Tracheotomy

Tracheotomy

Anesthesia type	General or local/MAC
Airway	ETT Tracheostomy tube (TT)
Lines and access	PIV ± Arterial line
Monitors	Standard 5-lead ECG ± ABP
Primary anesthetic considerations
Preoperative	Cause of respiratory failure and ability to perform tracheostomy under general vs awake Avoidance of premedication if concern for airway obstruction
Intraoperative	If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using dexmedetomidine, then converting to general when the tube is secured
Postoperative	Creation of a false passage Occlusion of tracheostomy tube Tube displacement Tracheoinnominate artery fistula Airway stenosis
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A tracheotomy refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.

Indications for 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 in 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 reduce the need for sedation and improve overall patient comfort and 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 also be performed at the bedside with several percutaneous techniques.

In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.

In a percutaneous tracheostomy, various procedure methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.

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

Labs and studies

• Head and Neck CT/MRI
• Neck ultrasound to identify anatomy
• CXR, ABG as indicated from H&P

Operating room setup

• For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula
• Most institutions have a "trach set" for the surgical team
• Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventilation is impossible

Patient preparation and premedication

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

Regional and neuraxial techniques

• Local infiltration of neck and transtracheal instillation of local anesthetic

Intraoperative management

Monitoring and access

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

Induction and airway management

Critically ill patients, already intubated	Convert ICU sedation to GA with carefully titrated inhalational agent May consider TIVA if patient at decreased risk for hemodynamic instability
As part of scheduled procedure	Standard IV induction Consider awake FOI if airway problems anticipated
Awake	Consider sedation using precedex; avoid bolusing as it may cause airway obstruction Consider calming music such as classical

Positioning

• Supine, head extended with shoulder roll
  • Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon
  • Important to tape ETT securely

• Table may be turned 180 degrees in awake cases

Maintenance and surgical considerations

General

Consider TIVA with propofol/remifentanil; remifentanil may not be necessary however consider small boluses of fentanyl Muscle relaxation required, may use rocuronium Usually no antibiotics indicated PONV prophylaxis with dexamethasone, ondansetron Normovolemia, normothermia To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss Once TT secured, connect to circuit and gently suction Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits

Awake

Once TT secured, convert to GA while surgeons finish the procedure Can use propofol/remifentanil

Emergence

Critically ill patients, already intubated	Transport to ICU on similar ventilator settings and level of sedation
Awake or as part of scheduled procedure	Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties

Postoperative management

Disposition

• Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum
• Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated
• Humidification of inspired air
• Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period
• Do not remove for 5-7 days until track formed

Critically ill patients, already intubated	Continue on similar ventilatory support settings in the ICU
Awake or as part of scheduled procedure	Inpatient unit

Pain management

• Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/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 fistula
  • Tracheoinnominate artery fistula
    • Potential for catastrophic bleeding
  • Airway stenosis
    • Posterior glottic, subglottic, tracheal
    • Risk factors: inappropriately large TT (>7.5), obese patients (often sized with inappropriately large TT)
    • Tracheal airway diameters do not correlate with body weight

Procedure variants

	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
Potential complications	2.2x more likely to have early postoperative complications vs open