(1)
Department of Surgery Division of Surgical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Introduction
The creation of a surgical airway by directly accessing the trachea is most often indicated in one of two situations, (1) chronically ventilator-dependent patients who require a durable airway and (2) patients with an acute loss of airway patency who require an emergency airway.
The need for a tracheostomy is commonly encountered in the intensive care unit when a critically ill patient is too unstable or too weak to be weaned from a ventilator. Long-term use of an oral endotracheal tube is associated with damage to the larynx; therefore, patients who are estimated to require mechanical ventilation for more than 2 weeks should undergo early tracheostomy.
Although sometimes family members may be resistant to the idea of a tracheostomy, this procedure actually provides several benefits to the patient. A tracheostomy facilitates weaning from the ventilator, since—by shortening the amount of tubing required in the circuit—the work of breathing is significantly decreased. Also, by eliminating the tubing in the mouth, a tracheostomy allows for better oral hygiene and is more comfortable for the patient, thus reducing sedation requirements. A tracheostomy allows for more effective control of airway secretions, thereby improving oxygenation. Finally, as the patient’s status improves, a tracheostomy can be fitted with a speaking valve, which allows the patient to speak, without compromising the presence of a secure airway.
While a tracheostomy is the most secure airway, it is difficult to perform in emergency situations. An urgent airway may be required in any situation where patency of the airway is compromised, such as in anaphylaxis, aspiration of a foreign body, failed attempts at orotracheal intubation, or massive facial trauma. In the setting of extensive injury to the face and mouth, even if the airway itself is patent, the presence of blood and debris can hinder the visualization required for oral intubation. In these situations, a cricothyroidotomy allows rapid bypass of the oropharynx, thus restoring normal air supply (Fig. 25.1). A cricothyroidotomy is made higher up in the neck than a tracheostomy, through the cricothyroid membrane. This allows for rapid access to the airway, with minimal surgical equipment, and without the need to hyperextend the neck. While cricothyroidotomy has the benefit of being easier to perform, its long-term use is associated with subglottic stenosis, a type of airway stricture. Therefore, patients who require intubation for longer than approximately 3 days should undergo conversion to a formal tracheostomy, which is a more durable airway.
Fig. 25.1
Depiction of an emergency cricothyroidotomy; note that the incision is through the cricothyroid membrane [Reprinted from Lennquist S. Incidents Caused by Physical Trauma. In: Lennquist S (ed). Medical Response to Major Incidents and Disasters: A Practical Guide for All Medical Staff. Heidelberg, Germany: Springer Verlag; 2012: 111-196. With permission from Springer Verlag]
Surgical Technique
The procedure for a tracheostomy begins by positioning the patient with hyperextension of the neck to allow for access to the lower tracheal rings. Either a vertical or transverse skin incision can be used. The platysma is divided, and the underlying strap muscles are spread apart at the midline. The thyroid isthmus is identified and gently retracted upward or divided as needed to visualize the second or third tracheal ring (Fig. 25.2). An opening is made in the trachea by incising the center of a tracheal ring and spreading the trachea open. The patient’s oral endotracheal tube is slowly backed out and the tracheostomy tube is inserted in through the trachea. The balloon is inflated, the tracheostomy is connected to the ventilator, the presence of end-tidal CO2 is confirmed, and the tracheostomy is secured in place. The skin and subcutaneous tissues can be loosely approximated or left open to heal by granulation.
