Figure 18.1. Schematic representation of cricothyroidotomy [8].

Commercial cricothyroidotomy kits are readily available and generally involve a small vertical incision followed by placing a needle through the cricothyroid membrane, passing a guidewire through the needle into the trachea, employing the Seldinger technique to push a dilator and an airway simultaneously into the trachea. Either technique is suitable for an emergent surgical airway and should be performed based on the comfort level of the operator. It is generally advisable that any patient with a cricothyroidotomy be converted to a formal tracheostomy within 24 hours to avoid permanent damage to the larynx. This, however, can be delayed somewhat if the patient’s clinical status is too unstable.

18.2.3 Tracheostomy

Tracheostomy should generally be regarded only as an elective procedure. Emergent awake tracheostomy performed under local anesthesia are beyond the scope of this chapter and unlikely to be employed in the neurocritically ill. The benefits of a tracheostomy compared to oral-tracheal intubation include enhanced patient comfort, improved access to the airway for suctioning and pulmonary toilet, improved patient communication, less need for sedation, and decreased vocal cord injuries. Tracheostomy should be reserved for neurocritically ill patients who fail ventilator weaning either due to respiratory function or because of decreased GCS and airway protection issues.

Timing of tracheostomy has changed over the past quarter century. Previously, patients were traditionally maintained intubated with endotracheal tubes for prolonged periods of time. Several studies have evaluated the effect of early tracheostomy. A recent prospective randomized trial in medically critically ill patients deemed to require long term ventilatory support found that those who underwent an early tracheostomy, i.e., within 48 hours, versus those receiving a tracheostomy at 14-16 days, had significantly reduced complications including ventilator-associated pneumonia, accidental extubation, and less damage to the oral cavity. Early tracheostomy was also associated with fewer days in the ICU, days on mechanical ventilation, and a significantly lower 30-day mortality. These findings have also been observed in retrospective studies and a recent meta-analysis [3]. It is the authors’ opinion that any patient who is deemed to need prolonged mechanical ventilation be offered an early tracheostomy [2,4], within 72 hours, for all these reasons.

Tracheostomy can be performed safely either in the surgical suite or at the bedside in the intensive care unit (ICU). Our published experience with bedside tracheostomy revealed a 2.9% incidence of major complications and a 3.4% incidence of minor complications. These are comparable to rates reported in the literature for a surgical suite tracheostomy. A comparison of hospital charges shows that tracheostomy is less expensive when performed in the ICU rather than the surgical suite because it incurs no facility or anesthesia fees. Another advantage of bedside tracheostomy is that critically ill patients do not require being transported. While it is these authors’ practice to perform virtually all tracheotomies in the surgical ICU [6], we recognize that patient safety takes precedent over financial considerations and suggest that the reader’s practice be tailored as such.

Tracheostomy can be performed either open or with a percutaneous dilational technique. An open tracheostomy begins with appropriate patient positioning. This generally entails hyperextension of the neck over a blanket roll if possible, the neck is then prepped and a sterile field created; local anesthetic with epinephrine is given to anesthetize the skin and subcutaneous tissues. A transverse incision is made two fingerbreadths above the sternal notch. The platysma is divided with electrocautery. The midline fascia is incised and the strap muscles are separated. At this point, the thyroid can be gently retracted superiorly, exposing the second and third tracheal rings. This space is incised and widened with Metzenbaum scissors and an inferior tracheal flap is created by incising the lower tracheal ring bilaterally. The endotracheal tube is gradually withdrawn until it is out of the field, and the tracheostomy can then be gently inserted into the trachea and balloon inflated. Placement is confirmed with end-tidal carbon dioxide monitoring and return of appropriate tidal volumes on the ventilator. The tracheostomy is then secured with a tight cloth tied around the neck rather than sutures to the neck. Once the trachea is opened, cautery, because it is a potential fire hazard in an oxygen enriched environment, must never be used. It is our practice to postpone tracheostomy until the patient’s oxygen requirement is <50% FiO₂ and there is no coagulopathy.

The percutaneous technique, as originally described by Ciaglia [1], employs a bronchoscope through the endotracheal tube to view the airway; the tube is gently withdrawn to the level of the cricothyroid cartilage. A small vertical incision is then made approximately 2 fingerbreadths above the sternal notch. Hemostats are used to dissect the tissues to the level of the trachea. Next, a large bore needle is introduced into the trachea under direct bronchoscopic visualization. A guidewire is then passed and serial enlarging dilations of the trachea are performed via the Seldinger technique. The tracheostomy can then be placed under direct visualization of the bronchoscope. As opposed to the open technique, these patients should be placed 100% FiO₂ prior and for the duration of the procedure as the bronchoscope limits both oxygenation and ventilation during the procedure.

The advantages of the open technique include no need for muscle relaxants, which are commonly used for percutaneous tracheotomies, and no need for bronchoscopy. Again, a review of hospital charges shows that the percutaneous technique is more expensive because it requires bronchoscopy during the procedure [5]. The advantages of the percutaneous technique are that the patient’s neck is not hyperextended for exposure, which is useful in patients with concomitant cervical spine injuries or non-clearance, the minimal dissection causes less bleeding, which is an important consideration in patients who recently received anticoagulants or antiplatelet agents. Also, the percutaneous technique may be easier to perform in patients with a history of neck radiation. Again, we recommend that the practitioner be adept with both techniques and employ each on a selective basis.

Complications of tracheotomies can be divided into operative, postoperative, and late. The most common operative complication is hemorrhage, which occurs in 1-3% of cases, and is usually due to aberrant anatomy, i.e., a thyroidea ima artery. Less common operative complications include pneumothorax (0-4%) and recurrent laryngeal nerve injury. Such complications are generally due to technical error. Postoperative hemorrhage is rare and generally results from a missed bleeding vessel during dissection. Minor bleeding more than 48 hours after placement is generally associated with coagulopathy. Wound infections are rare and are generally averted by not closing the skin incision over an open tracheostomy. Most infections will be treated with a short course of antibiotics only.

Late complications are well described and include tracheal stenosis, tracheomalacia, and tracheoinnominate artery fistula. Fortunately, these complications are quite rare. We advocate the use of minimal leak techniques with high-volume low-pressure cuffs to to avoid the initial mucosal ischemic event precipitating these other complications. Tracheesophageal fistula is an extremely rare event following tracheostomy (1%). Tracheoinnominate artery fistula generally occurs approximately 1-3 weeks postoperatively due to the cuff pressing anteriorly on the innominate artery. Patients present with either a herald bleed event or massive hemoptysis. Control, prior to operative repair, can be obtained by either hyperinflation of the cuff or removing the tracheostomy and occluding it with a finger against the sternum through the stoma. In over 35 years of our ICU experience, a tracheotomy created high between the second and third tracheal rings has never led to the development of a tracheoinnominate fistula.

18.3 Conclusions

The patient with an acute traumatic brain injury will often need to be intubated for either respiratory distress or decreased mental status, raising concerns about their ability to protect their airway. When oral-tracheal intubation is not possible, it becomes imperative to establish an airway in an expedited fashion to avert secondary injury due to prolonged hypoxia. This can be performed in an emergent fashion with a cricothyroidotomy.

Once a patient is intubated and deemed to need prolonged mechanical ventilation or airway protection, an early tracheostomy should be strongly considered. The advantages include decreased sedative requirements, less infectious complications, fewer days on the ventilator, and shortened ICU length of stay. The type of tracheostomy technique and the location of the operation are both secondary considerations. While it is more cost effective to perform bedside open tracheotomies in the ICU, it is more important to perform the procedure safely with the most competent staff available.

References

1. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilational tracheostomy: anew simple bedside procedure: preliminary report. Chest 1985; 87: 715-9

2. Flaatten H, Gjerde S, Heimdal JH, et al. The effect of tracheostomy on outcome in the intensive care unit patients. Acta Anaesthesiologica Scandinavica 2006; 50: 92-8

3. Rumbak M, Newton M, Truncale T et al. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004; 32: 1689-94

4. Griffiths J, Barber V, Morgan L, et al. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005; 330: 1243

5. Grover A, Robbins J, Bendick P, et al. Open versus percutaneous dilational tracheostomy: efficacy and cost analysis, Am Surg 2001; 67: 297-302

6. Wease G, Frikker M, Villalba M, et al. Bedside tracheostomy in the intensive care unit. Arch Surg 1996; 131: 552-5

7. Feliciano D, Mattox K, Moore E. Trauma; sixth edition. New York: McGraw-Hill, 2008

8. Carrico C, Thal E, Weigelt J. Operative Trauma Managment, an atlas. Conneticut: Appleton and Lange, 1998

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