35. What is Tracheostomy? What are the types, indications and complications? (10 Marks) (SMIMER)***** *Tracheostomy. (6 Marks) (NAMO) *Indications and types of Tracheostomy. (6 Marks) (GMC) *Tracheostomy - indications. (6 Marks) (KMCRI) *Complications of tracheostomy. (6 Marks) (VALMED)
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Tracheostomy - Complete Answer (10 Marks)
Definition
Tracheostomy (or tracheotomy) is a surgical procedure in which an opening (stoma) is created through the anterior wall of the neck into the trachea, and a tracheostomy tube is inserted to provide an airway. It is the most common surgical procedure performed in critically ill patients requiring prolonged mechanical ventilation.
- Sabiston Textbook of Surgery, p. 960
Types of Tracheostomy
A. Based on Duration / Purpose
| Type | Description |
|---|---|
| Temporary | Performed for a short-term need (e.g., post-operative airway protection); closed once the cause resolves |
| Permanent | Created when a permanent airway is needed (e.g., total laryngectomy, irreversible neurological disease) |
B. Based on Urgency
| Type | Description |
|---|---|
| Elective / Planned | Performed in a controlled setting (ICU or OT) on ventilated patients |
| Emergency | Performed urgently when intubation fails and airway is at risk; equipment must always be available as backup |
C. Based on Technique
-
Standard Open (Surgical) Tracheostomy
- Traditional technique performed in the operating room or at the bedside
- Skin incision, dissection through strap muscles, retraction of thyroid isthmus, and tracheal window created between 2nd and 4th tracheal rings
- Preferred when anatomy is abnormal, coagulopathy is present, obesity makes percutaneous approach difficult, or in goiter
-
Percutaneous Dilatational Tracheostomy (PDT)
- First described by Ciaglia in 1985; widely used in ICUs
- Uses a Seldinger-based technique: needle insertion into trachea under bronchoscopic guidance, guidewire placement, serial dilation, and tracheostomy tube insertion
- Advantages: less wound infection, more cost-effective, similar complication rate to open
- Meta-analysis shows decreased wound infection and clinically relevant bleeding compared to open surgical tracheostomy
- Periprocedural mortality < 0.2%
-
Mini-tracheostomy
- A 4-mm cuffless cannula inserted through the cricothyroid membrane
- Used solely for tracheal suctioning in patients with intact cough and normal ventilation
- Not suitable in children due to small airway diameters
- Sabiston Textbook of Surgery, p. 960-961; Scott-Brown's Otorhinolaryngology Vol 1, p. 405
Indications
Indications fall into three broad categories:
1. Upper Airway Obstruction
- Tumors of the upper airway (laryngeal/hypopharyngeal cancers)
- Significant maxillofacial/laryngeal trauma
- Angioedema
- Bilateral vocal cord palsy
- Congenital anomalies (subglottic stenosis)
- Severe acute infections (epiglottitis, Ludwig's angina) - when intubation fails
- Burns to the face/neck with airway involvement
2. Prolonged Mechanical Ventilation
- Patients predicted to require ventilation > 7-14 days benefit from tracheostomy over endotracheal tube:
- Reduced sedation needs (no glottic stimulation)
- Reduced work of breathing (lower airway resistance)
- Reduced dead space
- Improved mouth care and bronchial toilet
- Easier weaning from ventilator
3. Neurological Conditions Preventing Safe Extubation
- Brain injury (acute or progressive - head trauma, CVA)
- Spinal cord injury (including patients in halo fixation)
- Severe agitation or delirium
- Prolonged altered mental status
- Neuromuscular diseases (GBS, MND, myasthenia gravis)
- High risk of aspiration (bulbar palsy)
Additional Specific Indications
- Difficult airway anticipated or established
- Post-laryngectomy (permanent stoma)
- To reduce anatomical dead space
- To facilitate clearance of secretions (suction toilet)
- Sleep apnea (morbidly obese, when CPAP fails)
(Table 47.1 - Sabiston Textbook of Surgery, p. 960)
Contraindications (Relative)
- Recent anterior neck surgery (< 7 days)
- High ventilator settings (FiO₂ > 50%, PEEP > 10 cmH₂O)
- Hemodynamic instability
- Significant coagulopathy / bleeding risk
- Elevated intracranial pressure
- Local infection or malignancy at proposed site
- Predicted early mortality
Complications
Complications are classified as early (intra-operative / < 24 hrs), intermediate (24 hrs - 3 weeks), and late (> 3 weeks).
A. Early / Intra-operative Complications
| Complication | Notes |
|---|---|
| Hemorrhage | From anterior jugular veins, thyroid isthmus; most common early complication |
| False passage / Tube misplacement | Tube placed outside trachea (extraluminal); risk of hypoxia and death |
| Posterior tracheal wall injury | Laceration of posterior trachea or esophagus |
| Pneumothorax / Pneumomediastinum | Due to air leak; more common in children |
| Subcutaneous emphysema | Air dissecting into neck tissues |
| Apnea / Hypoxia | Loss of airway during procedure |
| Cardiac arrest | Due to hypoxia or vagal stimulation |
| Air embolism | Rare |
B. Intermediate Complications (24 hrs to 3 weeks)
| Complication | Notes |
|---|---|
| Tube obstruction | Dried secretions occluding tube; prevented by regular inner cannula cleaning |
| Tube dislodgement | Especially dangerous < 5 days (tract not yet formed) |
| Wound infection / Cellulitis | Stoma site infection |
| Aspiration pneumonia | Particularly if cuff is deflated |
| Mucosal injury/Tracheitis | From repeated suctioning |
| Difficulty swallowing | Tethering of the trachea |
| Atelectasis | From over-suctioning |
C. Late Complications (> 3 weeks)
| Complication | Notes |
|---|---|
| Tracheal stenosis | Most important late complication; occurs in 6% (symptomatic), subclinical in 40%; typically at subglottic/cuff level |
| Tracheoinnominate artery fistula | Life-threatening hemorrhage; tracheostomy tube erodes into innominate artery |
| Tracheoesophageal fistula (TEF) | Due to cuff over-inflation or tube tip pressure on posterior tracheal wall |
| Tracheomalacia | Weakening of tracheal cartilage |
| Persistent tracheal fistula | Failure of stoma to close after decannulation |
| Scar / Cosmetic deformity | Hypertrophic or keloid scar |
| Voice changes | Dysphonia, aphonia |
| Dysphagia | Long-term swallowing difficulty |
| Granuloma formation | At stoma site; may need further surgical procedures |
- Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 204; Sabiston Textbook of Surgery, p. 961
Key Clinical Points (Exam Tips)
- Most common early complication: Hemorrhage
- Most important late complication: Tracheal stenosis
- Most dangerous late complication: Tracheoinnominate artery fistula (sentinel bleed precedes massive hemorrhage)
- PDT vs Open: PDT has less wound infection; open preferred in coagulopathy, obesity, difficult anatomy
- Timing: Early tracheostomy (< 7 days) vs. late (> 10 days) - major RCTs show no mortality difference, but early reduces ICU stay and ventilator days in selected patients
- Benefits over prolonged ETT: Reduced sedation, reduced work of breathing, improved mouth care, better patient comfort, facilitates weaning
Sources: Sabiston Textbook of Surgery (Table 47.1, p. 960-961); Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 1 (p. 405); Roberts and Hedges' Clinical Procedures in Emergency Medicine (p. 204, 209)
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