Tracheotomy

Tracheotomy

Anesthesia type	General, awake/local
Airway	ETT, tracheotomy
Lines and access	PIV
Monitors	Standard, Invasive depending on patient condition
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
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A tracheotomy refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.

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 also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP), as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care. 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, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques.

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	Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.
Neurologic	Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure
Cardiovascular	All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN
Pulmonary	Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease
Gastrointestinal	Assess for GERD/possible recurrent aspiration
Hematologic	If malignancy or chronic disease, coagulopathies or anemia may be present
Renal	Assess for renal disease if chronic disease
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

Patient preparation and premedication

• Standard premedication if elective
  • Avoid if critically ill or symptoms upper airway obstruction

Intraoperative management

Monitoring and access

• Standard monitors
  • Invasive monitors depending on condition
• Avoid ECG pads in the prepped area

Induction and airway management

Intubated	Convert ICU sedation to GA with propofol/remifentanil or inhalational agent
Not intubated with plan for GETA	Standard IV induction Consider awake FOI if airway problems anticipated
Awake Tracheostomy	Precedex

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	Consider TIVA with propofol/remifentanil Muscle relaxation required, may use rocuronium Normovolemia, normothermia PONV prophylaxis with dexamethasone, ondansetron To avoid ETT cuff puncture, may advance closer to carina before trachea opened Slowly remove ETT under visualization of surgeon however do not remove completely Once tracheostomy tube secured, connect to circuit/suction Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits
Awake

Postoperative management

Disposition

• Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum

Critically ill patients	Continue on ventilatory support in the ICU Careful suctioning, humidified oxygen Opioid sedation will minimize reaction to suctioning in early postoperative period Regular cleaning of tube, stomal care, and monitoring of cuff pressure Do not remove for 5-7 days until track formed
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
    • Most commonly from cut edge of the thyroid
  • Pneumothorax
    • Seen if low neck dissection of false passage formation
  • Pneumomediastinum
  • Subcutaneous emphysema
  • Pulmonary edema from breathing against obstruction prior to procedure
  • 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

• Early postoperative complications (within 1 week):
  • Granulation tissue, cellulitis / tracheitis
  • Infection such as pneumonia
  • Vocal cord dysfunction
  • 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
  • Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula
  • Airway stenosis
    • Posterior glottic, subglottic, tracheal
    • Risk factors: inappropriately large tracheal tube (>7.5), obese patients (often sized with inappropriately large tracheal tube)
    • Tracheal airway diameters do not correlate with body weight

Procedure variants

	General	Awake	Bedside - Percutaneous
Unique considerations			Advantages over tracheostomies in the OR Less time/personnel required Half of cost Absolute contraindications pediatric age group Relative contraindications short/large neck or obesity with unidentifiable anatomy enlarged thyroid inability to extend the neck suspected/confirmed C-spine fracture prior neck surgery some believe anticoagulation
Postoperative disposition
Pain management
Potential complications			2.2x more likely to have early postoperative complications vs open