56.Tracheotomy and ion

8/2/2019 56.Tracheotomy and ion

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Editors: Bailey, Byron J.; Johnson, Jonas T.; Newlands, Shawn D.

Title: Head & Neck Surgery - Otolaryngology, 4th Edition

Copyright 2006 Lippincott Williams & Wilkins

> Table of Contents > Volume One > IV - Airway and Swallowing > 56 - Tracheotomy and

Intubation

56

Tracheotomy and Intubation

Mark C. Weissler

Marion Everett Couch

TracheotomyTracheotomy is the establishment of a surgical opening in the trachea for

ventilation. The tube placed through the tracheal opening is a tracheostomy tube.Tracheostomy is the opening itself, or the stoma.

History of TracheotomyTracheotomy is a much older procedure than transoral or transnasal cannulationof the trachea with a tube. The history of tracheotomy and intubation is outlinedin Table 56.1.

Indications for TracheotomyThe basic indications for tracheotomy are as follows:

To bypass upper airway obstruction

To assist respiration over prolonged periods

To assist with the clearance of lower respiratory tractsecretions

To help reduce aspiration

To reduce the dead space dur ing ventilation to promote weaning from theventilator

To reduce the probability of subglottic stenosis.

Perhaps more controversial are the comparative indications for tracheotomyversus intubation or other noninvasive methods of assisted ventilation. Certainlywhen there is mechanical or anatomic obstruction of the upper airway as bycarcinoma, translaryngeal intubation may be impossible or may carry great risk ofcausing further immediate deterioration of the airway. In cases of trauma to thelarynx, attempted intubation may cause further injury or acute deterioration ofthe airway and is relatively contraindicated. When performing complex operations

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on the upper aerodigestive tract, an endotracheal tube would often be in the way,and the subsequent upper airway obstruction resulting from pos toperative edemaoften mandates a perioperative tracheotomy. In emergencies , the skill andknowledge of those in attendance also play a role in deciding the bes t way toproceed. Establishment of an airway is the most basic tenet in the support of life;therefore, it is difficult to find fault with its attainment by almost any

means. Nonetheless, there are safe ways of obtaining an airway with the leastchance of causing iatrogenic harm to the patient.

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TABLE 56.1 HISTORY OF TRACHEOTOMY

Date Event

10002000BC

There were obscure references to tracheotomy in theEbers papyrus and Rig Veda.

124 BC Asclepiades is credited with performing firsttracheotomy.

AD 117 Antyllus performs tracheotomy through transverseincision with patient in sitting position.

Dark ages Few references.

Albucasis of Cordova shows that tracheal rings wouldheal.

1546 First well-documented tracheotomy is performed byAntonius Musa Brasavola.

1600 Fabricius suggests use of a cannula.

1700s George Martin suggests use of an inner cannula on the

tracheostomy tube.

1833 Trousseau reports more than 200 cases of tracheotomy for diphtheria.

1932 Chevalier Jackson standardizes the technique of




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CLINICAL INDICATORS FOR TRACHEOTOMY

tracheotomy and warns against hightracheotomy.

The American Academy of OtolaryngologyHead and Neck Surgery hasproposed the following clinical indicators for tracheotomy:

Indications (one or more required)History

Upper airway obstruction with any of the followingStridorAir hungerRetractionsObstructive sleep apnea with documented arterial desaturationBilateral vocal cord paralysisProlonged intubation

Inability of patient to manage secretions includingAspirationExcessive bronchopulmonary secretionsFacilitation of ventilation supportInability to intubateAdjunct to manage head and neck surgeryAdjunct to manage major head and neck trauma

Physical examination (one required)RespirationdescribeVoicedescribeEndotracheal tubedocumentLarynxdescribe, if possibleNeck examination (always required)

Tests (none required)Postoperative observationsBreathingsatisfactory; both sides of lung ventilatingBleeding from wounddescribe and notify surgeon




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Techniques of TracheotomyElective TracheotomyElective tracheotomy is best performed in an operating room with adequateequipment and assistance. The patient is positioned supine with a roll betweenthe shoulder blades to hyperextend the neck and bring the trachea up out of thechest. An incision is made midway between the sternal notch and the cricoidcartilage. The incision is carried down through skin, subcutaneous tissue, andplatysma muscle to reveal the strap muscles. At the level of the strap musc les,the dissection is changed to the vertical plane. The pairs of sternohyoid andsternothyroid muscles are separated from each other in the midline by means of a

vertical incision through the fascia that connects the muscles on the two sides.Retractors are used to pull the strap muscles to each side to reveal the thyroidisthmus. The cricoid cartilage is identified by means of palpation through thewound, and the overlying fascia is sectioned near its inferior border . A cricoidhook is used to pull the trachea superiorly by means of placing it between thecricoid cartilage and the first tracheal ring. At this level, a bloodless plane justanterior to the trachea is identified, the thyroid isthmus is clamped andtransected, and each side is suture ligated. A Kittner sponge dis sector is used to

Subcutaneous emphysemanotify surgeonWound packing and suturesdocument removalTracheotomy tubetighten if looseChest radiographdocument. Usually ordered after surgery to check forpneumothorax or proper tube placement.Outcome review

Document complications for departmental review.Patient informationAlthough often performed as an emergency in life-threatening situations,tracheostomy may also be required for urgent and elec tive reasons. Atracheostomy is an opening made in the trachea (windpipe) to allow breathingwhen the larynx is obstructed or to allow long-term ventilation of the lungsthrough a tube inserted into the neck opening. The main complication isbleeding, and this is often related to the speed required to perform thisoperation in emergency situations. Other complications include subcutaneousemphysema (escape of air into the tissues of the neck and mediastinum),which can be controlled, and postoperative scar formation in the lower neck.

Although an endotracheal tube can be used to maintain the airway for severaldays, there is no alternative to tracheostomy in some cases.

The American Academy of OtolaryngologyHead and Neck Surgery and theAmerican Society for Head and Neck Surgery have pub lished clinical indicatorsfor surgical procedures. These clinical indicators are educationalstatementsthat have been drafted to assist surgeons in their practice and to promotediscussion. These indicatorsare not practice guidelines nor do they representstandards of practice with which individual physicians mustconform.




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push the fine fascia away from the anterior tracheal wall.

Controversy surrounds the best incision to use in the trachea. The safest incisionmay be an inferiorly based (Bjrk) flap consisting of the second or third trachealring anteriorly (see later in this chapter). Alternatives include a single or ahorizontal H incision based on the second or third tracheal ring, resection of theanterior section of a single tracheal ring, or use of a tracheal punch; these

procedures carry little risk of tracheal stenosis when performed on adults. Atracheotomy wound should never be closed tightly around the tube, and ingeneral no suturing should be done other than suturing the tracheos tomy tubeflange to the skin. Suturing the wound may lead to subcutaneous emphysema,pneumomediastinum, pneumothorax, and infection.

During the surgical procedure, a reinforced tube is left in the tracheostomy,which aids in ease of positioning the

patient and keeps the bulky tracheostomy tube out of the surgeon's way.Accidental intraoperative decannulation is prevented (Fig. 56.1).

Bjrk FlapIn 1960 Bjrk introduced the concept of suturing an inferiorly based flapconsisting of the anterior portion of a single tracheal ring to the inferior skinmargin to greatly reduce the incidence of accidental decannulation (Fig. 56.2).Use of this flap facilitates reinsertion of the tracheostomy tube if accidentaldecannulation were to occur. The technique is contraindicated in operations onchildren, among whom it can cause an unacceptable rate of tracheal stenosis andpersistent tracheocutaneous fistulae. The risk of tracheocutaneous fistula can belargely ameliorated if the suture securing the trachea to the skin surface is cut atthe time of the first tracheostomy tube change.

When the tracheostomy is to be permanent or of long duration, the Bjrkprocedure can be modified by means of de fatting the surrounding skin andsuturing the tracheostoma to the skin circumferentially. This procedure isespecially useful in operations on patients who are obese who are unde rgoingtracheotomy because of intractable obstructive sleep apnea. A semipermanenttracheostoma can be made that is less susceptible to maceration because it isimmediately matured by means of apposing skin to respiratory mucosa. It alsoallows the tracheostomy tube to sit better and makes removal and reinse rtioneasier by means of decreasing the length of the tract.

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Figure 56.1 Elective tracheotomy: horizontal skin incision, cricoid hook, anddivision of thyroid isthmus.




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Emergency TracheotomyAnoxia causes death in about 4 to 5 minutes. Emergency tracheotomy, the refore,must be performed within 2 or 3 minutes. In general, emergency tracheo tomy isto be avoided. It is too often needed because of ill-advised management of atenuous but adequate airway. For example, an unskilled attempt at translaryngealintubation of a patient with bulky glottic cancer with an improper level ofanesthesia may precipitate an acute airway emergency that can be managed withfew other options. It is much better to perform elective tracheotomy unde r localanesthesia than to induce such a situation.

Emergency tracheotomy is best performed through a vertical incision, whichbegins at the level of the cricoid cartilage and extends inferiorly about 1.5 inches

(3.75 cm). A right-handed surgeon uses the left hand to palpate and stabilize thelarynx and to extend the neck if there are no contraindications to neck extensionsuch as possible cervical

spine trauma. A shoulder roll is also helpful, but it is usually not germane to thesituation. The surgeon's right hand wields the blade and makes a vertical incisionthrough skin, platysma, and subcutaneous tissues and thyroid isthmus. The indexfinger of the left hand can be used as a dissector to attempt to push the thyroidisthmus inferiorly and to palpate the trachea. It is possible to avoid incising thecricoid cartilage and to position the actual vertical tracheal incision at about thesecond or third tracheal ring by means of palpating the cricoid arch with the

index finger of the left hand. The vertical skin incision is crucial to the speed ofthe procedure and to avoid damage to adjacent neck structures. After the incisionis made in the trachea, a tracheal dilator is helpful but not necessary to aid in theintroduction of an endotracheal tube, which then is sewn to the adjacent skin. Areinforced endotracheal tube is preferable, if available, because it res ists kinking.Bleeding in the wound is controlled after the tracheotomy is complete. If thesituation allows, the tracheotomy is carefully assessed to determine the actuallocation of the tracheal incision. Revision, if necessary, is undertaken as soon asthe patient's condition allows (Fig. 56.3).

CricothyrotomyIn most instances, cricothyrotomy is far preferable to emergency tracheotomy.The main advantage is that the cricothyroid membrane is near the skin surface;thus much less dissection is necessary. The procedure is easily standardized andtaught to residents and emergency department personnel. The main limitation isthe risk of damage to the subglottic larynx, but this is mostly associated withleavingthe cricothyrotomy tube in too long. Cricothyrotomy isrelativelycontraindicated in the care of children younger than age 12 years, in patientswith infection in the larynx, in patients who have sustained laryngeal trauma, and

Figure 56.2 Bjrk flap.

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when it risks transecting a tumor.

Cricothyrotomy is performed best through an incision directly over thecricothyroid membrane. It is best for a right-handed surgeon to stand on thepatient's right side, grasp the thyroid cartilage with his or her left hand, andpalpate the cricothyroid space with the index finger of the left hand. A shortstabbing incision is made with the right hand directly through the cricothyroid

membrane. Hugging the cricoid cartilage may avoid injury to the cricothyroidartery. Once the subglottic space is entered, the handle of the knife is insertedinto the wound and twisted vertically to open the wound. An endotracheal tube isinserted and secured (Fig. 56.4).

Much controversy has surrounded the use of cricothyrotomy as a definitive long-term airway. If respiratory support through a surgical airway is needed for longerthan 3 to 5 days, a cricothyrotomy may be converted to a tracheotomy as anelective procedure in the operating room to avoid the long-term sequelae ofsubglottic or laryngeal stenosis, which may result from cricothyrotomy. At thetime of conversion of a cricothyrotomy to a tracheostomy, the cricothyrotomy

wound should be explored for possible fracture of the cricoid or thyroid cartilagesthat may have occurred at the time of the initial surgery. Such iatrogenic injuriescan often be repaired at the time. Granulation tissue that may have formed at thecricothyrotomy site can also be removed at this time.

Maneuvers to Stabilize Emergent AirwaysSeveral techniques have been desc ribed to ventilate a patient for a short timebefore more definitive airway management can be undertaken. Transcricothyroidpuncture with a 14-gauge catheter has been described. In the care of adults,there seems to be little to recommend this procedure over cricothyrotomy unlessthe physicians in attendance are untrained in the technique. An adult cannot

breathe through such a catheter, so a method to supply oxygen under pressuresuch as jet ventilation with an anesthesia machine or pressurized tank or wallcircuit is necessary. A means of intermittent inflation of the lungs and control ofpeak pressures is also desirable. If the oxygen is delivered under high pressure,there is a risk of pneumothorax. Oxygen also must have a route of egress fromthe lungs. If there is obstruction at the level of the glottis, a second catheter mayhave to be placed through the cricothyroid membrane to allow a route for oxygenescape; otherwise, overinflation of the lungs with pneumothorax ensues . Avariety of small pocket devices are manufactured for use in the field. There areno controlled studies of such devices. The usefulness of these devices byuntrained persons remains questionable.

Transcricothyroid puncture is perhaps more useful in children, in whomcricothyrotomy is best avoided. Emergency tracheotomy should also be avoided.When transoral intubation is impossible, cannulation of a child's cricothyroidmembrane with a large-bore catheter may buy enough time to allow a moreorderly tracheotomy. The

same admonishments apply concerning a site of egress for delivered oxygen.P.789




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Tracheotomy in the Pediatric PatientPerformance of tracheotomy on a child is similar to the procedure on an adult.For children, however, a simple vertical incision in the trachea is best, as shownin an animal model (1). The incision is made in the second and third trachealrings. Excision of any anterior tracheal wall or the use of a Bjrk flaptraditionally has been avoided in operations on children. A starplasty tracheotomy technique, which creates a matured permanent tracheos toma, hasbeen recommended because of the increased safety and prevention of

tracheotomy-related complications it affords in infants (2). Subsequent closure ofthe fistulas has been possible.

Figure 56.3 Emergency tracheotomy performed through vertical skinincision.




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If at all possible, tracheotomy on children is performed only with a securedairway either from intubation with an endotracheal tube or over a ventilatingbronchoscope. As in the treatment of adults, emergency tracheotomy is avoided ifpossible. The smaller diameter, shorter length, greater deformability, and limitedstability of the infantile trachea and the greater mobility of the soft tissues of theneck in a child call for special techniques.

During tracheotomy on a child, it is wise to place two sutures, one on either sideof the vertical incision in the trachea, to serve as guides if the tracheostomy tubeaccidentally comes out of the trachea. If such a technique is used, it is essentialthat the personnel taking care of the child in the hospital be trained in the properuse of these guide sutures. In a panic, it is easy to pull the sutures out. With

gentle pulling on the sutures, the trachea can be elevated into the wound and theincision in the trachea can be slightly opened to assist reinsertion of the tube. Asmall 4-0 or 5-0 nonabsorbable monofilament suture usually is used. It isremoved at the first tracheostomy tube change 3 or 4 days after tracheotomy(Fig. 56.5).

Polyvinyl chloride or polymeric silicone tubes tend to collect fewer secretions thando metal tubes. The plastic tubes, however, have no inner cannula and are prone

Figure 56.4 Cricothyrotomy.

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to accidental decannulation owing to intrinsic malleability, which allows the tip tocome out of the trachea while the body of the tube remains in the neck wound .Pediatric tracheostomy tubes usually have no cuff.

Studies have shown a change in the indications and outcomes of ped iatrictracheotomies. Pediatric tracheotomy is more frequently performed today forchronic diseases than for acute infections such as supraglottitis as was the caseas

recently as the 1970s. This change in indications is associated with an increase inthe duration of these tracheostomies and a decreased decannulation rate (3).

Complications of TracheotomyIn the most general sense, complications can be divided into those o ccurringintraoperatively, during the early postoperative period, and during the latepostoperative period (Table 56.2). During the operation, damage can be done tothe great vessels or the wall between the trachea and the esophagus. The cupulaof the lung enters the low neck and can be damaged, resulting in pneumothoraxor pneumomediastinum. Although chest radiography traditionally has been

mandatory after tracheotomy, its necessity after routine noncomplicatedprocedures with a normal postoperative physical examination of the heart andlungs has been questioned (4).

Obstruction by dried mucus can be largely prevented by means of meticuloustracheostomy care. A humidifier is used postope ratively, and the tube issuctioned frequently after instillation of 1 to 2 mL sterile saline solution.Postobstructive pulmonary edema, often a result of the sudden re lief ofpulmonary obstruction, is managed with mechanical ventilation with positive end-expiratory pressure and possibly diuretics. Cuff pressure is checked regularly andkept at less than 25 cm water, the pressure at which submucosal capillaries areoccluded. Some patients with severe anatomic distortion of the neck may need

special tracheostomy tubes, such as a Rusch tube, which is es sentially a softendotracheal tube that can be variably advanced through the neck plate toaccommodate a variety of anatomic situations. Granulation tissue commonlyforms at the level of the tracheostoma and can be present more distally becauseof too vigorous tracheal suctioning.

TABLE 56.2 COMPLICATIONS TRACHEOTOMY

Intraoperative Damage to great vesselsDamage to tracheoesophageal common wallPneumothoraxPneumomediastinum

Early postoperative




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One of the most feared complications of tracheotomy is tracheainnominateartery fistula, which commonly occurs at the level of the tip of the tracheostomy

tube and has been ascribed to too low tracheotomy (below the level of the thirdtracheal ring), erosion from a high pressure cuff, tube torsion and movementfrom a ventilator, and local infection. Of cases of fistula, 60% occur within 2weeks of the tracheotomy, and the complication carries a 73% mortality.Tracheainnominate artery fistula may be heralded by a small amount ofsentinel bleeding. The best initial management is to attempt to control thehemorrhage by means of overinflating the tracheostomy tube cuff o r inserting anendotracheal tube below the level of the bleeding while attempting to compressthe innominate artery anteriorly against the sternum with a finger insertedthrough the tracheotomy wound anterior to the trachea. Definitive treatmentinvolves dividing and suture ligating the two ends of the innominate artery (Fig.

56.6).

The incidence of complications of pediatric tracheotomy is gene rally consideredhigher than that among adults. In one study there was a 3.3% incidence ofintraoperative complications, a 13.3% incidence of early postoperativecomplications, and a 38.3% incidence of late complications among childrenyounger than age 1 year. Tube obstruction was the most common ear lypostoperative complication, and granulation tissue was the most common latecomplication (5). The mortality for the procedure itself

ranges from 0.7% to 1.6%, but the overall mortality in the group of patients was42%, reflecting the degree of underlying illness. Duration of tracheos tomy wasthe most important factor influencing the rate of late complications. Highercomplication rates occurred among preterm infants as opposed to term infants,and infants undergoing tracheotomy for upper airway obstruction had morecomplications than those undergoing tracheotomy for ventilator dependency. Thiscorrelation, however, seemed to be explained by the longer survival of patientsundergoing tracheotomy for upper airway obstruction than that of thoseundergoing the procedure for ventilator dependency and the subsequently greaterperiod over which complications had a chance to develop. App roximately 40% of

Tracheostomy tube obstructionTracheostomy tube displacementPulmonary edemaInfection

LateTracheal stenosisGranulation tissueTracheainnominate artery fistula

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patients may have serious complications including tube occlusion or acc identaldecannulation that may require a separate

surgical procedure (6). As noted earlier, some feel that the starplasty technique may decrease the rate of tracheotomy-related complications in infantsand children.

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Figure 56.5 Pediatric tracheotomy. The vertical incision in the trachea andguide sutures allow ease of reintubation in the event of accidentaldecannulation.




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Percutaneous Dilational TracheotomyThe percutaneous tracheotomy technique was deve loped as an alternative toconventional standard open tracheotomy for patients intubated in the intensivecare unit (ICU). Management of these patients remains controversial becausethere are at least three options for performing tracheotomies, including thestandard open tracheotomy performed in the operating room, percutaneousdilatational tracheotomy performed in the ICU, and minimally invasive opentracheotomy performed in the ICU. Multiple factors including the patient's overallmedical condition, body habitus, propensity to bleed, and the surgeon'sexperience with a particular technique must be considered when selecting themost appropriate surgical approach.

HistoryCiaglia, in 1985, is credited with incorporating the Seldinger wire technique intoprevious descriptions of trans-cutaneous tracheal cannulation, allowing serialdilation of the tracheal wall before placing a tracheostomy tube into the airway.His technique of percutaneous dilatational tracheotomy consisted of making asmall incision, dissecting to the tracheal wall, inserting a needle into the tracheallumen, and cannulating the trachea with a flexible J wire guide over which werepassed serial dilators followed by placement of the tracheos tomy tube.

It is the blind entry into the trachea that creates the potential for life-threateningcomplications, and some of the early studies with percutaneous tracheotomieswere done without endoscopic guidance and with commercially available kits thatproved to be unsafe. Serious safety issues have marred the past history ofpercutaneous tracheotomy and made its use controvers ial in many institutions.Two developments, however, have made the technique much safer. First, theincreased use of bronchoscopy has been shown to significantly reduce theprobability of complications by visualizing the entry of sharp instruments,needles, dilators, and tubes into the trachea. Second, the newer commerciallyavailable kits have been designed to address many o f the safety issues thatplagued earlier kits. One example of this is the use of a Seldinger wire with asingle hydrophilic, curved, cone-shaped dilator, which obviates the need fo rmultiple dilators to be passed into the airway. This may result in lessmanipulation of the trachea and allow the procedure to be done more quickly.

Clinical Indications and ContraindicationsThe general consensus is that percutaneous tracheotomy should be performed onpatients who are already intubated. It is considered to be a minimally invasivebedside procedure that is performed in the ICU, with continuous monitoring of the

Figure 56.6 Low tracheotomy resulting in tracheainnominate arteryfistula.




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patient's vital signs (electrocardiogram, blood pressure, oximetry, heart rate).Full ventilatory support of the patient is necessary. Table 56.3 outlines thecurrent indications for a percutaneous tracheotomy.

Absolute contraindications include emergency situations, pediatric applications,patients who are not intubated, and patients with a midline neck mass. Relativecontraindications include the requirement for positive end expiratory ventilator

settings of greater than 20 cm H2O and an uncorrected coagulopathy.

Because a percutaneous tracheotomy is considered an elective procedure forselected patients, the criteria for a percutaneous tracheotomy are more stringentthan those for a surgical tracheotomy. Patients should have a clearly palpablecricoid cartilage and tracheal rings. The ability to extend the neck is necessary,as is the ability to easily reintubate the patient should the endotracheal tube slipout of the glottis during the procedure. Patients who are obese or difficult toreintubate generally should not be considered candidates for percutaneoustracheotomies. A complete listing of important patient selection criteria isincluded in Table 56.4.

TechniqueThe procedure is generally carried out in the ICU on a patient who is intubatedand ventilated with continuous monitoring under deep intravenoussedation/analgesia. Personnel requirements include the surgeon, someone tomanage the sedation/analgesia, someone to manage the ventilator, abronchoscopist, and an assistant. An airway cart with instruments for an urgentsurgical tracheostomy or urgent intubation should be readily available. Thepatient is preoxygenated with 100% oxygen, which is continued during theprocedure. A shoulder roll is placed to extend the patient's neck. A 1.5 to 2.0 cm

TABLE 56.3 CURRENT INDICATIONS FORPERCUTANEOUS TRACHEOTOMY

Prolonged ventilatory supportAirway controlPulmonary toilet

Upper airway obstructionFacilitate weaning from mechanical ventilation support

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incision is made through the skin of the neck approximately 2 cm below thepalpable cricoid cartilage. Blunt horizontal and vertical dissection with a hemostatis used to carry the dissection down to a pretracheal plane, attempting to sweepthe thyroid isthmus (which should not be enlarged) inferiorly. Finger dissection isused to palpate the cricoid cartilage and tracheal rings. A small-caliber, flexiblebronchoscope attached to a video camera and monitor is passed via a swivel

adaptor down the endotracheal tube, allowing for ventilation around the scope.The bronchoscopist withdraws the endotracheal tube and bronchoscope, afterdeflating the endotracheal tube cuff, to a subglottic level, taking care not tocompletely withdraw the tube from the larynx. During this maneuver, ventilatorsettings may have to be modified to accommodate the air leak or space taken upby the bronchoscope. The surgeon can use the light from the bronchoscope anddigital palpation to guide passage of the needle from the percutaneoustracheotomy kit through the anterior tracheal wall under direct bronchoscopicvisualization. Ideally the puncture should be made between the second and thirdtracheal rings. High placement of the tracheotomy in the immediate subcricoidposition is associated with fracture of the cricoid cartilage and subglottic stenosis

and should be avoided. The wire guide is then inserted, the tract is dilated pe rthe kit instructions, and the tracheostomy tube is inserted over a specialintroducer that is then withdrawn. The endotracheal tube and bronchoscope arewithdrawn from the mouth, and the tracheostomy tube is sutured into positionand secured with a tracheostomy tube tie (Fig. 56.7). It is essential that thesurgeon be intimately familiar and trained in the nuances of the specific kit beingused.

TABLE 56.4 PATIENT SELECTION

Indications Easily palpable anterior neck anatomy

Intubated patientAbility to extend neck

Contraindications Difficult airway (for any reason)Inability to palpate cricoid cartilage and tracheaNonintubated patientChildrenObesity

Inability to extend neckKyphosisArthritis of cervical spineCervical fusionDocumented or suspected cervical spine injuryImmobilization of neckCervical collars




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Advantages and DisadvantagesPurported advantages of percutaneous tracheotomy include the avoidance oftransportation from the ICU to the operating room and the subsequentconfinement of multiple drug-resistant bacteria to the ICU, reduced cost,improved patient flow through the ICU with earlier placement of tracheotomy andsubsequent earlier discharge from the ICU, and improved patient and family

comfort. The earlier use of percutaneous tracheotomy has also been associatedwith a decrease in the incidence of nosocomial pneumonia (7,8).

In one study comparing early percutaneous dilational tracheotomy (within 48hours of intubation) with delayed tracheotomy (after 2 weeks of endotrachealintubation) in a prospective randomized study of 120 ICU patients projec ted torequire mechanical ventilation for >14 days, there were significant advantages tothe early tracheotomy. The

early percutaneous group showed significantly less mortality (31.7% vs. 61.7%),pneumonia (5% vs. 25%), and accidental extubations compared with theprolonged intubation group. The early tracheotomy group spent less time in theICU and less time on mechanical ventilation. There was also significantly moredamage to mouth and larynx in the prolonged translaryngeal intubation group(9).

Halo tractionNeck massesEnlarged thyroid glandTumor

Recent neck surgeryInfection of soft tissues of the neckSuperior vena caval syndromePediatric airwayUncorrectable coagulopathyHemodynamic instabilityEmergent airway neededHigh peak airway pressures (>20 cm H2O)

Relative ContraindicationsScarring from previous neck surgeryPrevious tracheostomy

Correctable bleeding diathesisIrradiation-induced tissue changes

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Purported disadvantages include the bedside nature o f the procedure with lesslighting, less exposure, and fewer instruments. Percutaneous tracheotomyrequires specific additional training of the surgeon. Multiple studies havedocumented an identifiable learning curve that exists for the first 20 casesperformed by an inexperienced surgeon (10). The surgeon must be prepared andable to immediately convert to a standard operative tracheotomy to avoidpotentially fatal complications.

Complications of PercutaneousDilational TracheotomyIn many studies, the rate of major and minor perioperative complications frompercutaneous dilational tracheotomy are actually lower than with standard opentracheotomies (11). Although there are some well-controlled prospective studiesaddressing safety, many retrospective s tudies are biased, with the patients whoare sicker being selected for standard open tracheotomy. In addition, the use ofthe bronchoscope to confirm proper entry into the trachea has been shown toprevent inadvertent paratracheal placement of the tracheotomy tube, but no t allstudies used endoscopy. There are many different types of commercial kits that

Figure 56.7 Percutaneous dilational tracheotomy with bronchoscopicmonitoring. The endotracheal tube is pulled back into the glottis so that thepuncture site can be seen with a bronchoscope .




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have varying degrees of safety. Finally, the level of experience of the surgeonsmay vary. Therefore, studies must be compared keeping in mind these variables.

Several prospective randomized trials comparing percutaneous and standard opentracheotomy found that either both techniques were associated with low rates ofserious complications or that the percutaneous technique had significantly lowerpostoperative complication rates (12,13,14,15). The mortality rate in all of these

studies was 0% to 0.6%, which compares favorably with the death rate of 0% to7.4% for standard open tracheotomy (16,17). Several articles show thatbronchoscopic monitoring of the technique is es sential to its safety (18). Thepossible complications encountered are listed in Table 56.5.

The most important immediate complications include misplacement of thedilator/tracheotomy tube in a paratracheal position within the soft tissues of theneck or laryngeal structures, hemorrhage, subcutaneous emphysema, damage tothe posterior tracheal wall, and death. The tight fit of the percutaneous tubeplaced via dilation tends to tamponade most bleeding. Long-term comp licationsparallel those of conventional tracheotomy, although some authors are concerned

about the possibility of a higher incidence of long-term tracheal stenosis with thistechnique. Although the dilation process theoretically

causes symmetric enlargement of a hole in the anterior tracheal wall, more likelythere is tearing of tracheal cartilage and soft tissue and displacement of theanterior wall of the trachea directly above the tracheostomy into the tracheallumen. During percutaneous dilational tracheotomy on a patient who has anendotracheal tube in place, the tube must be withdrawn to near the level of thevocal cords to afford space for the needle and dilators. During this p rocedure, itis possible for the endotracheal tube to become d isplaced, and unless personnelskilled at reintubation are available, acute, life-threatening loss of airway can

occur.

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TABLE 56.5 COMPLICATIONS PERCUTANEOUSTRACHEOTOMY

Intraoperative DeathMajor hemorrhagePneumothorax

PneumomediastinumTracheoesophageal fistula or lacerationParatracheal insertion (false passage)Failure to complete procedureMild hemorrhageHematomaAccidental extubation




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In cadaver studies, damage to the party wall between the esophagus and tracheais significant with blind passage of the guidewires and dilators. This damage canbe drastically reduced with the use of a bronchoscope. Initial blind puncture wasfound to be incorrect in 18% of patients and could be correc ted before dilationwhen bronchoscopy was used (19). The placement of the tube may be visualizedto avoid collapse of the anterior tracheal wall or creation of a false passage. Withproper patient selection and bronchoscopic guidance, the incidence ofpneumothorax, subcutaneous emphysema, hemorrhage, and paratracheal tubeplacement is very low.

The size of the bronchoscope should be considered because large bronchoscopesdecrease oxygen exchange in the endotracheal tube during the procedure.Hypercapnia may ensue, which is especially deleterious for neurosurg ical ortrauma patients with increased intracerebral pressure (20). Smaller-sized scopesthat allow for clear visualization are best suited for this procedure.

Comparison of Standard Open SurgicalandPercutaneous TracheotomyAlthough almost every patient requiring a tracheotomy is a candidate for astandard, open surgical tracheotomy, not every patient is a suitable candidate for

a percutaneous tracheotomy. Therefore, it is difficult to compare the twoprocedures because the patient populations may be very different. In studies thatdo compare the techniques, most found that percutaneous tracheotomies costless and were either as safe or safer than standard open tracheotomies (21).

Because careful patient selection is a critical factor in safely performingpercutaneous tracheotomies, there will always be patients who will be betterserved by performing standard tracheotomies. Surgical residency trainingprograms must teach both standard surgical tracheotomies and percutaneous

Subcutaneous emphysemaPostoperative

BleedingTracheitis

CellulitisWound infectionSubcutaneous emphysemaPulmonary edemaTracheal stenosisAccidental decannulationTracheotomy tube obstructionTracheomalaciaStomal granulation tissuePoor cosmetic resultPersistent stoma




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tracheotomies because there will be patients suitable for each technique.

Comparison of Minimally Invasive Open Tracheotomyand Percutaneous TracheotomyPatients considered appropriate candidates for percutaneous tracheotomy are alsooften good candidates for bedside open tracheotomy in the ICU setting.

Comparing these techniques is, therefore, more meaningful. Both techniques aresafe, but there is currently no standardized kit for the bedside open tracheotomyprocedure. Therefore, every institution must deve lop its own set of necessaryequipment and instruments. Because a bedside open tracheotomy depends ongood lighting and the use of standard operating equipment, some o f thelimitations of performing surgery at the bedside must be addressed. Most ICUbeds are not surgical beds, and space is limited in most ICU rooms . If acomplication occurs, there is often only a limited set of instruments available inthe ICU. These potential problems are less of an issue with the bedsidedilatational percutaneous tracheotomy technique.

Many institutions have developed protocols that include the use of portable boviecautery units, headlights, and reusable instrument sets, which allow bedside opentracheotomies to be performed safe ly and at a significant cost savings (22). Oftenonly the surgeons and respiratory therapists are needed. Because nobronchoscopy is required, bedside open tracheotomies are less expensive thanpercutaneous tracheotomies (23). A prospec tive study randomizing patients toeither procedure found that although both techniques are safe , bedside opentracheotomy had a lower incidence of postoperative complications and costs (24).

Conclusions about Percutaneous TracheotomyThere is a trend toward embracing minimally invasive procedures that are cost-

effective. The percutaneous tracheotomy technique appears to reduce hospitalcharges, expedite patient flow out of the ICU, and eliminate the need to transportthe patient by allowing the procedure to be performed in the ICU. Howeve r, itremains a controversial technique because of concerns about its safety and truecost-effectiveness. Many series in the literature support its safety, and someimportant conclusions have been reached (25).

First, patient selection is critical. Poor judgment regarding patient selection maylead to disastrous results. Bad candidates include patients with poor surgicallandmarks, obesity, untreatable coagulopathies, or neck masses . Second, there isa definite learning curve with this technique, and to underestimate the

importance of being carefully mentored is to invite serious comp lications. Third,bronchoscopic guidance significantly reduces the probability of seriouscomplications such as paratracheal insertion, pneumothorax, hemorrhage, anddamage to the posterior tracheal wall. It should be used during the procedure,preferably with video assistance, so that the entire team may see thebronchoscopic view. Finally, the safety features of the kit are important toconsider (26). A minimum use of sharp needles, wires, and introducers in thetrachea is critical. To prevent possible long-term complications, the angle ofentry of the dilators and tubes into the trachea must not be oblique; they should




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be straight through the tracheal rings.

If all of these safety issues are addressed, percutaneous tracheotomy currentlyrepresents a safe, expeditious way to manage an intubated patient's airway whilein the ICU. However, the surgical operator must be ready to convert to an opensurgical tracheotomy, and the instruments for this must always be available.

Surgical training should continue to emphasize all three common methods ofaccessing the airway so that the correct procedure may be performed on thepatient (27). Further studies will allow us to refine the indications and thetechnique to make it even safer and more cost-effe ctive.

Endotracheal Intubation

History of Endotracheal IntubationThe history of endotracheal intubation and endotracheal tubes is shown in Table56.6. Much controversy surrounds the question o f prolonged intubation as

opposed to tracheotomy, but most physicians pre fer tracheotomy except in thecare of neonates and patients with extensive burns, for whom the tracheostomycan be a source of continual contamination of the burn wounds. The choice ofintubation or tracheotomy also depends in part on the facilities available. Forexample, children with supraglottitis often are treated with short-term intubation.This approach mandates the availability of trained personnel around the clockwho can reinsert a tube that becomes dislodged.

Techniques of Intubation

Orotracheal IntubationOrotracheal intubation is undertaken ideally with the patient in the sniffingposition, the patient's neck flexed slightly on the chest, and the head extendedslightly on the neck. A right-handed operator directs a laryngoscope into the rightaspect of the mouth with the left hand holding the scope and pushing the tongueto the left. A Macintosh laryngoscope with a curved blade is directed into thevallecula, and the entire larynx is lifted anteriorly or ventrally to expose theglottis. A Miller laryngoscope with a straight blade is introduced under theepiglottis. It fixes the larynx at the petiole of the epiglottis and lifts the larynxanteriorly to expose the glottis. Other varieties of laryngoscopes, some withintegral video capabilities, now exist, but the Macintosh and the Miller are themost likely to be found on an emergency cart. The right hand is used to inse rt the

endotracheal tube, which should not be overly tight in the glottis. In children, anair leak around the tube is desirable. Slight pressure on the cricoid cartilage byan assistant sometimes helps to visualize the larynx. This maneuver also can helpto prevent aspiration of gastric contents by pressing the crico id cartilagebackward against the vertebral column to close the esophagus and help preventregurgitation. This technique is desirable when a patient has a full stomach.

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Nasotracheal IntubationNasotracheal intubation is used when it is important to leave the oral cavity clearof obstruction for operative procedures , when elective intubation is performed ona patient in whom orotracheal intubation is impossible, when endotrachealintubation is expected to be prolonged, and in emergencies when patients are

breathing spontaneously and there is a relative contraindication toorotrachealintubation.

In elective procedures in which the patient has received general anesthesia, thenasal cavity is topically anesthetized and decongested. It then is dilated withprogressively larger nasal airways that are copiously lubricated with viscouslidocaine or a water-soluble lubricant. The nasotracheal tube is introducedtransnasally into the pharynx, at which point a laryngoscope is introduced

TABLE 56.6 HISTORY OF INTUBATION

Date Event

AD1000

First account of orotracheal intubation with gold and silvercannulas is written by Avicenna.

1788 Charl es Ki te report s use of a curved metal cannula toresuscitate a drowning victim.

1878 Wil li am Macewen descr ibes orot rachea l intubat ion w ith a brasstube for the administration of anesthesia.

1889 Annandale devises a rubber tube.

1917 Magill makes a rubber tube standard.

1928 Guedel and Waters add a rubber cuf f to Magil l' s endotrachea ltube.

1964 F irst polyv inyl chlor ide tube w ith an integra l inf la tablepolyvinylchloride cuff is marketed.

1970 H igh-vo lume, l ow-pressure cuf fs a re i ntroduced.




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through the mouth, the tube is grasped with a Magill forceps, and the tube isintroduced through the glottis.

Transnasal intubation over a fiberoptic bronchoscope can be unde rtaken whendifficult intubation problems are expected. In this case, the patient usually isawake and the nose is prepared as described earlier. Topical anesthesia to thelarynx and pharynx with either orally introduced topical agents or a superior

laryngeal nerve block greatly increases patient comfort. The patient is sittingbecause this prevents the larynx from falling posteriorly as it does in the sup ineposition. The bronchoscope is introduced through the endotracheal tube, nose,and larynx into the cervical trachea. The endotracheal tube is advanced over thebronchoscope and into the trachea, and the bronchoscope is withdrawn. Mostbronchoscopes used for adults cannot be passed through an endotracheal tubesmaller than 7 French. This technique can sometimes also be help ful in difficultemergency situations.

Blind nasotracheal intubation is indicated in the treatment of patients awake

enough not to tolerate orotracheal intubation with a laryngoscope but when thereis no time to await anesthesia or it is unavailable. Patients must be breathingspontaneously if this technique is to be attempted. The endotracheal tube isintroduced through the nose and into the pharynx. The operator places his or herear over the proximal end of the tube as it is slowly advanced. When the tube is

just above the glo tt is , the operato r feels and hears the resp irat ions and wa it s fo rthe end of an expiration to advance the tube concomitantly with the nextinspiration. A variety of Ray tubes are available with an inherent bend superiorlyat the level of the lips or nares. Although these tubes can make draping easier,they also fix the distance between the lips or nares and the tip of theendotracheal tube. These tubes can be displaced f rom the glottis if the neck is

extended during the operative procedure.

Intubation in Head TraumaHead trauma raises a number of important issues for endotracheal intubation.First is the possibility of exacerbating cervical spinal trauma with intubation. Allpatients with severe head trauma are assumed to have a cervical spinal fractureuntil this is excluded radiologically. Midfacial trauma and concern about possiblefracture through the cribriform plate or fovea ethmoidalis usually arecontraindications to nasotracheal intubation for fear of intracranial placement ofthe tube. Nasogastric intubation likewise is contraindicated. In the treatment ofpatients with suspected cervical spine fracture who need an airway secu red,

options include blind nasotracheal intubation if the patient is breathing and thereare no midfacial fractures; cricothyrotomy; and orotracheal intubation withmanual inline axial traction of the cervical spine, which is the techniquerecommended by the American College of Surgeons.

Patients with increased intracranial pressure or rupture of the eye can be harmedfurther by the increase in intracranial pressure that accompanies difficult,struggling intubation of a patient who is combative. For these patients, someauthors recommend use of priming doses of pancuronium, topical lidocaine,

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sodium thiopental, and succinylcholine to try to avoid increases in intracranialpressure.

Difficult Intubation with Large-Bore LaryngoscopeIf one performs laryngoscopy often, the situation eventually arises in which whatwas expected to be a simple intubation suddenly proves difficult. One technique

that can be helpful in this situation is use of a large-bore operating laryngoscope,such as the Dedo or Jako scope, to ass ist intubation. The laryngoscope usually isimmediately available. The rigid nature and wide bore of the laryngoscope allowan experienced operator to fix the larynx and expose the glottis. An endotrachealtube with the anesthesia adapter removed from the proximal end can be inse rtedthrough the closed tube of the laryngoscope. The proximal end of the tube isgrasped with a cup forceps to stabilize it, and the laryngoscope is removed fromaround the endotracheal tube. The anesthesia adapter is reattached , andventilation is begun.

Use of Bronchoscope for IntubationA rigid bronchoscope is a time-tested tool for secu ring an airway. An experiencedoperator can secure an airway in this manner, even if attempts with othermethods have failed. Because it is rigid, the bronchoscope sometimes can beforced through a partially obstructed glottis. The rigid bronchoscope also allowscontrolled suction of secretions or blood and concomitant ventilation.Tracheotomy can be undertaken, if indicated, over a bronchoscopically controlledairway.

New Types of TubesOne of several new types of airway tubes can be used, although the exact place

in airway management remains uncertain. The laryngeal mask airway andesophagotracheal combination tube (see Chapter 57 ) are the most widely used.The laryngeal mask airway has probably gained the widest acceptance for use inotherwise uncomplicated outpatient surgery. It does not protect the airway fromaspiration, but it has been used in emergency management of the airway to buytime or when endotracheal intubation has failed. A flexible bronchoscope can beinserted through this device, and intubation can be performed over thebronchoscope. A laryngeal mask airway can be used as an adjunct to flexiblebronchoscopy, to assist with percutaneous tracheotomy, and du ringcardiopulmonary resuscitation. The main advantages are increased speed andease of placement by inexperienced personnel, improved hemodynamic stability

during induction of and emergence from anesthesia, minimal increase inintraocular pressure after insertion, reduced anesthetic requirements for airwaytolerance, and lower frequency of coughing during emergence. The other devicesmentioned are used mostly for the emergency control of the airway by personneluntrained in endotracheal intubation. Several other new adjuncts to intubationinclude the light wand, Bullard laryngoscope, and retrograde intubation.

Complications of Intubation




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The complications of intubation are listed in Table 56.7.

Acute Pulmonary EdemaSome patients who have labored under partial airway obstruction for some timecan have a rapid onset of pulmonary edema when the obstruction is sudden lyrelieved. This so-called postobstructive pulmonary edema is believed to be

caused by the sudden loss of highly negative intrathoracic

pressure during inspiration and positive pressure during expiration. The result isa rapid increase in systemic venous return and subsequently in pulmonaryhydrostatic pressure with an imbalance in the pressure gradients across thealveolar membrane. This edema can occur in the operating room or, morecommonly, in the recovery room after extubation. Frothy fluid is present in theendotracheal tube, or the patient has hypoxia and inadequate ventilation in therecovery room. Chest radiographs show pulmonary edema. It is managed withinstitution of mechanical ventilation with continuous positive airway pressure andpositive end-expiratory pressure. Diuretics also can be helpful (28).

Improper Tube Placement

An endotracheal tube can be passed through the mucosa of the pyriform sinusinto the soft tissues of the neck. This usually occurs during difficult emergencyintubations in which excessive force has been used, and it can be acute withsubcutaneous emphysema or occur later with deep neck infection. Theendotracheal tube can be passed into the esophagus unwittingly. Ventilationcauses gastric distention, and hypoxia occurs. Modern carbon dioxide monitorsoften can detect the absence of returned carbon dioxide. The endotracheal tubecan be advanced too far, usually into the right mainstem bronchus, which cancause atelectasis of the left lung. After intubation, the chest always is examined

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TABLE 56.7 COMPLICATIONS INTUBATION

Improper tube placementPulmonary edemaLaryngeal stenosisTracheoesophageal fistula

Recurrent laryngeal nerve injurySinusitis




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by means of auscultation for equal and bilateral breath sounds. In cases oflaryngeal trauma, attempts at translaryngeal endotracheal intubation can causefurther damage to the larynx and even convert a partial injury to completelaryngotracheal separation. For this reason, translaryngeal intubation iscontraindicated in cases of significant laryngeal trauma, unless no other means ofsecuring the airway is available (Fig. 56.8).

Long-Term IntubationLong-term endotracheal intubation can damage the larynx by causing laryngealstenosis. Largely for this reason, long-term intubation has given way to timelytracheotomy. The injury usually occurs at the narrowest portion of the airway. Ininfants and children, this is the subglottic larynx. In adults, the glottis is thenarrowest portion, and it may bear the brunt of the injury. Tube motion,infection, and high cuff pressure add to the injury. Tube motion can be minimizedwith adequate stabilization of the tube. Some authors believe a nasotracheal tubeis better stabilized by the tissues of the nasopharynx and nose than is anorotracheal tube.

Tubes of the proper size must be used. The smallest tube that allows adequateventilation of the patient usually is used. For children, an air leak around theuncuffed tube is desirable. The pumping action of a ventilator adds to tubemotion, as does the thrashing of an inadequately sedated patient. Cuffs areinflated only to the minimally occlusive volume, and cuff pressures should bemonitored several times a day. Pressures less than 25 cm water are maintainedwhenever possible. Neonates who have needed long-term intubation notinfrequently develop subglottic stenosis, whereas adu lts develop ulceration of the

Figure 56.8 Laryngotracheal separation. The tip of the endotracheal tube isvisible in the soft tissues of the right neck (arrow). There is massivesubcutaneous emphysema.




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posterior larynx, where the tube tends to sit. This can cause intubationgranuloma

over the vocal processes o f the arytenoids or frank glottic stenosis, frequentlyposteriorly.

Tracheoesophageal fistula can be caused by chron ic intubation. The incidence

likely increases with the concomitant presence of an endotracheal and anasogastric tube. This is a rare complication that often manifests as severeaspiration.

The recurrent laryngeal nerve enters the larynx between the cricoid and thyroidcartilages near their articulation and can be pinched in this position by anendotracheal tube. Patients develop recurrent laryngeal nerve paralysis.

Most patients who have a nasotracheal tube in place for more than several dayshave obstruction of drainage from the paranasal sinuses, which predisposes tothe development of purulent sinusitis.

Emergency Management of the AirwayThe best technique for managing the airway in an emergency depends on theclinical situation. In cases associated with trauma, the cervical spine must beconsidered unstable until proved otherwise, and techniques aimed at protectingthe spine from further iatrogenic harm must be used. If the midface istraumatized, one must be cognizant of the possibility of skull-base fracture, anda transnasal approach is used with great care, if at all. The patient's level ofconsciousness also must be cons idered. Awake and alert patients usually do nottolerate oral intubation with a laryngoscope. An algorithm for the emergencymanagement of the airway is shown in Figure 56.9.

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Figure 56.9 Algorithm for emergency management of the airway.




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Noninvasive Ventilation TechniquesThe use of noninvasive ventilation techniques using positive pressure delivered

via a tightly fitting face mask has been investigated in the ICU as an alternativeto tracheotomy in patients having difficulty weaning from mechanical ventilation.In a study of patients who had failed a weaning trial for 3 consecutive days, thegroup randomly assigned to extubation with noninvasive ventilation had fewerdays of mechanical ventilation, fewer days of ICU care, fewer days ofhospitalization, less need for tracheotomy to withdraw ventilation, lowerincidence of nosocomial pneumonia and septic shock, and inc reased 90-daysurvival than the conventional-weaning group (29). Earlier extubation withnoninvasive ventilation results in shorter mechanical ventilation and length ofstay, less need for tracheotomy, lower incidence of complications, and improvedsurvival in these patients.

Areas for Future StudyThe role of percutaneous dilational tracheotomy continues to expand, and furtherwork is needed to define the best way to perform this procedure and to determineits appropriate earlier use in the ICU setting to assist with weaning frommechanical ventilation and improve overall outcomes. A comparison betweenpercutaneous dilational tracheotomy and newer noninvasive methods ofventilation needs to be undertaken to define the precise role of each in

this setting. The addition of ultrasound might be beneficial to the percutaneoustechnique. Further refinement and standardization of the percutaneous kits areneeded. There is room for improvement in the design of endotracheal andtracheostomy tubes. The field of biomaterials is likely to produce materials thatare less traumatic to the laryngeal and tracheal tissues. Changes in design, suchas the shape of tube cuffs, are likely to result in improved tubes in the future.New laser-safe tubes are in a state of rapiddevelopment.

Highlights

The development of tracheotomy preceded that of endotracheal intubationby several centuries.

The four basic indications for tracheotomy and intubation are to bypass

upper airway obstruction, to assist respiration for prolonged periods, toassist with the clearance of lower respiratory tract secretions, and toprevent aspiration of oral or gastric secretions.

Techniques used for tracheotomy vary with the clinical setting and generallycan be divided into emergencies, timely procedures, and electiveprocedures. Emergency tracheotomy is to be avoided whenever possible.

Cricothyrotomy is best in the emergency treatment of adults when

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endotracheal intubation is contraindicated and there is no intrinsic trauma orinfection of the larynx.

Techniques such as transcricothyroid needle puncture can be used to buytime until someone more skilled in definitive management of the airway isavailable.

Pediatric tracheotomy carries risk and morbidity peculiar to it and requires

special care and knowledge.

Complications of tracheotomy can be divided into early and late. The mostcommon early complications are tube obstruction and displacement. Latecomplications include laryngeal and tracheal stenosis. Complications occu rmore frequently among pediatric patients than among adults.

High-volume, low-pressure tube cuffs are extremely useful in preventingsome of the more devastating complications of prolonged intubation. Thetechnique and route of endotracheal intubation vary with the clinicalsituation. Orotracheal and nasotracheal routes can be used. Blindnasotracheal intubation and intubation over a fiberoptic bronchoscope are

useful techniques in some clinical situations. A patient with head trauma poses special problems to the physician

concerned with securing an airway. The possibility of cervical spinal traumamust be considered in every case.

Otolaryngologisthead and neck surgeons must be intimately familiar withmanagement of a critical airway. These clinicians are uniquely qualified todeal with this difficult, life-threatening situation.

Percutaneous dilational tracheotomy is now an accepted procedure in theICU setting. Proper patient selection, appropriate training, and the use ofbronchoscopic guidance are essential to its safe utilization.

References

1. Fry TL, Fischer ND, Jones RO, et al. Comparisons of tracheostomy incisionsin a pediatric model. Ann Otol Rh inol Laryngol 1985;94: 450453.

2. Koltai PJ. Starplasty: a new technique of pediatric tracheotomy. ArchOtolaryngol Head Neck Surg 1998;124:11051111.

3. Carron JD, Derkay CS, Strope GL, et al. Pediatric tracheotomies: changingindications and outcomes. Laryngoscope 2000;110: 10991104.

4. Smith DK, Grillone GA, Fuleihan N. Use of postoperative chestx-ray afterelective adult tracheotomy. Otolaryngol Head Neck Surg1999;120:848851.




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5. Gianoli GJ, Miller RH, Guarisco JL. Tracheotomy in the first year of life. AnnOtol Rhinol Laryngol1990;99:896901.

6. Carr MM, Poje CP, Kingston L, et al. Complications in pediatrictracheostomies. Laryngoscope 2001;111:19251928.

7. Van Natta TL, Morris JS, Eddy VA, et al. Elective bedside surgery incritically injured patients is safe and cost-effective. Ann Surg 1998;227:618624.

8. Kearney PA, Griffen MM, Ochoa JB. A single-center 8-year experience withpercutaneous dilational tracheostomy. Ann Surg 2000; 231:116.

9. Rumbak MJ, Newton M, Truncale T, et al. A prospective, randomized, study

comparing early percutaneous dilational tracheotomy to prolongedtranslaryngeal intubation (delayed tracheotomy) in critically ill medicalpatients. Crit Care Med2004; 32:17961797.

10. Massick DD, Yao S, Powell DM, et al. Bedside tracheostomy in theintensive care unit: A prospective randomized trial comparing open surgicaltracheostomy with endoscopically guidedpercutaneous dilational tracheotomy.Laryngoscope 2001;111: 494500.

11. Friedman Y, Mayer AD. Bedside percutaneous tracheostomy in critically ill

patients. Chest1993;104:532535.

12. Kearney PA, Griffen MM, Ochoa JB. A single-center 8-year expe rience withpercutaneous dilational tracheostomy. Ann Surg 2000; 231:116.

13. Gysin C, Dulguerov P, Guyot JP, et al. Percutaneous versus surgicaltracheotomy. A double-blind randomized trial. Ann Surg1999;203:708714.

14. Heikkinen M, Aarnio P, Hannukaninen J. Percutaneous dilational

tracheostomy or conventional surgical tracheostomy? Crit Care Med2000;28:17.

15. Wu JJ, Huang MS, Tang GJ, et al. Percutaneous dilational tracheostomyversus open tracheostomya prospective, randomized, controlled trial. JChin Med Assoc2003;66:467473.




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16. Manara AR. Experience with percutaneous tracheostomy in intensive care:the technique of choice? Br J Oral Maxillofac Surg 1994; 32:155160.

17. Toursarkissian B, Zweng TN, Kearney PA, et al. Percutaneous dilationaltracheostomy: report of 141 cases. Ann Thorac Surg 1994; 57:862867.

18. Barba CA, Angood PB, Kauder DR, et al. Bronchoscopic guidance makespercutaneous tracheostomy a safe, cost-effective, and easy-to-teachprocedure. Surgery1995;118:879883.

19. Winkler WB, Karnik R, Seelmann O, et al. Bedside percutaneous dilationaltracheostomy with endoscopic guidance: Experience with 71 ICU patients.Intensive Care Med1994;20:476479.

20. Muttini S, Melloni G, Gemma M, et al. Percutaneous or surgicaltracheotomy. Prospective, randomized comparison of the incidence of earlyand late complications. Minerva Anestesiol1999; 165:521527.

21. Levin R, Trivikram L. Cost/benefit analysis of open tracheotomy, in theOR and at the bedside, with percutaneous tracheotomy. Laryngoscope2001;111:11691173.

22. Wang SJ, Sercarz JA. Blackwell KE, et al. Open bedside tracheotomy inthe intensive care unit. Laryngoscope 1999;109:891893.

23. Moe KS, Stoeckli SJ, Schmid S, et al. Percutaneous tracheos tomy: Acomprehensive evaluation. Ann Otol Rh inol Laryngol 1999;108: 384391.

24. Massick DD, Yao S, Powell DM, et al. Bedside tracheostomy in theintensive care unit: A prospective randomized trial comparing open surgicaltracheostomy with endoscopically guided percutaneous dilationaltracheotomy. Laryngoscope 2001;111: 494500.

25. Bikhazi, NB. Percutaneous tracheotomy: has its time arrived? ArchOtolaryngol Head Neck Surg 2001;127:221223.

26. Fazekas-May MA. Percutaneous tracheotomy: is it time to reconside r ourapproach? Arch Otol aryngol Head Neck Surg 2001;127: 223224.

27. Donovan DT. Percutaneous tracheotomy may be useful in both surgical

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and intensive care settings, but is no replacement for the open procedure.Arch Otolaryngol Head Neck Surg 2001;127: 225226.

28. Feinberg AN, Shabino CI. Acute pulmonary edema complicatingtonsillectomy and adenoidectomy. Pediatrics 1985;75:112114.

29. Ferrer M, Esquinas A, Arancibia F, et al. Noninvasive ventilation duringpersistent weaning failure: a randomized controlled trial. Am J Respir Cri tCare Med2003;168:7076.


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56.Tracheotomy and ion