Basics of tracheostomies from a surgical perspective meant for medical students and junior residents, with slight focus on comparing open vs. percutaneous tracheostomies.

1. TRACHEOSTOMIES:
WHY, WHEN, HOW
GAZI M. RASHID, MD

2. OUTLINE
Why?
• Indications
When?
• Timing
How?
• Open
• Percutaneous
• Comparison

3. THE PARTS

4. INDICATIONS FOR A TRACHEOSTOMY
• Oxygenation
• Ventilation
• Airway Protection
• Patients with impending airway obstruction
• Planned surgical loss of airway
• Pulmonary toilet – if having excessive secretions
An elective, urgent, or emergent surgical airway for long-term support for:
Indications for Tracheostomy?

5. • check INR, PT, platelets & correct as needed
Major coagulopathy
• PEEP – generally want lower (5-7.5) to avoid alveolar collapse once ETT is out
• FiO2 – generally want lower (30-50%) to avoid fire injuries in the airway
Significant ventilator support
Pre-tracheal soft-tissue infection
Laryngeal cancer (increased risk of stomal recurrence)
Patient goals of care
Contraindications for Tracheostomy?

6. TIMING
No definitive evidence, guidelines for staying intubated vs. doing trach
Outcomes: Weaning off ventilator, length of hospital and ICU stay, nosocomial infections, rates of subglottic stenosis
Early: Better for severe injuries, neuro dz (ALS, etc), likely will need long-term ventilation or has permanent inability to protect airway
7-10 days intubated: Might be more beneficial than doing it too early (see: The TracMan RCT) to give pt chance to be extubated
“Late” > 10-14 days: risks of less likely to wean from vent, longer ICU stays and sedation, more cost, increased risk of stenosis
Timing?

7. ANATOMY

8. OPEN TRACHEOSTOMY
1. Performed in OR under GA
2. Horizontal vs. Vertical Incision 2 fingerbreadths above sternal
notch
3. Dissect through skin, subcutaneous, platysma
4. Vertical incision in fascia between strap muscles, retract
laterally
5. Divide the isthmus of the thyroid (allows for great exposure)
6. Horizontal incision in between 2nd, 3rd tracheal ring
7. Flap (often Bjork) + Place stay sutures and dilate the incision
8. Through incision, visualize withdrawal of ET tube
9. Once ET tube proximal to incision, quickly place trach tube
10. Confirm placement (CO2) and secure

10. 1. Can be done at bedside with conscious sedation,
relaxation
2. Bronchoscopy done to visualize most steps of the
procedure
3. Horizontal incision at skin and superficial dissection with
Kelly
4. Direct palpation and visualization
5. Withdrawal of ET tube proximal
6. Seldinger technique – introducer needle, catheter,
guidewire, dilation with Rhino (all under direct
visualization)
7. Tracheostomy Tube introduced
8. Visualize placement and secure
PERCUTANEOUS TRACHEOSTOMY

12. COMPARISON
PROS
CONS
Open
Direct visualization
Better control of bleeding
Better for anatomically difficult patients
Less time with ineffective ventilation –
is pulled only when incision dilated enough,
so will have poor ventilation for ~ < 1 min
Higher risk of post-op complications like tracheal
stenosis, infections
Perc
Decreased risk of infection
Decreased post-op complications
Less likely to bleed
Cheaper – faster, less staff, resources
Cannot visualize tissues, vasculature
Bronchoscopy required
Higher risk of intraoperative complications
Longer time with ineffective ventilation – ET
needs to be pulled proximally for visualization
from start of the case; that makes it hard to
ventilate lungs from so far from carina -> makes
perc trach worse option for someone with high
vent setting requirements

13. • PTX
• Damage to RLN
• Posterior wall perforation
• Bleeding
• Fire (keep FiO2 < 0.4)
• Lose Airway
• Decannulation!!!
• Minor Bleeding (pressure)
• Plugging
• Significant bleeding -
consider Tracheo -
Innominate Fistula
• Minor Bleeding
• Tracheal Stenosis
Weeks
Intraoperative
Days Long Term
COMPLICATIONS

14. SUMMARY
 Indications for tracheostomy are long-term oxygenation, ventilation, airway protection, pulm hygiene
 There are no absolute contraindications, but relative contraindications exist and are specific to different
approaches and the patient
 No consensus for timing, but generally aim for between after 7-14 days of being intubated
 Open trach better for visualization, difficult necks, and patients who need higher ventilator settings
 Perc trachs better for simple necks and are generally cheaper/faster/less resource intensive
 Decannulation in <7d is an airway emergency and management depends on patient condition

15. RESOURCES
 https://tracheostomyeducation.com/tracheostomy-tubes/
 Terris, David, Tracheostomy in Current Surgical Therapy
 LITFL: https://litfl.com/percutaneous-
tracheostomy/#:~:text=Tracheostomy%20is%20an%20airway%20that,dilatation%20of%20trachea%20be
tween%20rings.
 https://resusreview.com/2015/perc-trach-tutorial/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197980/
 http://www.emdocs.net/core-em-common-tracheostomy-issues/
 http://www.surgicalcriticalcare.net/Guidelines/Timing%20of%20tracheostomy%202020.pdf