Tracheotomy and Cricothyrotomy

Published on 16/04/2015 by admin

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Last modified 16/04/2015

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Tracheotomy and Cricothyrotomy

Rod Rezaee, Yi-Chun Carol Liu and Pierre Lavertu

Introduction

Tracheotomy (tracheostomy) is one of the oldest surgical procedures known, with the first reference 3000 to 4000 years ago. Chevalier Jackson is credited with standardizing the tracheotomy procedure in 1932, outlining the individual steps for establishing a direct airway through the anterior neck tissues and into the trachea. Jackson had the foresight to consider potential surgical complications when he warned against placement of a high tracheotomy or cricothyrotomy (cricothyroidotomy). Although the procedure has evolved and now includes a percutaneous technique, this chapter focuses on open tracheotomy.

Indications and Principles of Tracheotomy

Indications for tracheotomy are multiple and include the need to bypass an airway obstruction caused by congenital anomaly, vocal cord paralysis, inflammatory disease, benign or malignant laryngeal pathology, laryngotracheal trauma, facial trauma, or severe sleep apnea refractory to other interventions. Additional indications for tracheotomy include the need to provide an airway for patients receiving mechanical ventilation for respiratory failure and for those with chronic aspiration secondary to inadequate cough. Tracheotomy may also allow for a more secure and comfortable airway for home ventilation in patients with neuromuscular or other chronic diseases.

Preoperative Considerations

Once a tracheotomy is planned, certain factors influence whether patients should have an open tracheotomy or a percutaneous dilatational tracheotomy, as first described by Ciaglia in 1985. Regardless of the tracheotomy method chosen, a patient’s overall medical condition must be optimized, body habitus assessed, and coagulation profile addressed. Other preoperative factors to consider include the urgency of the procedure (emergency vs. elective); need for general or local anesthesia, adult or pediatric patient, current status of the airway (intubated vs. nonintubated patient), availability of proper equipment, patient portability, surgeon’s experience (open vs. percutaneous technique), and capability of the institution to perform bedside procedures. This will determine which team performs the procedure and whether it will be done in the operating room or at the bedside in the intensive care unit.

Surgical Anatomy and Tracheotomy Procedure

External Anatomy

The patient is placed in the supine position. The surgeon might consider placing the neck into slight extension, but this should not be too far past the neutral position, so that the skin incision remains in line with the tracheal incision. A shoulder roll may be used in some patients to assist with positioning (Fig. 2-1).

FIGURE 2–1 Tracheotomy procedure, steps 1-6.

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