Tracheostomy

Indications for Tracheostomy

Need for Prolonged Mechanical Ventilation (see Mechanical Ventilation-General, [[Mechanical Ventilation-General]])

Rationale

  • Tracheostomy is Generally Performed in Patients Who Require >3 wks of Mechanical Ventilator Support
    • The 3 Week Cutoff Has Been Derived from Historical Data Related to the Adverse Effects of Prolonged Endotracheal Tube Cuff Pressure on the Tracheal Wall Associated with High-Pressure Cuffs: however, current generation endotracheal tubes have low-pressure cuffs and this data likely no longer applies
  • As Compared to Endotracheal Intubation, Tracheostomy is Generally Believed to Decrease the Work of Breathing, Increase Patient Comfort, and Improve Secretion Clearance

Clinical Efficacy-Improved Respiratory Mechanics Associated with Tracheostomy (as Compared to Endotracheal Intubation)

  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Am J Respir Crit Care Med, 1999) [MEDLINE]
    • Tracheostomy Decreased the Work of Breathing, Pressure-Time Index of the Respiratory Muscles, and PEEP/Auto-PEEP (as Compared to Endotracheal Tube)
  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Arch Surg, 1999) [MEDLINE]
    • Tracheostomy Decreased the Work of Breathing, Due to the Short, Rigid Nature of the Tube (as Compared to the Longer, Thermolabile Endotracheal Tube): effect is more pronounced at higher respiratory rates
  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Anaesth Intensive Care, 1999) [MEDLINE]
    • Tracheostomy Decreased Peak Inspiratory Pressure, But Changed Respiratory Mechanics Very Little
    • Patients Who Had Better Underlying Mechanics (Higher Cstatic, Lower PEEP) Had Better Chances of Weaning from Mechanical Ventilation After Tracheostomy
  • Study of the Effects of Tracheostomy Dead Space (J Trauma, 2001) [MEDLINE]
    • Tracheostomy Minimally Improved Respiratory Mechanics
    • Post-Tracheostomy Change in Physiologic Dead Space Did Not Predict Outcome of Weaning from Mechanical Ventilation
    • Tracheostomy Improved Pulmonary Toilet, Initiation of the Removal of Mechanical Ventilation, and Control of the Upper Airway
  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Eur Respir J, 2002) [MEDLINE]
    • Tracheostomy Decreased Inspiratory Resistive Work, Intrinsic PEEPi, Inspiratory Pressure-Time Product (and its Resistive and Elastic Components)
  • Observational Study of the Effects of Tracheostomy on Respiratory Mechanics in Difficult to Wean Mechanically Ventilated Patients (PLoS One, 2015) [MEDLINE]
    • Tracheostomy Improved Weaning Parameters (Rapid Shallow Breathing Index, etc) in Difficult to Wean Mechanically Ventilated Patients Who Weaned from the Ventilator
    • However, Tracheostomy Only Improved Airway Resistance in Mechanically Ventilated Patients Who Failed to Wean from the Ventilator

Clinical Efficacy-Patient Communication

  • xxxx

Upper Airway Obstruction (see Obstructive Lung Disease, [[Obstructive Lung Disease]])

Rationale

  • Tracheostomy is Utilized to Manage Prolonged Upper Airway Compromise (Due to Tumors, Laryngeal Edema, etc)

Clinical Efficacy

  • Study of the Effects of Tracheostomy Dead Space (J Trauma, 2001) [MEDLINE]
    • Tracheostomy Minimally Improved Respiratory Mechanics
    • Post-Tracheostomy Change in Physiologic Dead Space Did Not Predict Outcome of Weaning from Mechanical Ventilation
    • Tracheostomy Improved Pulmonary Toilet, Initiation of the Removal of Mechanical Ventilation, and Control of the Upper Airway

Technique

Advantages of Tracheostomy

  • Ease of Replacement (Once Tract Has Formed)
  • Speech

Timing of Tracheostomy Placement in Respiratory Failure

  • Clinical Efficacy
    • Systematic Review Studying the Impact of the Timing of Tracheostomy in Adults Supported on Mechanical Ventilation (BMJ, 2005) MEDLINE]
      • Performance of Early Tracheostomy Did Not Impact the Mortality Rate or Risk of Pneumonia
      • Performance of Early Tracheostomy Decreased the Duration of Mechanical Ventilation (8.5 Days Less; 95% Confidence Interval: -15.3 to -1.7 Days) and Duration of ICU Stay (15.3 Days Less; 95% Confidence Interval: -24.6 to -6.1 Days)

Brands of Tracheostomy Tubes

Cuffed Non-Fenestrated Tracheostomy

  • Shiley (Covidien)
    • Size 6
    • Size 8
  • Portex
    • Portex Suctionaid Traceostomy: has subglottic suction port
      • Suctionaid 6
      • Suctionaid 7
      • Suctionaid 8
  • Bivona
    • xxxx

Cuffed Fenestrated Tracheostomy

  • xxx

Tracheostomy Sizing Comparison

  • Note: Portex = Portex Suctionaid

Portex Size|Inner Diameter|Outer Diameter|Length
:————-:|:————-:|:—————:|:————:
Size 6|6 mm|9.2 mm|64.5 mm
Size 7|7 mm|10.5 mm|70 mm
Size 8|8 mm|11.9 mm|75.5 mm
Size 9|9 mm|13.3 mm|81 mm

Shiley Size|Inner Diameter|Outer Diameter|Length
:————-:|:————-:|:—————:|:————:
Size 4|5 mm|9.4 mm|62 mm
Size 6|6.4 mm|10.8 mm|74 mm
Size 8|7.6 mm|12.2 mm|79 mm
Size 10|8.9 mm|13.8 mm|79 mm

Passy-Muir Valve

Device

Use of the Passy-Muir Valve

  • Passy-Muir Valve is a One-Way Valve Which Requires Deflation of the Tracheostomy Tube Cuff and Permits Inspiration, But Not Exhalation, Via the Tracheostomy Tube: exhalation is directed through the glottis/vocal cords, allowing phonation
    • Passy-Muir Valve is Usually Well-Tolerated and Can Even Be Used in Patients with Neuromuscular Disease
    • Use of Passy-Muir Valve with Patient with Tracheostomy, But Not on Mechanical Ventilation: since mechanical ventilation is not required and tidal volume leak is not an issue, this is tolerated in almost all patients
    • Use of Passy-Muir Valve with Patient with Tracheostomy and on Mechanical Ventilation: since mechanical ventilation is required and tidal volume leak may be an issue, patient selection is critical to determine if the patient will tolerate trials
      • Due to Tracheostomy Tube Cuff Deflation in Patients Requiring Ventilator Support, Passy-Muir Valve Use Requires an Approximate 50% Increase in Ventilator Tidal Volume (on Volume-Cycled Ventilation) to Maintain Adequate Ventilation (Crit Care Med, 1993) [MEDLINE]
      • Alternatively, if the Patient is Able to Tolerate Pressure Support Ventilation, this Ventilation Approach May Be Utilized (Especially in Patients with Neuromuscular Disease) (Am J Respir Crit Care Med, 2003) [MEDLINE] (Chest, 2003) [MEDLINE]
  • Requirements for Passy-Muir Valve Use
    • Ability to Clear Secretions
    • Adequate Gas Exchange
    • Hemodynamic Stability
    • Normal Mental Status
  • Advantages of the Passy-Muir Valve
    • Aspiration During Eating is Reduced: as it restores more normal subglottic and glottic airflow during exhalation
    • Decrease in Amount of Bronchial and Pharyngeal Secretions: because air escaping through the mouth and nose contributes to their evaporation
    • Improved Cough Effectiveness: because of the restoration of glottic function
    • Reestablishment of the Ability to Smell
  • Adverse Effects/Complications of the Passy-Muir Valve
    • Inappropriate Use of Excessively Large Tracheostomy, Which Impedes Expiratory Airflow Through the Trachea
    • Accidental Use with Tracheostomy with Cuff Still Inflated, Which Results in Completely Obstructed Expiratory Airflow

Tracheostomy Configurations

Adverse Effects/Complications of Tracheostomy

General Comments

  • Obesity (see Obesity, [[Obesity]])
    • Tracheostomy Complication Rates are Higher in Obese Patients (Laryngoscope, 2015) [MEDLINE]: n= 151
      • Complication Rates are Particularly Higher in Obese Patients with BMI ≥35
      • Complication Rates are Particularly Higher in Obese Patients the Intraoperative and Early Postoperative Periods
      • Procedure Duration Has Also Been Noted to Be Longer in Obese Patients

Acute Adverse Effects/Complications

Pulmonary Adverse Effects/Complications

  • Aspiration
    • Epidemiology
      • Aspiration of Oropharyngeal Secretions is Common with Both Endotracheal Tubes and Tracheostomy Tubes (see Endotracheal Intubation, [[Endotracheal Intubation]])
      • Presence of Gag Reflex Does Not Confer Protection Against Aspiration with Endotracheal Intubation or Tracheostomy (Crit Care Med, 1990) [MEDLINE]
      • Aspiration is Not Increased with Occlusion of the Tracheostomy with a Cap/Finger for Phonation (Ear Nose Throat J, 2006) [MEDLINE]
    • Physiologic Mechanisms
      • Delayed Triggering of the Swallowing Response (Crit Care Med, 1990) [MEDLINE] (Br J Anaesth, 2012) [MEDLINE]
        • Swallowing Dysfunction (Particularly Disorder of the Pharyngeal Phase) and Aspiration are Common with Tracheostomy (Chest, 1994) [MEDLINE]: increasing age increases the risk of aspiration and aspiration is frequently silent
        • Increasing Tracheostomy Cuff Pressure Worsens Swallowing Dysfunction (as Measured by Submental Electromyogram and Amplitude of Laryngeal Acceleration) (Br J Anaesth, 2012) [MEDLINE]
        • Tracheostomy Removal Does Not Appear to Immediately Improve Swallowing Dysfunction (Dysphagia, 2012) [MEDLINE]
      • Pharyngeal Pooling of Secretions Above the Airway Cuff (Crit Care Med, 1990) [MEDLINE]
        • Risk of Aspiration is Correlated with the Amount of Oropharyngeal Secretions
    • Diagnosis
      • Methods to Detect Aspiration
        • Direct Visualization: considered the gold standard method to detect aspiration in tracheostomized patients
        • Glucose Oxidase Testing of Tracheal Secretions: glucose oxidase testing is easier to perform and has higher sensitivity for aspiration than methylene blue dye testing (Chest, 1993) [MEDLINE]
        • Dye Added to Tube Feedings (Evans Blue, Methylene Blue): detection of dye in tracheal aspirate indicates aspiration (Ear Nose Throat J, 2006) [MEDLINE] (J Cardiothorac Vasc Anesth, 2017) [MEDLINE]
    • Clinical
      • Fiberoptic Study of Swallowing Function in Patients with Tracheostomy (Chest, 2002) [MEDLINE]
        • Approximately 33% of Patients Manifested Aspiration
        • When Aspiration Occurred, 82% of These Cases were Silent Aspiration
        • Swallowing Success Occurred Most Frequently in Patients <70 y/o with Improving Respiratory and Medical Status
        • The Optimal Timing for Successful Swallowing Outcome was Approximately 3 wks Post-Tracheostomy in Patients >70 yo/ and 1 wk in Patients <70 y/o
  • Barotrauma
    • Physiology
      • Inadvertent Extraluminal Positioning of the Tracheostomy Fenestration During Tracheostomy Placement: for this reason, fenestrated tracheostomies are typically not selected for initial percutaneous tracheostomy placement
      • Laceration of the Posterior Tracheal Wall
    • Clinical
  • Decreased Phonation/Impaired Ability to Communicate
    • Epidemiology
      • Lack of Verbal Communication Can Be Very Frustrating for Patients Requiring Prolonged Mechanical Ventilatory Support with Either Endotracheal Intubation of Tracheostomy (Chest, 1990) [MEDLINE]
    • Clinical
      • Decreased Phonation May Be Prolonged (or Indefinite in Some Cases)
    • Prevention
      • Early Passy-Muir Valve Trials with Speech Pathology: although Passy-Muir speech valves have historically been used in tracheostomized patients (with a deflated cuff) after they have weaned from the ventilator (for at least some part of the day), data suggest that speech valve trials can be started even in mechanically ventilated tracheostomized patients and may shorten the time to phonation (Crit Care Med, 2016) [MEDLINE]
    • Treatment
      • Passy-Muir Valve: one-way valve device which requires tracheostomy cuff deflation
      • Use of Voice Tracheostomy Tube in Patients with Low PEEP Requirement (Chest, 2004) [MEDLINE]: utilizes slits to expand with positive-pressure inspiration and deflate during expiration, allowing phonation
      • Use of Communicating Tracheostomy Device (Portex Talk Tube, Communitrach I): these devices use a small diameter tube which expels gas above the tracheostomy tube cuff when the proximal end has been manually occluded (however, these devices require the use of manual occlusion and the patient frequently will be able to speak only in short sentences)
  • Hemorrhage from Tracheostomy Site
    • Physiology
      • Hemorrhage from the Tracheostomy Site May Result in Significant Blood Clots in the Airways with Consequent Difficulty Ventilating the Patient
    • Clinical
      • Hemoptysis (see Hemoptysis, [[Hemoptysis]])
      • Increased Peak Inspiratory Pressure (PIP) on the Ventilator
    • Treatment
      • Control of Hemorrhage
      • Removal of Airway Clots: cryoprobe removal of clots may be required in cases where clots are difficult to evacuate
      • Tracheostomy Removal and Endotracheal Reintubation: may be required in cases with significant hemorrhage, as reintubation allows clot to form above the endotracheal tube cuff (tamponading the bleeding site) and prevents further soiling of the airways with blood
  • Tracheostomy Dislodgment
    • Epidemiology
      • Uncommon when Vigilant Postoperative Management is Utilized in the Intensive Care Unit
    • Clinical
      • Inability to Ventilate
        • Attempting to Ventilate Via a Dislodged Tracheostomy (with a Bag-Valve-Mask or Ventilator) Can Result in Pneumomediastinum (and Resultant Pneumothorax)
        • Inability to Ventilate May Require Emergent Removal of the Tracheostomy and Endotracheal Reintubation
    • Prevention
      • Strict Precautions Should Be Employed Regarding Patient Movement/Repositioning in the Days Following Tracheostomy Placement to Prevent Dislodgment
      • Tracheal Ring Sutures: unclear if the use of tracheal ring sutures at the time of tracheostomy placement decreases the risk of tracheostomy dislodgement (or improves the ability to replace a dislodged tracheostomy, if it occurs)
  • Tracheostomy Obstruction
    • Epidemiology
      • Partial Tracheostomy Obstruction by the Posterior Tracheal Membrane Can Occur with Percutaneous Tracheostomy: has been reported with use of the Portex Per-Fit tracheostomy tube (Chest, 2002) [MEDLINE]
      • Swelling of the Posterior Tracheal Wall Has Been Reported (Chest, 2003) [MEDLINE]: in these cases, swelling appeared to be intermittent, resulting in periodic obstruction of the tracheostomy
      • Tracheostomy Malpositioning (with >50% Obstruction of the Tracheostomy Lumen by Tissue) Has Been Reported in Up to 10% of Cases (Chest, 2008) [MEDLINE]: reported in 40/430 patients in this retrospective study performed in a acute care facility specializing in ventilator weaning
        • While Thoracic/General Surgeons were Equally Likely to Have Malpositioned Tracheostomies, Other Subspecialty Surgeons were More Likely to Have Malpositioned Tracheostomies (Odds Ratio: 6.42)
        • Malpositioned Tracheostomy was Associated with Prolonged Mechanical Ventilation
        • Malpositioned Tracheostomy was Not Associated with Increased Hospital Length of Stay or Mortality Rate
    • Physiology
      • Tracheostomy Obstruction by the Posterior Tracheal Membrane
    • Diagnostic
      • Bronchoscopy (see Bronchoscopy, [[Bronchoscopy]]): diagnostic
    • Clinical
      • Inability to Ventilate Patient
      • Failure to Wean from Mechanical Ventilation
  • Tracheostomy Site Infection
    • Epidemiology
      • Uncommon

  • Ventilator-Associated Pneumonia (VAP) (see xxxx, [[Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia]])

    • Epidemiology

      • Data Conflict as to Whether Tracheostomy Increases the Risk of VAP

        • XXXXX

      • Risk Factors Associated with Early VAP (within 5 Days of Tracheostomy Placement) (Chest, 2000) [MEDLINE]: in this retrospective study, incidence of VAP was 26% (occurring at mean of 9 days post-tracheostomy placement)

        • Fever on Day of Tracheostomy Placement
        • Requirement for Sedation Beyond 24 hrs Post-Tracheostomy
        • Significant Bacterial Colonization (>100k cfu/mL)
    • Physiology
    • Clinical
    • Prevention
      • XXXX

Chronic Adverse Effects/Complications

Pulmonary Adverse Effects/Complications

  • Aspiration
    • Epidemiology
      • Aspiration of Oropharyngeal Secretions is Common with Both Endotracheal Tubes and Tracheostomy Tubes (see Endotracheal Intubation, [[Endotracheal Intubation]])
      • Presence of Gag Reflex Does Not Confer Protection Against Aspiration with Endotracheal Intubation or Tracheostomy (Crit Care Med, 1990) [MEDLINE]
      • Aspiration is Not Increased with Occlusion of the Tracheostomy with a Cap/Finger for Phonation (Ear Nose Throat J, 2006) [MEDLINE]
    • Physiologic Mechanisms
      • Delayed Triggering of the Swallowing Response (Crit Care Med, 1990) [MEDLINE] (Br J Anaesth, 2012) [MEDLINE]
        • Swallowing Dysfunction (Particularly Disorder of the Pharyngeal Phase) and Aspiration are Common with Tracheostomy (Chest, 1994) [MEDLINE]: increasing age increases the risk of aspiration and aspiration is frequently silent
        • Increasing Tracheostomy Cuff Pressure Worsens Swallowing Dysfunction (as Measured by Submental Electromyogram and Amplitude of Laryngeal Acceleration) (Br J Anaesth, 2012) [MEDLINE]
        • Tracheostomy Removal Does Not Appear to Immediately Improve Swallowing Dysfunction (Dysphagia, 2012) [MEDLINE]
      • Pharyngeal Pooling of Secretions Above the Airway Cuff (Crit Care Med, 1990) [MEDLINE]
        • Risk of Aspiration is Correlated with the Amount of Oropharyngeal Secretions
    • Diagnosis
      • Methods to Detect Aspiration
        • Direct Visualization: considered the gold standard method to detect aspiration in tracheostomized patients
        • Glucose Oxidase Testing of Tracheal Secretions: glucose oxidase testing is easier to perform and has higher sensitivity for aspiration than methylene blue dye testing (Chest, 1993) [MEDLINE]
        • Dye Added to Tube Feedings (Evans Blue, Methylene Blue): detection of dye in tracheal aspirate indicates aspiration (Ear Nose Throat J, 2006) [MEDLINE] (J Cardiothorac Vasc Anesth, 2017) [MEDLINE]
    • Clinical
      • Fiberoptic Study of Swallowing Function in Patients with Tracheostomy (Chest, 2002) [MEDLINE]
        • Approximately 33% of Patients Manifested Aspiration
        • When Aspiration Occurred, 82% of These Cases were Silent Aspiration
        • Swallowing Success Occurred Most Frequently in Patients <70 y/o with Improving Respiratory and Medical Status
        • The Optimal Timing for Successful Swallowing Outcome was Approximately 3 wks Post-Tracheostomy in Patients >70 yo/ and 1 wk in Patients <70 y/o
  • Decreased Phonation/Impaired Ability to Communicate
    • Epidemiology
      • Lack of Verbal Communication Can Be Very Frustrating for Patients Requiring Prolonged Mechanical Ventilatory Support with Either Endotracheal Intubation of Tracheostomy (Chest, 1990) [MEDLINE]
    • Clinical
      • Decreased Phonation May Be Prolonged (or Indefinite in Some Cases)
    • Prevention
      • Early Passy-Muir Valve Trials with Speech Pathology: although Passy-Muir speech valves have historically been used in tracheostomized patients (with a deflated cuff) after they have weaned from the ventilator (for at least some part of the day), data suggest that speech valve trials can be started even in mechanically ventilated tracheostomized patients and may shorten the time to phonation (Crit Care Med, 2016) [MEDLINE]
    • Treatment
      • Passy-Muir Valve: one-way valve device which requires tracheostomy cuff deflation
      • Use of Voice Tracheostomy Tube in Patients with Low PEEP Requirement (Chest, 2004) [MEDLINE]: utilizes slits to expand with positive-pressure inspiration and deflate during expiration, allowing phonation
      • Use of Communicating Tracheostomy Device (Portex Talk Tube, Communitrach I): these devices use a small diameter tube which expels gas above the tracheostomy tube cuff when the proximal end has been manually occluded (however, these devices require the use of manual occlusion and the patient frequently will be able to speak only in short sentences)
  • Tracheal Stenosis (see Tracheal Stenosis, [[Tracheal Stenosis]])
    • Epidemiology
      • Tracheal Stenosis Below the Glottis But Above the Tracheal Stoma Has Been Reported Following Percutaneous Tracheostomy (Crit Care Med, 2003) [MEDLINE]
      • Studies Report that Tracheal Stenosis Occurred a Mean of 54.5 Days After Tracheostomy Placement with 85% of Cases Demonstrating Stenosis Located Around the Tracheal Stoma (BMC Pulm Med, 2008) [MEDLINE]
        • In Contrast, Patients with Tracheal Stenosis Due to Endotracheal Tubes Predominantly Manifested Web-Like Stenosis at the Cuff Site
    • Physiology
      • Development of Granulation Tissue
    • Treatment
      • Rigid Bronchoscopy with Nd:YAG Laser Treatment and Mechanical/Balloon Dilatation: preferred treatment (BMC Pulm Med, 2008) [MEDLINE]
      • Surgery: required only in a small percentage of cases (BMC Pulm Med, 2008) [MEDLINE]
  • Tracheoarterial Fistula (see Tracheoinnominate Artery Fistula, [[Tracheoinnominate Artery Fistula]])
    • Epidemiology
      • This Complication Occurred More Commonly in the Past, Associated with a Low-Positioned Tracheostomy Tube (Ann Surg, 1976) [MEDLINE]
      • Current Incidence: <1% of cases (Chest, 2005) [MEDLINE]
    • Physiology
      • Usually a Tracheoinnominate Artery Fistula
      • Erosion of the Tracheostomy Tube Tip or Cuff into the Anterior Wall of the Trachea, Resulting in a Fistula into the Innominate Artery as it Passes Anterior to the Trachea
    • Diagnostic
      • Bronchoscopy (see Bronchoscopy, [[Bronchoscopy]]): may be useful in cases which are not massive
      • CT Angiogram (see xxxxx, [[xxxx]]): may be useful in cases which are not massive
    • Clinical
      • Hemoptysis (see Hemoptysis, [[Hemoptysis]]): may be preceded by a “sentinel bleed” and may be massive
    • Treatment
      • Temporizing Measures: overinflate the tracheostomy tube/endotracheal tube cuff (to compress the innominate artery), remove tracheostomy and place an oral endotracheal tube (with cuff distal to the site of the fistula), or insert a finger into the tracheostomy stoma and advance distally in the trachea with compression anteriorly toward the sternum (“little Dutch boy maneuver”)
      • Prompt Surgical Intervention is Required
    • Prognosis
      • Mortality Rate: 86% (Clin Chest Med, 1991) [MEDLINE]
  • Tracheoesophageal Fistula (see Tracheoesophageal Fistula, [[Tracheoesophageal Fistula]])
    • Epidemiology
      • Most Cases of Tracheoesophageal Fistula are Due to Endotracheal Intubation, Rather than Tracheostomy (see Endotracheal Intubation, [[Endotracheal Intubation]])
      • Risk Factors (J Anaesthesiol Clin Pharmacol, 2012) [MEDLINE]
        • Corticosteroids (see Corticosteroids, [[Corticosteroids]]): possible risk factor
        • Diabetes Mellitus (see Diabetes Mellitus, [[Diabetes Mellitus]]): possible risk factor
        • Excessive Motion of the Tracheostomy Tube/Endotracheal Tube
        • High Airway Pressures
        • High Cuff Pressure in the Tracheostomy Tube/Endotracheal Tube Cuff: predominant risk factor
        • Infection: possible risk factor
        • Nasogastric Tube (see Nasogastric-Orogastric Tube, [[Nasogastric-Orogastric Tube]]): possible risk factor
        • Prolonged Duration of Mechanical Ventilation
    • Diagnostic
    • Physiology
      • Erosion of Tracheostomy Tube or Cuff into the Posterior Tracheal Wall, Fistulizing into the Esophagus
    • Clinical
      • Air Leak from Ventilator Circuit (see Ventilator Mechanics, [[Ventilator Mechanics]])
      • Aspiration Pneumonia (see Aspiration Pneumonia, [[Aspiration Pneumonia]]): may be recurrent
      • Enteral Feedings Found in Endotracheal Aspirate
      • Gastric Distention (see Gastric Distention, [[Gastric Distention]]): due to insufflation of gas into the stomach by the ventilator
    • Treatment
      • Avoidance of Enteral Nutrition
      • Elevation of the Head of the Bed
      • Frequent Suctioning
      • Positioning of the Endotracheal Tube Cuff Distal to the Site of the Fistula
      • Stenting: may be used for palliation or temporary medical management until closure can be accomplished
      • Closure
        • Endoscopic Closure
        • Surgical Correction: definitive cure (since spontaneous closure is rare), although operative mortality is approximately 11%
  • Tracheomalacia (see Tracheobronchomalacia, [[Tracheobronchomalacia]])
    • Physiology
      • Damage to Tracheal Cartilage at Stoma/Cuff/Distal Tube Sites Due to Pressure Necrosis, Impaired Blood Flow, Recurrent Infection, Mucosal Friction, or Mucosal Inflammation
    • Clinical
      • Usually Segmental Tracheomalacia (with Maximum Length of 3 cm)
    • Clinical
      • Failure to Wean from Mechanical Ventilation

References

General

  • Verbal communication of ventilator-dependent patients. Crit Care Med 1993; 21:512-517
  • Scintigraphic quantification of aspiration reduction with the Passy-Muir valve. Laryngoscope 1996; 106:231-234

Indications

  • Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med. 1999;159(2):383 [MEDLINE]
  • Changes in respiratory mechanics after tracheostomy. Arch Surg. 1999;134(1):59 [MEDLINE]
  • Pulmonary mechanics in patients with prolonged mechanical ventilation requiring tracheostomy. Anaesth Intensive Care. 1999;27(6):581 [MEDLINE]
  • The role of dead space ventilation in predicting outcome of successful weaning from mechanical ventilation. J Trauma. 2001;51(5):843 [MEDLINE]
  • Effects of tracheotomy on respiratory mechanics in spontaneously breathing patients. Eur Respir J. 2002;20(1):112 [MEDLINE]
  • Effect of Tracheostomy on Weaning Parameters in Difficult-to-Wean Mechanically Ventilated Patients: A Prospective Observational Study. PLoS One. 2015;10(9):e0138294 [MEDLINE]

Timing of Tracheostomy

  • Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005;330:1243 [MEDLINE]

Adverse Effects/Complications

  • Ulcerative tracheo-oesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation. Thorax. 1972;27(3):338 [MEDLINE]
  • Tracheo-innominate artery erosion: Successful surgical management of a devastating complication. Ann Surg. 1976;184(2):194 [MEDLINE]
  • Tracheostomy and its complications. A retrospective study of 794 tracheostomized patients. Ann Chir Gynaecol. 1981;70(3):96 [MEDLINE]
  • Tracheoesophageal fistula formation in intubated patients. Risk factors and treatment with high-frequency jet ventilation. Chest. 1990;98(1):161 [MEDLINE]
  • Importance of verbal communication for the ventilator-dependent patient. Chest. 1990;98(4):792 [MEDLINE]
  • Swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes. Crit Care Med. 1990;18(12):1328 [MEDLINE]
  • Late complications of tracheotomy. Clin Chest Med. 1991 Sep;12(3):597-609 [MEDLINE]
  • Comparison of blue dye visualization and glucose oxidase test strip methods for detecting pulmonary aspiration of enteral feedings in intubated adults. Chest. 1993;103(1):117 [MEDLINE]
  • Verbal communication of ventilator-dependent patients. Crit Care Med. 1993;21(4):512 [MEDLINE]
  • Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest. 1994;105(2):563 [MEDLINE]

  • Management of acquired tracheoesophageal fistula. Chest Surg Clin N Am. 1996 Nov;6(4):819-36 [MEDLINE]

  • Predisposing factors for nosocomial pneumonia in patients receiving mechanical ventilation and requiring tracheotomy. Chest. 2000;118(3):767 [MEDLINE]

  • Percutaneous tracheostomy tube obstruction: warning. Chest. 2002;122(4):1377 [MEDLINE]

  • Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheotomy. Chest. 2002;122(5):1721 [MEDLINE]
  • Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication. Chest. 2003;123(5):1595 [MEDLINE]
  • Tracheoesophageal fistula. Chest Surg Clin N Am. 2003 May;13(2):271-89 [MEDLINE]
  • Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. Am J Respir Crit Care Med. 2003;167(2):114 [MEDLINE]
  • Clinical ventilator adjustments that improve speech. Chest. 2003;124(4):1512 [MEDLINE]
  • Tracheal stenosis and obliteration above the tracheostoma after percutaneous dilational tracheostomy. Crit Care Med. 2003;31(5):1574 [MEDLINE]
  • Tracheostomy tube enabling speech during mechanical ventilation. Chest. 2004;125(3):1046 [MEDLINE]
  • Emphysema and pneumothorax after percutaneous tracheostomy: case reports and an anatomic study. Chest. 2004;125(5):1805 [MEDLINE]
  • The incidence of tracheoarterial fistula in patients with chronic tracheostomy tubes: a retrospective study of 544 patients in a long-term care facility. Chest. 2005;128(6):3906 [MEDLINE]
  • Secretions, occlusion status, and swallowing in patients with a tracheotomy tube: a descriptive study. Ear Nose Throat J. 2006;85(12):831 [MEDLINE]
  • Review of tracheo-esophageal fistula associated with endotracheal intubation. J Surg Educ. 2007 Jul-Aug;64(4):237-40 [MEDLINE]
  • Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Crit Care Med. 2008;36(2):409 [MEDLINE]
  • Tracheostomy tube malposition in patients admitted to a respiratory acute care unit following prolonged ventilation. Chest. 2008;134(2):288 [MEDLINE]
  • Post tracheostomy and post intubation tracheal stenosis: report of 31 cases and review of the literature. BMC Pulm Med. 2008 [MEDLINE]
  • Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed tracheostomy tube. Respir Care. 2010 Dec;55(12):1661-70 [MEDLINE]
  • A clinical audit of the management of patients with a tracheostomy in an Australian tertiary hospital intensive care unit: Focus on speech-language pathology. Int J Speech Lang Pathol. 2011 Dec;13(6):518-2 [MEDLINE]
  • Posttracheostomy tracheoesophageal fistula. J Anaesthesiol Clin Pharmacol. 2012 Jan;28(1):140-1 [MEDLINE]
  • Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. Br J Anaesth. 2012 Oct;109(4):578-83 [MEDLINE]
  • Does removal of tracheostomy affect dysphagia? A kinematic analysis. Dysphagia. 2012 Dec;27(4):498-503 [MEDLINE]
  • Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience. Ann Thorac Surg. 2013 Apr;95(4):1141-6 [MEDLINE]
  • Optimizing Communication in Mechanically Ventilated Patients. J Med Speech Lang Pathol. 2014;21(4):309-31 [MEDLINE]
  • Causes and consequences of adult laryngotracheal stenosis. Laryngoscope. 2015 May;125(5):1137-43 [MEDLINE]
  • The impact of obesity on adult tracheostomy complication rate. Laryngoscope. 2015 Jan;125(1):105-10 [MEDLINE]
  • Endoscopic closure of acquired oesophagorespiratory fistulas with cardiac septal defect occluders or vascular plugs. Respir Med. 2015 Aug;109(8):1069-78 [MEDLINE]
  • Split latissimus dorsi muscle flap repair of acquired, nonmalignant, intrathoracic tracheoesophageal and bronchoesophageal fistulas. Heart Lung Circ. 2015 Jun;24(6):e75-8 [MEDLINE]
  • Return of Voice for Ventilated Tracheostomy Patients in ICU: A Randomized Controlled Trial of Early-Targeted Intervention. Crit Care Med. 2016 Jun;44(6):1075-81 [MEDLINE]
  • Surgical Management of Benign Acquired Tracheoesophageal Fistulas: A Ten-Year Experience. Ann Thorac Surg. 2016;102(4):1081 [MEDLINE]
  • Treatment of large persistent tracheoesophageal peristomal fistulas using silicon rings. Braz J Otorhinolaryngol. 2016 Jul [MEDLINE]
  • A New Modified Evans Blue Dye Test as Screening Test for Aspiration in Tracheostomized Patients. J Cardiothorac Vasc Anesth. 2017;31(2):441 [MEDLINE]