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ADULT TRACHEOTOMY CONSULTS

While tracheotomies are frequently performed by other specialties, the Otolaryngologist is the definitive expert in management of tracheostomies, surgical airways, and associated complications. This section covers the initial tracheostomy consult. Other sections cover tracheostomy tube exchange and tracheostomy-related complications (e.g., tracheostomy site hemorrhage).

Overview
Most commonly, ICU teams may place a tracheotomy consult for long-term (>7days) intubated adult patients. Prolonged intubation (beyond 7-10 days) has been associated with increased rates of glottic/subglottic stenosis and ventilator-associated pneumonia. In most cases, it is reasonable to consider a tracheotomy if the patient is not progressing toward extubation after 7 days. Placement of a tracheostomy improves pulmonary toilet, as it allows for direct tracheal suctioning. Notably, tracheostomies do not directly minimize the risk of aspiration, and in some cases, the placement of a tracheostomy can worsen dysphagia. Nevertheless, it can be helpful in patients with aspiration as direct suctioning can mitigate some of the complications of aspiration. Tracheostomy placement also facilitates sedation weaning and hospital discharge in ventilator-dependent patients, and it may facilitate ventilator weaning as well. Additional indications for placement of a tracheostomy include upper airway masses, swelling, upper airway or craniofacial trauma, laryngotracheal stenosis, severe neurologic deficit, or recalcitrant obstructive sleep apnea.

Management
A detailed history and physical examination should be performed with attention to underlying etiology of ventilator requirement, intubation and reintubation history, prior airway examinations and access, anatomic abnormalities, and prior respiratory and upper airway procedures. Additionally, ventilator settings at the time of examination (PEEP and FiO2) and pulmonary reserve will be important in determining how long a patient can be without ventilator support safely. This is important to consider when performing initial tracheotomy placement and also during tracheotomy tube exchange. Peak ventilatory pressures may also be important; pressures above 40cm H2O may cause air leaks around an appropriately inflated tracheostomy tube cuff and impede ventilation.

Complete head and neck physical exam
- focus on oral examination (dental status, tongue size and position, mouth opening) to estimate intubation access, and neck examination for surgical landmarks (hyoid, thyroid notch, thyroid gland, cricoid, depth of trachea, and distance from sternal notch to cricoid)
- Palpate for a thyroid goiter or vascular anomaly such as high riding innominate artery
- Patients with previous sternotomy may have an abnormal venous plexus at or above the sternal notch
- If feasible and safe for the patient, neck extension can be tested. Relative contraindications to neck extension such as cervical spine trauma, severe cervical stenosis, cervical spinal fusion, and Trisomy 21 are relevant for surgical positioning and determination of percutaneous or open tracheostomy
Ensure basic pre-operative labs have been obtained including CBC, BMP, and coagulation panel. (Anticoagulation is not a contraindication to tracheostomy placement but warrants a cautious and meticulous operative approach and careful postoperative care)
Pre-operative imaging is usually reserved for select cases
- Consider open vs. percutaneous tracheostomy as described below:
  - Open Tracheostomy
    - Advantages: Best exposure, easy control of bleeding, controlled environment in the OR, allows for superior cricoid traction to expose trachea that otherwise might be substernal (patients who cannot extend neck), ideal for patients without palpable landmarks, and can create Bjork flap if desired to allow for easier tracheostomy changes and protection of the innominate artery
    - Disadvantages: requires OR time, larger incision, requires transport of clinically ill patient to the OR (though open tracheostomy can be done at the bedside in selected ICU settings)
  - Percutaneous Tracheostomy
    - Advantages: No need for OR (performed at bedside if patient is in ICU), only need sedation, do not need OR space/time
    - Disadvantages: difficult to perform in patients without palpable landmarks, potentially more difficult tracheostomy changes (no Bjork flap), can fracture trachea or pierce posterior tracheal wall, bleeding less easy to control, requires visualization by bronchoscopy, risk of injuring innominate vessels

Example Operative Note (open tracheostomy)

PREOPERATIVE DIAGNOSIS: ___
POSTOPERATIVE DIAGNOSIS: ___
PROCEDURE: ___
SURGEON: ___
ASSISTANT: ___
ANESTHESIA: ___ (e.g. GETA, general mask, local)
ESTIMATED BLOOD LOSS: ___
SPECIMENS: ___
INDICATION: ___
KEY FINDINGS: ___
COMPLICATIONS: ___

DICTATION OF EVENTS: The patient and surgical site were correctly identified preoperatively. The patient was then brought to the operating room and placed on the operating table in the supine position. The surgical site was prepped and draped in a sterile fashion. A preoperative time-out was completed verifying the correct patient, procedure, site, positioning and equipment.

After the time-out, the thyroid and cricoid cartilage were palpated and the skin and subcutaneous tissue in this area was anesthetized with ___ ml 1___% lidocaine with ___ epinephrine. A 2cm transverse incision was made over the 2nd tracheal ring. Monopolar/electrocautery and blunt dissection were used to identify the strap muscles, which were then retracted laterally. Palpation confirmed no high-riding innominate artery. The thyroid isthmus was divided and thoroughly cauterized with monopolar electrocautery. Dissection was continued down to the cricoid cartilage and trachea. The endotracheal tube and cuff were advanced after communication with the anesthesia team. A cricoid hook was used to retract the cricoid cartilage superiorly. Prior to entry into the trachea, FiO2 was confirmed to be 30% or lower. Next, a transverse incision was made between the second and third cartilaginous tracheal rings using a #15 blade. A Bjork flap was developed with lateral tracheal ring incisions using curved Mayo scissors. The Bjork flap was then retracted inferiorly and secured to the subcutaneous tissue with _-0 _ stitch. Hemostasis was achieved with electrocautery. After coordination with the Anesthesia team, the endotracheal tube cuff was deflated and the tube was retracted above the tracheostomy site. A ___-0 cuffed ___ tracheostomy tube was placed and connected to the anesthesia machine. Positional confirmation with end-tidal CO2 and condensation within the circuit were noted. The tracheostomy tube was sutured in placed with ___-0 ___ suture in 4 corners. The cuff was inflated with _cc or [air/water]. The obturator was kept with the patient. Next, the patient was turned over to the care of anesthesia. The patient tolerated the procedure well and was taken to the intensive care unit in stable condition.

References

Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. doi:10.1177/0194599812460376
Kraft SM, Schindler JS. Tracheotomy. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 95-103). Philadelphia, PA: Elsevier.
Durbin CG Jr. Tracheostomy: why, when, and how?. Respir Care.2010;55(8):1056-1068.