Tracheotomy – colloquially known as tracheotomy – refers to surgical access to the trachea (windpipe) through the skin in the area below the larynx. Tracheotomy is one of the most common procedures performed on ventilated patients in the intensive care unit. It is performed as percutaneous dilated tracheotomy (PDT) or open surgical tracheotomy (OCT) (see “The surgical procedures” below). Today, the term tracheotomy is usually replaced by “tracheostomy” (= permanent fixation of the trachea to the neck skin, i.e., creation of an epithelialized tracheal incision by suturing skin flaps to the opened trachea). However, it would be more correct to consider tracheostomy as a subtype of tracheostomy. Tracheostomy should only be performed under sterile conditions by trained medical professionals. It is not usually appropriate for emergency situations.
Indications (areas of application)
- Securing the airway when intubation (insertion of a tube (a hollow probe) into the trachea) or coniotomy (opening the airway at the level of the larynx in case of acute risk of suffocation) fail (→ emergency tracheotomy with creation of a tracheostoma/surgically created opening of the trachea (windpipe) to the outside).
- Long-term ventilation – facilitates oral care, weaning (English : to wean; ventilator weaning: this refers to the phase of weaning a ventilated patient from the ventilator), reduces infections, greater patient comfort, ability to speak.
- Upper airway abnormalities, fractures (broken bones) of the face or base of the skull that prevent intubation
Contraindications for percutaneous dilatation tracheostomy (PDT)
- Failure to undergo tracheoscopy (endoscopy of the trachea) or bronchoscopy (endoscopy of the lungs).
- Difficult or impossible intubation, i.e. laryngoscopically not intubable patient.
- Difficult anatomic conditions:
- Previous operations on the neck with significant scarring.
- Need for a tracheostoma for more than 8 weeks
- Manifest infection in the neck
- Severe coagulation disorders
- Most severe gas exchange disorders
- Planned transfer of patient within 10 days (e.g., peripheral ward, rehabilitation or nursing facility)
Before percutaneous dilatation tracheostomy
Use of sonography to image the two inferior thyroid veins on both sides can reduce the risk of bleeding during puncture. Note: The image of the trachea with two inferior thyroid veins on both sides above the trachea resembles the head of a frog with its eyes open: the “blinking frog” sign reveals where pretracheal (“located in front of the trachea”) blood vessels are located.
Surgical procedures
The following forms can be distinguished:
- Percutaneous dilatation tracheostomy (PDT) – in this case, the tracheostoma is inserted using the seldinger technique (the seldinger technique is a method of puncturing blood vessels for the purpose of catheterization); the stoma (Gr. στόμα stóma “mouth”, also “orifice”, “opening”) is smaller and less stable than the plastic tracheostoma
- Open surgical tracheostomy (OCT; synonym: plastic tracheostomy) – i.e. surgical creation of a tracheostoma.
Considering the above contraindications, PDT is a low-complication alternative to open surgical tracheostomy when only a passive tracheostoma is needed.
Potential complications
- Pressure ulcers (pressure sores)
- Fistula connections between the trachea and esophagus
- Tracheoesophageal fistulas – fistula connections between the trachea (windpipe) and esophagus (esophagus).
- Obstruction of the stoma (gr. στόμα stóma “mouth“, also “mouth”, “opening”) by secretion (wound water).
- Injury to vessels, nerves, skin or soft tissues.
- Wound infection
- Tracheostomy-associated deaths:
- OCT (0.62%, 95% confidence interval: [0.47; 0.82]).
- PDT (0.67% [0.56; 0.81])
The most common causes of tracheostomy-associated deaths are hemorrhage, loss of airway, and via falsa (Latin for wrong way, to: via (way) and falsus (wrong); in the context of surgical procedures, the unintentional (iatrogenic) departure from the correct or planned course of an inserted instrument).
Potential complications of cannula exchange in dilatation stoma in permanently tracheotomized patients:
- Bleeding
- Lesions
- Granulations on the stoma
- Formation of tracheal stenosis (tracheal narrowing; most common long-term complication).
- With keloid tendency (bulge scarring), 1 in 5 patients develops tracheal stenosis after tracheostomy and 15% after tracheal intubation; stenosis (narrowing) is high in approximately 80%
- Increased risk of via falsa (see above).
Percutaneous dilatation tracheostomy (PDT) versus open surgical tracheostomy
- Both procedures have few complications.
- If complications do occur with PDT, they are often life-threatening.
- Pro percutaneous dilatation tracheostomy:
- Shorter intervention time
- Lower incidence of wound infections
- Better cosmetic outcome after closure of the tracheostoma.
- Per open surgical tracheostomy:
- Can also be performed in the case of contraindications to PDT.
- Postoperatively, a stable tracheostoma is immediately available with simple nursing care
Further notes
- Outcome of 1,890 tracheostomies in critical COVID-19 patients: a national cohort study in Spain: Most tracheostomies (n = 1461; 81.3%) were open and the remainder percutaneous (n = 429; 22.7%). Indication and timing of elective tracheostomy were usually determined by ICU staff based on the patient’s respiratory status.The complication rate was low; bleeding was the most notable adverse outcome in 49 patients (2.6%). One patient died from bleeding. Among other adverse events was desaturation (oxygen desaturation) with cardiac arrest (n = 8; 0.42%) immediately after tracheal opening with 5 (0.2%) subsequent intraoperative deaths. Pneumothorax (collapse of the lung) after tracheostomy was reported in 3 cases.
