Tracheostomy: What is it? Indications, Contraindications, Planning and Prevention of Complications

It is a surgical procedure that creates a surgical airway in the cervical trachea.

It is performed more frequently in patients who have suffered a trauma or a serious injury.

Infectious and neoplastic processes are less common in diseases that require a surgical airway.

Tracheostomy is a surgical access procedure in the duct between the upper airways and the lungs that supplies moist hot air and expels carbon dioxide.

Failure or blocking at any point along that conduit can be corrected more easily with the provision of access for mechanical fans and suction equipment.

In the case of obstruction of the upper airway, the tracheostomy provides a low resistance path for air exchange.

The trachea is made with a cross section, is D-shaped and measures approximately 11 cm in length.

This structure begins from the lower part of the larynx (cricoid cartilage) in the neck, opposite the sixth cervical vertebra, to the intervertebral disc between the vertebrae T4-5 in the thorax, where it is divided into the carina on the right main stem and left.

Indications

The advent of the era of antibiotics and advances in anesthesia have made tracheostomy a commonly performed elective procedure. However, it is important to keep in mind that there are situations in which the Tracheostomy is quite urgent.

This usually involves the patient who needs a surgical airway immediately due to impending obstruction of the airway.

For the realization of a Tracheostomy the following should be taken into account:

  • Congenital anomaly: that the patient suffers, for example, from laryngeal hypoplasia.
  • Obstruction: foreign body of the upper airway that can not be displaced with Heimlich and basic cardiac life support maneuvers.
  • Pathological supraglottic or glottic condition: the affected could suffer from infection, neoplasia, bilateral paralysis of the vocal cords, among others.
  • Neck trauma: this can cause serious injuries to the thyroid, cricoid cartilages or hyoid bone.
  • Facial fractures: this can lead to upper airway obstruction, such as comminuted fractures of the midface and jaw.
  • Edema of the upper airway: the procedure is performed due to trauma, burns, infection or anaphylaxis .
  • Prophylaxis: is performed as a preparation for extensive head and neck procedures during the convalescence period.
  • Severe sleep apnea : when this condition is not modifiable, the tracheostomy is performed to continuous positive pressure devices in the respiratory tract or other less invasive surgery.

Tracheostomy can also be performed to provide a long-term route for mechanical ventilation in cases of respiratory failure as in the following cases:

  • Inadequate cough due to chronic pain or weakness.
  • Aspiration and inability to manage secretions.
  • The tube with sleeve allows to seal the trachea from the esophagus and its reflux content. Therefore, this intervention can prevent aspiration and provide for the removal of any aspirated substance.

However, some researchers argue that the risk of aspiration does not actually decrease, since secretions can leak around the cuffed tube and reach the lower airway.

Additional diagnoses for which the tracheostomy is often considered at the beginning of treatment include botulism , amyotrophic lateral sclerosis, and cervical spine injury, among others.

Contraindications of Tracheostomy

There are no absolute contraindications for Tracheostomy. A strong relative contraindication for discrete surgical access to the airways is the anticipation that the blockage is a laryngeal carcinoma .

In this case, the definitive procedure is planned and the previous manipulation of the tumor is avoided because it can cause a greater concurrence incidence. Temporal tracheostomy can be performed just below the first tracheal ring in anticipation of a laryngectomy at a later time.

End-of-life problems can also affect the decision to perform a tracheostomy, as it may represent a greater mechanization of patient care for family members.

Procedure planning

Tracheostomies can be performed through an open or percutaneous technique. Open tracheostomy is one of the oldest procedures and remains the procedure of choice for some trauma centers.

However, the use of percutaneous tracheostomy has been increasing since its introduction in the 1980s.

Studies have supported percutaneous tracheotomies over open tracheotomies. But the final technique depends on the experience and comfort of the surgeon, in addition to the guidelines of the facility where this procedure will be performed.

The following patients are commonly recognized as unfavorable candidates:

  • Patients with obesity.
  • Patients with abnormal or palpable mean line neck anatomy.
  • Patients who need emergency airway.
  • Patients with coagulopathy.
  • Pediatric patients.
  • Patients with enlarged thyroid.

Prevention of complications

Possible complications are due to a direct injury. Head ultrasound is often used to examine the tracheotomy site during the planning stage, especially for percutaneous tracheotomies.

This is to identify the vessels that may be under the intended incision and to help prevent injury.

The innominate artery, or brachiocephalic trunk, crosses from left to right in front of the trachea at the upper thoracic inlet and is just below the sternum.

The trachea is membranous posterior and is formed by cartilaginous rings semicircular anteriorly and laterally. The spaces between the rings are membranous.

Recurrent laryngeal nerves and lower thyroid veins that travel in the tracheoesophageal groove are paratracheal structures vulnerable to injury if the dissection deviates from the midline.

The recurrent laryngeal nerve is also vulnerable to tracheostomy tube cuff injuries, particularly if the cuff is too inflated.

The large vessels (ie, the carotid arteries, the internal jugular veins) could be damaged if the dissection was too far away, which is a real risk in pediatric or obese patients.

The thyroid gland lies anterior to the trachea with a lobe on both sides and the isthmus, which crosses the trachea approximately at the level of the second and third tracheal rings. This tissue is extremely vascular and should be divided with careful hemostasis.