibly requiring an additional surgical procedure to repair it
Once the tracheostomy tube is removed, the opening may not close on its own. Tubes remaining in place for 16 weeks or longer are more at risk for needing surgical closure

A clean tracheostomy site, good tracheostomy tube care and regular examination of the airway by an otolaryngologist should minimize the occurrence of any of these complications.

High-risk groups

The risks associated with tracheostomies are higher in the following groups of patients:

children, especially newborns and infants
smokers
alcohol abusers
diabetics
immunocompromised patients
persons with chronic diseases or respiratory infections
persons taking steroids or cortisone

Types of Tracheostomy Tubes

A tracheotomy (trach) tube is a curved tube that is inserted into a tracheostomy stoma (the hole made in the neck and windpipe (Trachea)). There are different types of tracheostomy tubes that vary in certain features for different purposes. These are manufactured by different companies. However, a specific type of tracheostomy tube will be the same no matter which company manufactures them.
A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or velcro strap around the neck. The inner cannula fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning. The obturator is used to insert a tracheostomy tube. It fits inside the tube to provide a smooth surface that guides the tracheostomy tube when it is being inserted.
There are different types of tracheostomy tubes available and the patient should be given the tube that best suits his/her needs. The frequency of these tube changes will depend on the type of tube and may possibly alter during the winter or summer months. Practitioners should refer to specialist practitioners and/or the manufacturers for advice.


Tube	Indication	Recommendations
CuffedTube with Disposable Inner Cannula
	Used to obtain a closed circuit for ventilation	Cuff should be inflated when using with ventilators. Cuff should be inflated just enough to allow minimal airleak. Cuff should be deflated if patient uses a speaking valve. Cuff pressure should be checked twice a day. Inner cannula is disposable.
Cuffed Tube with Reusable Inner Cannula
	Used to obtain a closed circuit for ventilation	Cuff should be inflated when using with ventilators. Cuff should be inflated just enough to allow minimal airleak. Cuff should be deflated if patient uses a speaking valve. Cuff pressure should be checked twice a day. Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Cuffless Tube with Disposable Inner Cannula
	Used for patients with tracheal problems Used for patients who are ready for decannulation	Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to talk without a speaking valve. Inner cannula is disposable
Cuffed Tube with Reusable Inner Cannula
	Used for patients with tracheal problems Used for patients who are ready for decannulation	Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to speak without a speaking valve. Inner cannula is not disposable. You can reuse it after cleaning it thoroughly.
Fenestrated Cuffed Tracheostomy Tube
	Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak	There is a high risk for granuloma formation at the site of the fenestration (hole). There is a higher risk for aspirating secretions. It may be difficult to ventilate the patient adequately.
Fenestrated Cuffless Tracheostomy Tube
	Used for patients who have difficulty using a speaking valve	There is a high risk for granuloma formation at the site of the fenestration (hole).
Metal Tracheostomy Tube
	Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes.	Patients cannot get a MRI. One needs to notify the security personnel at the airport prior to metal detection screening.