2010 BC Decker Inc ACS Surgery: Principles and Practice

2 HEAD AND NECK 8 TRACHEOSTOMY 1

DOI 10.2310/7800.S02C08
04/10
8 TRACHEOSTOMY
H. David Reines, MD, FACS, and Elizabeth Franco, MD, MPH&TM
History
The word tracheotomy rst appeared in Libri Chirgurae 12,
published in 1649, but it was not until Laurence Heruter,
a German surgeon, reintroduced it that it became part of
modern medicine. It was initially performed as a lifesaving
procedure to establish an airway. Alexander the Great is
reported to have used his sword to open the trachea of a
suffocating soldier. The term tracheotomy is dened as a surgi-
cal creation of an opening in the anterior trachea that can be
reversible and temporary, whereas, technically, tracheostomy is
the formation of an opening into the trachea by suturing the
edges of the opening to the skin of the neck. However, over
the years, the two terms have been used interchangeably. For
this document, we use the term tracheostomy to describe the
procedure.
Indications
The indication for a tracheostomy has changed over the
years. Originally, it was conceived as a method to obtain an
airway for obstruction from infections, neoplasm, or trauma.
The most common indications for modern tracheostomy
are prolonged ventilation for respiratory failure and airway
protection following traumatic brain injury with neurologic
dysfunction.
Patients requiring tracheostomy or cricothyroidotomy fall
into four categories:
1. Emergency for airway control, that is, airway obstruction
from the epiglottis, foreign-body aspiration, laryngeal
trauma, or maxillofacial trauma
2. Semielective for patients requiring prolonged intubation or
mechanical ventilation for respiratory failure or high spinal
cord injury
3. Elective for airway protection, that is, traumatic brain
injury, stroke, sleep apnea, or vocal cord problems
4. Elective for long-term airway access. Permanent tracheos-
tomies are used to maintain airway access when patients
undergo major head or neck dissection for tumors of the
larynx and the base of the tongue.
Patients who arrive with either acute airway compromise
from neck trauma or facial burns should rst undergo an
attempt at oral intubation, and if this fails, an emergent surgi-
cal airway is required.
Laryngoscopy should be attempted prior to performing
surgical airway. If a patient arrives talking, but there is
evidence of hoarseness with increasing airway compromise,
the surgeon should be prepared for a surgical airway if
oral intubation is unsuccessful. When an attempt at oral
intubation fails and ventilation is a problem, immediate cri-
cothyroidotomy should be performed. A semielective surgical
airway should be undertaken in a patient whose injuries may
result in progressive laryngeal and cervical soft tissue edema
prior to decompensation from respiratory distress. Patients
with a Glasgow Coma Scale (GCS) less than or equal to
8 cannot protect their airway, and intubation should be
performed immediately. If this is not possible, then a surgical
airway should be considered prior to transporting the
patient.
Early Tracheostomy
If the patient is ventilator dependent or has severe head
injury and will need prolonged airway protection, early
tracheostomy should be considered when intracranial pres-
sure is not elevated. Early tracheostomy is dened as occur-
ring at or before 7 days, whereas late tracheostomy occurs
after 7 days. Early tracheostomy has been associated with
decreased incidence of ventilator-associated pneumonia,
decreased days of mechanical ventilation, decreased hospital
stay, decreased intensive care unit (ICU) length of stay,
and increased patient comfort. Although no study has dem-
onstrated a decrease in overall mortality with early tracheos-
tomy, tracheostomy does provide easier access for suctioning
and allows patients to be liberated from the ventilator without
the loss of an airway.
Pertinent Anatomy
The trachea lies relatively supercially in the anterior
neck covered by the strap muscles midline and the platysma.
The rst tracheal ring is just below the cricothyroid, whereas
the next three rings may lie beneath the thyroid isthmus. The
sixth through seventh rings lie low in the neck and into
the sternal notch [see Figure 1]. When performing a tracheos-
tomy, knowledge of the normal and potentially abnormal
vasculature is imperative. Care must be taken with a horizon-
tal incision to avoid bleeding from injury to the anterior
jugular vein. Other potential causes of hemorrhage may arise
from injury to a high-riding innominate artery, a medially
placed carotid artery, and the thyroid ima vessels in the
midline. Tumors, hematoma, and edema can cause tracheal
deviation from midline. Other anatomic variants should
also be considered. An obese patient may require deeper
dissection, longer instruments, and the use of an extra-long
tracheostomy tube. The length of the neck and the distance
from the jaw to the thyroid cartilage should also be examined.
Patients with a known or potential neck injury or with kypho-
sis must be positioned without extension. Access to the
trachea may be compromised, and plans for dissecting the
thyroid isthmus should be considered.
* The authors and editors gratefully acknowledge the contribu-
tions of the previous author, Ara A. Chalian, MD, FACS, to
the development and writing of this chapter.
Indicates the text is tied to a SCORE learning objective. Please see the
HTML version online at www.acssurgery.com.
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Physiology
When undergoing a tracheostomy, ideally, the patient
should be adequately ventilated and hyperoxygenated in
anticipation of a period of apnea during tracheostomy tube
placement. An oxygen saturation of 100% and a normal
pH and carbon dioxide tension (PCO
2
) are desirable at the
start of an elective tracheostomy. Use of 100% oxygen during
the procedure will help maintain adequate oxygenation
throughout the procedure. When an emergency cricothyroid-
otomy or tracheostomy is necessary, an attempt should be
made to preoxygenate and ventilate.
Counseling and Informed Consent
The patient, the family, or both should be advised of the
risks and benets of a tracheostomy. Commonly discussed
issues, including pain, mortality, and the range of possibilities
of early and late complications (see below), should be on
the consent form. A tracheostomy should be proposed as the
best option for the patient requiring prolonged mechanical
ventilation or airway protection. Tracheostomy contributes to
patient comfort, allowing improved oral care, oral alimenta-
tion, and speaking as well as the potential for earlier liberation
from the ventilator.
Site of the Procedure
Elective open tracheostomy requires good lighting and
electrocautery. Some may nd open tracheostomy in the ICU
more ergonomically difcult than in the operating room
(OR) because the patient is on a hospital bed; however,
nding OR time and transporting the patient may be incon-
venient. Several studies comparing bedside open to percuta-
neous tracheostomies nd the techniques to be essentially
equivalent in outcome with the open technique and possibly
lower in cost. Percutaneous tracheostomy is most commonly
performed at the bedside, in the ICU, and does not require
the same lighting or instrumentation and nursing availability
that an open tracheostomy does. A cricothyroidotomy is
frequently performed in the trauma bay, although it may be
executed anywhere and requires the least amount of instru-
mentation. Emergency tracheostomy and cricothyroidotomy
are frequently not performed in the OR.
Anesthesia
Anesthesia can frequently be given as conscious sedation
and/or local anesthesia with epinephrine. Paralysis should be
avoided when possible in a patient with any spontaneous
breathing.
Patient Positioning
Extension of the neck is desirable; however, if the patient
has a known or potential cervical spine injury, operation in
the neutral position is necessary. When possible, the patient
should be placed on an operating table with a shoulder roll
and a foam pad (donut) under the head. When the neck can
be extended, the head rest of the surgical bed can be lowered
and the patient placed in a 30 head elevation position to
decrease venous pressure. Extending the head allows better
palpation of the landmarks. If cervical spine precautions are
necessary, the posterior portion of the cervical collar should
remain in place and the head stabilized by a team member.
Another alternative is to stabilize the neck with bilateral head
rolls with tape over the forehead and chin extending across
the bed.
Operative Techniques
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Cricothyroidotomy
Cricothyroidotomy is generally performed for emergent
control of the airway. Inability to secure an airway, especially
with severe facial trauma, requires immediate access to the
trachea. A cricothyroidotomy can be performed rapidly and
does not risk the anatomic problems of a tracheostomy
because the cricothyroid membrane is thin and closest to
the skin directly under the thyroid membrane If a #5 or #6
tracheostomy tube is not available, an endotracheal tube can
be introduced for immediate airway access.
Transtracheal Needle Ventilation and Oxygenation
Transtracheal needle access also can be used in emergency
situations. A large-bore 12- or 14 gauge angiocatheter or a
pulmonary artery catheter introducer sheath is placed through
the cricoid membrane and attached to oxygen tubing with
the capability of providing oxygen at 50 psi. A hole in the
tubing is nger-occluded and intermittently opened to allow
for ventilation. Adequate ventilation can be provided for
Figure 1 Surgical tracheostomy. A transverse cutaneous
incision is made that is approximately 2 to 3 cm long (or as
long as is necessary for adequate exposure). The extent of ap
elevation may be 1 cm or less.
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20 to 30 minutes. This method is best used as a bridge
while awaiting the proper equipment and support for an
orotracheal or surgical airway.
oicN 1nacncos1o:v
Steps
1. Incision of the skin. The patient should be assessed for a
high-riding innominate artery, abnormally placed vessels,
and tracheal deviation. Incision can be made either verti-
cally or horizontally. The horizontal scar heals better
than the vertical scar. However, visualization, especially
if the neck cannot be extended, is frequently easier in a
vertical incision. Damage to the anterior jugular veins like-
wise is less likely with a vertical incision. In an emergency,
a longer vertical incision can facilitate exposure while
avoiding the subplatysmal anterior jugular veins [see
Figure 2]. In general, the incision should be made midway
between the cricoid cartilage and the sternal notch.
The size of the incision is up to the individual surgeon.
However, a minimum of 2 to 2.5 cm is desirable.
Subsequent dissection must be performed perpendicular
to the trachea. A common mistake when dividing the sub-
cutaneous tissue is to deect in a slightly oblique fashion,
arriving lower in the trachea than anticipated.
2. Retracting the strap muscles. The midline raphe is divided
and an assistant with Senn or Army-Navy retractors
or with a self-retraining retractor then retracts the strap
muscles laterally. Undermining should be minimized to
decrease the potential creation of dead-space areas. In
the case of a malignant neoplasm overlying the thyroid
compartment, the anatomic landmarks may be less clear.
In such a case, palpation of the thyroid cartilage and
dissecting caudally are helpful. Care must be taken, espe-
cially in women, to palpate the thyroid and not the hyoid
cartilage [see Figure 3].
3. Dissection of the thyroid gland. The thyroid isthmus fre-
quently lies in the eld of dissection. Because its size and
thickness vary greatly and can vary from 5 to 10 mm in
vertical dimension, dissection of this can be undertaken,
and, in many cases, immobilizing the trachea and retract-
ing the isthmus either superiorly or inferiorly to place the
tracheal incision in the second or third tracheal interspace
can be accomplished [see Figure 4]. However, if the isth-
mus is a problem, especially in cases where the neck cannot
be extended, it can be divided and the edges ligated either
with ties or with a Harmonic scalpel. When there is an
isthmus nodule, the isthmus should be removed for diag-
nostic and therapeutic purposes. Recurrent laryngeal
nerves should not be directly in the operative eld and are
rarely at risk as long as one stays in the midline anterior on
the trachea. If signicant deviation of the trachea is noted,
the nerves may be injured. Because the blood supply to the
trachea is laterally based, one should not encounter them.
However, a thyroid ima vessel is frequently noted in the
lower portion of the isthmus, and this may need to be
ligated prior to dissection.
4. Incision of the trachea. Tracheostomy should be performed
with a sharp blade. The pretracheal tissues may be
coagulated with a bipolar electrocautery. The opening of
the airway may bring volatile gasses into the operative
eld; therefore, monopolar electrocautery should be
avoided if volatile gasses are in use. Several types of
incisions are possible:
Figure 2 Surgical tracheostomy. Retractors are placed, the
skin is retracted, and the strap muscles are visualized in the
midline. The muscles are divided along the raphe and then
retracted laterally.
Figure 3 Surgical tracheostomy. With the strap muscles
retracted, the thyroid isthmus is visualized, and the inferior
(or superior) edge of the isthmus is dissected down to the
trachea. The isthmus is then retracted superiorly (or inferi-
orly) or divided to permit visualization of the trachea before
the tracheal incision is made.
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a. Linear incision. This transverse incision is made either
between the second and third rings or the third and
fourth rings. Stay sutures are then placed superiorly
and inferiorly around the tracheal rings [see Figure 5].
b. T-type incision. This incision is a combination of a
vertical incision that crosses the second ring and forms
a T with a transverse incision below the third
tracheal ring. Stay sutures are placed laterally and
allow for controlled opening of the trachea with a
tracheostomy spreader.
c. Tracheal window. Although a tracheal window with
removal of a portion of the third tracheal ring has been
performed, this is more difcult and may not heal as
rapidly as a ring-preserving incision.
d. Bjrk ap. A Bjrk ap is an inferiorly based U-shaped
ap that incorporates the ring below and the tracheal
incision [see Figure 4]. A U-type incision is made from
the third tracheal ring through the second tracheal ring,
and the second tracheal ring is then retracted inferiorly
and sutured with a dissolvable suture as high in the
neck as possible to the skin. The theoretical justica-
tion for this is to keep the tracheal incision close to
the skin edges in the instance of tracheostomy tube
displacement, to ensure ease of airway access. This
ap suture can be released 3 to 5 days after creation
once the tract has been established or after the rst
tracheostomy change.
5. Stay sutures. Stay sutures using a 2-0 nonabsorbable suture
on a UR6 needle can be placed either laterally or inferiorly
and superiorly. These help stabilize the tracheostomy
during the procedure. The sutures are then taped to the
chest and labeled so that they will not be inadvertently
removed. Stay sutures may provide access to a fresh
tracheostomy if the tracheostomy tube becomes dislodged
in the immediate postoperative period. These sutures are
left in place until the rst tube change.
In adults, a number 8(outside diameter [OD]) or 6(OD)
tube is preferable. If there is signicant edema or obesity, the
use of an extra-long tube is desirable. If a tracheostomy tube
is not available, a standard endotracheal tube can be used to
intubate the neck. Remember when trimming the tube to
spare the pilot balloon.
icncc1aNcocs 1nacncos1o:v
Percutaneous tracheostomy was rst described over 50
years ago, but the availability of a dilational percutaneous
tracheostomy kit prompted widespread use in the 1990s.
In many centers, this has become the method of choice
for tracheostomy. Although initial contraindications included
morbid obesity, inability to extend the neck as in potential
cervical spine injuries, short neck, enlarged thyroid isthmus,
and previous tracheostomy, these have been disproven with
increasing experience. A benet of the percutaneous approach
is the ability to perform the procedure at bedside in the
ICU, reducing OR costs and scheduling conicts. The
percutaneous approach has been championed for its ease
of performance at the bedside in the ICU; however, several
studies comparing cost and personnel use demonstrate
open bedside tracheostomy to be more cost-effective with
equivalent complications and safety outcomes. The long-term
cosmetic effects of percutaneous tracheostomy appear to be
better than those of the open technique.
The choice between percutaneous and open tracheostomy
remains a decision best left to individual centers.
Figure 4 Surgical tracheostomy. A tracheotomy is made
either between the second and third tracheal rings or between
the third and fourth rings. A Bjrk ap (inset) may be created
by extending the ends of the tracheostomy downward through
the next lower tracheal ring in an inverted U shape.
Figure 5 Surgical tracheostomy. The tracheostomy tube is
inserted into the tracheal opening from the side, with the
faceplate rotated 90 so that the tubes entry into the airway
can be well visualized.
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Operative Technique
Equipment and personnel The personnel necessary
for the procedure are a respiratory therapist, a critical care
nurse, a surgeon, and a bronchoscopist to safely perform a
percutaneous tracheostomy. The equipment required is a
bronchoscope and a percutaneous dilation tracheostomy kit.
Surgical instruments for an open tracheostomy should be
readily available. Maximum sterile barriers are employed,
including sterile gown, gloves, and drapes. All participating
personnel must wear mask and head covers.
Procedure
1. Incision. Once conscious sedation is initiated, the sub-
cutaneous tissue is inltrated with local anesthetic 1 cm
caudal to the cricoid cartilage. A 1 to 1.5 cm incision is
made either in a horizontal or a vertical fashion. The sub-
cutaneous tissue is then bluntly dissected using a hemostat
to spread the tissue down to the level of the trachea.
2. Bronchoscopy. The bronchoscope is advanced to the tip
of the endotracheal tube. With the surgeon providing
one-nger ballottement at the level of the rst or second
tracheal ring, the endotracheal tube is slowly withdrawn
while maintaining the bronchoscope at the tip of the tube
until one-to-one ballottement is appreciated. Every step
of the procedure involving instrumentation of the trachea
is preferably performed under direct bronchoscopic
visualization.
3. Transcutaneous tracheostomy. The introducer needle is
advanced through the incision at the level where one-
to-one ballottement was appreciated. Constant aspiration
of the syringe and direct bronchoscopic visualization
immediately identify the entrance into the trachea. Once
the needle is noted to be in a good position, the guide
wire is introduced again under direct bronchoscopic
visualization.
4. Dilation. Using a modied Seldinger technique, the needle
is removed and a stiff conical dilator is introduced and
removed. The tract is then dilated with the largest conical
dilator to the level marked for the skin. The dilator is
removed and fully introduced three times. The tracheos-
tomy tube is then introduced over the snuggest tting
dilator. Once the tracheostomy tube is in place, the guide
wire and dilator are removed. Often the endotracheal
tube must be withdrawn a short distance to allow for serial
dilation and introduction of the tracheostomy tube.
5. Conrmation of placement. Once the tracheostomy tube is
in place, the bronchoscope is withdrawn from the endotra-
cheal tube and introduced through the tracheostomy tube
to conrm placement within the trachea. The endotracheal
tube is kept in place until conrmation is complete. The
tracheostomy tube is then secured with sutures from the
faceplate to the skin and tied in place.
Tracheostomy Management
Tracheal sutures are removed on postoperative day 7. If
the patient is on minimal ventilator settings or liberated from
the ventilator, the tracheostomy tube is downsized. Once
the patient is liberated from the ventilator, the tracheostomy
tube cuff is deated and the patient is placed on humidied
air or oxygen. The humidied air can be delivered via a
tracheostomy collar or tracheostomy tube. A tracheostomy
collar allows more patient freedom and less torque than a T
tube when frequent suctioning is not required. Speech
pathology consultation should be obtained for swallowing
evaluation and speaking valve placement versus capping the
tracheostomy tube. The approach depends on the patients
mental status and suctioning requirements. Once the patient
is tolerating either tracheostomy tube occlusion or a speaking
valve for greater than 24 hours and managing his or her
own secretions, the tracheostomy is removed. In preparation
for decannulation, the patient should be suctioned and a
replacement tracheostomy with a stylet should be available
in case of sudden respiratory decompensation. An occlusive
dressing is left in place for 24 hours. Generally, no further
dressing is required afterward.
Complications
Reported complication rates from tracheostomy range
from 5 to 31%, with an average of nearly 12%. Major com-
plications range from 2 to 6%. Mortality is extremely low
(0.5%).
canLv co:iLica1ioNs
Displacement
The most dangerous complication is early accidental
displacement or decannulation. This can occur when moving
the patient to the ICU or recovery room and when patients
are turned for care or x-rays in the ICU in the rst 5 to 7 days
after placement. A loosely tied tracheostomy or one placed
in a precarious position can be dislodged, resulting in the
inability to ventilate and oxygenate. If this is suspected, the
patient should immediately be placed supine and an attempt
at ventilation should commence. If the patient cannot be
ventilated, an attempt to replace the tube should be tried
if stay sutures or a Bjrk ap is present. Emergency oral intu-
bation should be performed if the attempt fails. Multiple
attempts to replace the tube can result in a false passage. The
tracheostomy can then later be replaced via the same incision
with the proper light and proper retraction. A new tracheos-
tomy tube should be available in the room or above the bed
for all patients who have had a fresh tracheostomy.
Pneumomediastinum/Pneumothorax
Pneumomediastinum can occur, especially with a low
tracheostomy or if a false passage is created. Pneumothorax
is a rare (< 2%) complication that can occur especially in
children, in whom the cupola of the lung may ride high.
Pneumothorax can also occur in patients who require high
ventilatory pressures or who cough vigorously during the pro-
cedure. A low tracheostomy and deep dissection potentially
increase the risk of pneumothorax.
Bleeding
A small amount of blood via the wound or tracheostomy
immediately following the procedure is not alarming. How-
ever, the persistence of blood around the trachea implies
venous bleeding from either the skin, subcutaneous tissues,
or thyroid gland. In general, this can be controlled with gentle
packing and the use of a bioabsorbable hemostatic agent.
If bleeding continues, the patient should be taken to the OR
if possible and reintubated under ideal light and retraction;
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the tracheostomy should be removed and the bleeding con-
trolled with cautery or sutures if necessary. If hemorrhage
is demonstrated via the tracheostomy tube, early careful
bronchoscopy should be performed to ascertain the site of
bleeding. Signicant bleeding from the tracheostomy is
usually a late complication and may be related to a
tracheoinnominate stula (see below).
Infection
Tracheostomy infections requiring treatment are much
less common than one would imagine, considering the con-
tamination of the bronchial/tracheal tree in many patients
who have been intubated for a period of time. The majority
of infections can be treated with local wound care, although
deep infections from Staphylococcus aureus and Pseudomonas
aerigunosa may require antibiotics and removal of sutures.
Placing tracheostomies through burn eschar presents a
separate problem.
Acute Obstruction
The most common cause for acute obstruction of a trache-
ostomy is dislodgment. If that is not the case, the tracheos-
tomy may have accumulated blood or mucus, which can clog
the airways. To avoid this, humidied oxygen should always
be administered, and gentle careful suctioning should be
initiated by experienced personnel. The inner cannula should
be removed and examined. Occasionally, bronchoscopy will
be necessary to remove and irrigate mucus plugs.
Negative Pressure Pulmonary Edema
A rare complication of upper airway obstruction may occur
after a tracheostomy is performed for airway obstruction.
Patients generating large negative pressure against resistance,
which is suddenly released, can experience a noncardiogenic
pulmonary edema. The patient becomes hypoxic, develops
rales in the lungs, and can demonstrate pink frothy pulmo-
nary edema via the tube. A chest x-ray may demonstrate
bilateral pulmonary edema. This process is usually self-
limited and responds to positive end-expiratory pressure
(PEEP) and positive pressure ventilation.
La1c co:iLica1ioNs
Late complications of tracheostomy are often attributable
to the cuff, either from the tracheostomy tube or from the
endotracheal tube in place prior to tracheostomy. Complica-
tions attributable to cuff injuries are less common now than
previously as a result of improvement in technology allowing
for lower-pressure cuffs, but they still occur in patients who
undergo prolonged endotracheal intubation.
Tracheostomy cuff pressures should be measured daily
or more often to prevent tracheal necrosis. X-rays demon-
strating a dilated cuff in the trachea require assessment of the
tube, cuff, and trachea.
Subglottic Tracheal Stenosis
Tracheal stenosis has a reported incidence of 4 to 18%.
Stenosis is associated with a longer hospital stay and pro-
longed time to tracheostomy. Dyspnea and stridor result
when tracheal stenosis is greater than 50% of tracheal diam-
eter. In suspected tracheal stenosis, referral to a specialist for
evaluation either by computed tomography (CT) or rigid
laryngoscopy is essential for diagnosis. Once the diagnosis is
conrmed, treatment may require tracheal reconstruction.
Tracheal Granulation
Tracheal granulation may cause bleeding or occlusion
of the tracheostomy tube if a ap of granulation tissue is
elevated on exhalation. Granulation tissue may mimic tra-
cheal stenosis. This complication is often easily treatable with
removal of the tracheostomy tube. Occasionally, resection of
the granulation tissue is necessary.
Vocal Cord Dysfunction
Vocal cord dysfunction occurs in less than 2%, whereas
voice changes, including hoarseness and weakness, occur in
10 to 20% of patients. In cases of bilateral vocal cord paraly-
sis, a tracheostomy is necessary until the paralysis resolves.
Most complaints of vocal changes are considered minor by
patients.
Tracheoesophageal Fistula
Tracheoesophageal stula occurs in less than 0.3% of
patients following tracheostomy. It can occur if a puncture
is made into the posterior trachea or a cuff erodes into
the esophagus. The combination of a a tracheostomy tube
and a stiff nasogastric tube in the esophagus increases the risk
of this complication. Symptoms include aspiration and
persistent cuff leak around the tracheostomy. Persistent tra-
cheobronchitis or pneumonia may also be present. A swallow
study with the cuff deated or CT and panendoscopy
will demonstrate the defect. Denitive therapy is usually
necessary.
Tracheoinnominate Fistula
Tracheoinnominate stula has a reported incidence of
0.4 to 4.5% and presents initially as sentinel bleeding that
usually develops within the rst month following the proce-
dure. Mortality between 50 and 75% has been reported. Risk
factors include a low (below the third ring) tracheostomy,
caudal migration from leverage on the tube, and the presence
of a more cephalad-coursing innominate artery. An attempt
to visualize the site of bleeding should be undertaken. If
hemorrhage is signicant, hyperinate the cuff and try to
compress the vessel against the posterior sternum. If this
is unsuccessful, oral intubation should be performed. The
tracheostomy tube must be removed and replaced with
digital pressure through the tracheostomy to tamponade the
bleeding en route to the OR. Often the upper extremity of
the person responsible for maintaining digital pressure is
prepared into the operative eld in preparation for median
sternotomy
Tracheocutaneous Fistula
Rarely, the tracheostomy wound does not completely close
in 24 to 48 hours. Granulation tissue may be treated topically
with silver nitrate with good success. Occasionally, the
tracheostomy site must be surgically closed in layers for a
nonhealing tracheocutaneous stula.
Scar
Cosmetic results vary following tracheostomy. Ten to 15%
of patients consider scar revision of the tracheostomy site.
Financial Disclosures: None Reported.
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Additional Reading
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doctors, student edition. Chicago, IL: Ameri-
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Clech C, Albert C, Vincent F, et al. Tracheosto-
my does not improve the outcome of patients,
requiring prolonged mechanical ventilation: a
propensity analysis. Crit Care Med 2007;35:
1358.
Grifths J, Barber VS, Morgan L, Young JD.
Systematic review and meta-analysis of
studies of the timing of tracheostomy in adult
patients undergoing articial ventilation.
BMJ 2005;330(7500):124350.
Grover A, Robbins J, Bendick P, et al. Open ver-
sus percutaneous dilatational tracheostomy:
efcacy and cost analysis. Am Surg 2001;67:
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Marx WH, Ciaglia P, Graniero KD. Some
important details in the technique of percuta-
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Pratt LW, Ferlito A, Rinaldo A. Tracheostomy.
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Silva B, Andriolo R, Saconato H, Atalla A. Early
versus late tracheostomy for critically ill
patients. Cochrane Database and Systematic
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Silvester W, Goldsmith D, Uchino S, et al.
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Acknowledgments
Figures 1 through 5 Thom Graves