Difference between revisions of "Tracheotomy"
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Indications for a '''tracheotomy''' are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy | Indications for a '''tracheotomy''' are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is reasonable to consider tracheotomy after 10 days to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),<ref>{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}</ref><ref>{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}</ref><ref>{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}</ref> as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care<ref>{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}</ref><ref>{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}</ref>. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm. | ||
A tracheostomy may be performed open during a general anesthetic or awake with local anesthesia. It can be performed at the bedside with several percutaneous techniques. Absolute contraindications to performing bedside tracheostomy include pediatric age group, while relative contraindications to performing a bedside tracheostomy include short/large neck or obesity with unidentifiable anatomy, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery, and some believe anticoagulation.<ref>{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}</ref> | |||
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. | In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. | ||
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*** Posterior glottic, subglottic, tracheal | *** Posterior glottic, subglottic, tracheal | ||
*** Risk factors: inappropriately large ETT (>7.5), obese patients (often sized with inappropriately large ETT)<ref name=":0" /> | *** Risk factors: inappropriately large ETT (>7.5), obese patients (often sized with inappropriately large ETT)<ref name=":0" /> | ||
**** Tracheal airway diameters do not correlate with body weight<ref name=":0" /> | ***** Tracheal airway diameters` do not correlate with body weight<ref name=":0" /> | ||
** Tracheocutaneous fistula | ** Tracheocutaneous or tracheoesophageal fistula | ||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
Revision as of 10:27, 22 February 2022
Tracheotomy
| Anesthesia type |
General, awake/local |
|---|---|
| Airway |
ETT, tracheotomy |
| Lines and access |
PIV |
| Monitors |
Standard |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative | |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is reasonable to consider tracheotomy after 10 days to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),[1][2][3] as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care[4][5]. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.
A tracheostomy may be performed open during a general anesthetic or awake with local anesthesia. It can be performed at the bedside with several percutaneous techniques. Absolute contraindications to performing bedside tracheostomy include pediatric age group, while relative contraindications to performing a bedside tracheostomy include short/large neck or obesity with unidentifiable anatomy, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery, and some believe anticoagulation.[6]
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | |
| Cardiovascular | All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN. |
| Pulmonary | Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration. |
| Gastrointestinal | |
| Hematologic | If malignancy or chronic disease, coagulopathies or anemia may be present |
| Renal | Assess for renal disease if chronic illness |
| Endocrine | Consider adrenal suppression, hyperglycemia if ICU patient |
| Other | Note nutritional status |
Labs and studies
- Head and Neck CT/MRI
- CXR, ABG as indicated from H&P
Operating room setup
Patient preparation and premedication
- Standard premedication if elective
- Avoid if critically ill of symptoms upper airway obstruction
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
- Standard monitors
- Invasive monitors depending on condition
- Avoid ECG pads in the prepped area
Induction and airway management
| Intubated |
|
| Not intubated with plan for GETA |
|
| Awake Tracheostomy |
|
Positioning
- Supine, head extended with shoulder roll
- Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely
Maintenance and surgical considerations
| General |
|
| Awake |
Emergence
Postoperative management
Disposition
- Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum
| Critically ill patients |
|
| Awake or as part of scheduled procedure |
Pain management
- Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics
Potential complications
- Intraoperative
- Bleeding although EBL generally minimal
- Pneumothorax
- Seen if low neck dissection of false passage formation
- Pneumomediastinum
- Creation of false passage during procedure
- Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)
- Signs include absent end tidal, increased PIP
- If suspect, should attempt to reintroduce existing ETT
- Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications[7]
- Early postoperative complications (within 1 week):
- Cellulitis / tracheitis
- Occlusion of tracheostomy tube
- Secretions, mucus plug, blood, mainstem
- Tracheostomy tube displacement
- Re-intubate orally or through trach site
- Late complications (seen beyond 1 week):
- Note early postoperative complications may also occur after 1 week
- Airway stenosis
- Tracheocutaneous or tracheoesophageal fistula
Procedure variants
| General | Awake | Bedside - Percutaneous | |
|---|---|---|---|
| Unique considerations | |||
| Position | |||
| Surgical time | |||
| EBL | |||
| Postoperative disposition | |||
| Pain management | |||
| Potential complications | 2.2x more likely to have early postoperative complications vs open[7] |
References
- ↑ Ranes, Justin L.; Gordon, Steven M.; Chen, Pam; Fatica, Cynthia; Hammel, Jeffrey; Gonzales, Jeffrey P.; Arroliga, Alejandro C. (2006-10-01). "Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia". The American Journal of Medicine. 119 (10): 897.e13–897.e19. doi:10.1016/j.amjmed.2005.12.034. ISSN 0002-9343.
- ↑ HOLZAPFEL, L.; CHEVRET, S.; MADINIER, G.; OHEN, F.; DEMINGEON, G.; COUPRY, A.; CHAUDET, M. (1994-06). "Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia". Survey of Anesthesiology. 38 (03): 177???178. doi:10.1097/00132586-199406000-00057. ISSN 0039-6206. Check date values in:
|date=(help) - ↑ Cavaliere, S.; Bezzi, M.; Toninelli, C.; Foccoli, P. (2016-02-03). "Management of post-intubation tracheal stenoses using the endoscopic approach". Monaldi Archives for Chest Disease. 67 (2). doi:10.4081/monaldi.2007.492. ISSN 2465-1028.
- ↑ Heffner, John E.; Hess, Dean (2001-03). "Tracheostomy Management in the Chronically Ventilated Patient". Clinics in Chest Medicine. 22 (1): 55–69. doi:10.1016/s0272-5231(05)70025-3. ISSN 0272-5231. Check date values in:
|date=(help) - ↑ Diehl, J; El Atrous, S; Touchard, D; Lemaire, F; Brochard, L. (1999). "Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients". Cardiopulmonary Physical Therapy Journal. 10 (2): 60. doi:10.1097/01823246-199910020-00013. ISSN 1541-7891.
- ↑ Nun, Alon Ben; Altman, Eduard; Best, Lael Anson (2005-10-01). "Extended Indications for Percutaneous Tracheostomy". The Annals of Thoracic Surgery. 80 (4): 1276–1279. doi:10.1016/j.athoracsur.2005.02.007. ISSN 0003-4975.
- ↑ 7.0 7.1 7.2 7.3 Halum, Stacey L.; Ting, Jonathan Y.; Plowman, Emily K.; Belafsky, Peter C.; Harbarger, Claude F.; Postma, Gregory N.; Pitman, Michael J.; LaMonica, Donna; Moscatello, Augustine; Khosla, Sid; Cauley, Christy E. (2011-12-19). "A multi-institutional analysis of tracheotomy complications". The Laryngoscope. 122 (1): 38–45. doi:10.1002/lary.22364. ISSN 0023-852X.
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