Challenges in Tracheostomy

Abstract

Tracheostomy is a life saving procedure of placement of a surgical airway. It is imperative for every medical personnel to be conversant with it as it helps secure airway, the first step in resuscitation when necessary. It is not only thorough knowledge of the anatomy of the neck and procedural technique but also the awareness of the unusual challenging situations likely during this procedure that can help avoid complications and enable one to be better prepared for any eventuality. This chapter aims to draw the attention to the likely challenges during tracheostomy including pediatric tracheostomy and percutaneous dilatational tracheostomy. An encounter with pseudoneurysm of the internal carotid artery helps understand the gravity of the likely challenges that a surgeon must be prepared to manage.

1. Introduction

Tracheostomy, the placement of a surgical airway, is a life saving procedure when endotracheal intubation is not an option or fails. Today with advancements in technology most patients can be easily intubated with very few absolute indications for tracheostomy. Patients’ with severe maxillofacial injuries following road traffic accident and deep neck space abscess with impending airway obstruction are two of the glaring examples where emergency tracheostomy is the preferred option to secure airway. In the past, the primary reason for the placement of a surgical airway was emergent due to an impending airway obstruction, inability to intubate, or inability to ventilate with a bag mask [1]. A patient with stridor having a definitive contraindication for endotracheal intubation requires tracheostomy immediately. An otorhinolaryngologist is required many a times to perform this procedure either in the casualty or emergency operation theater itself. Now, elective placement is much more common with advances in emergency airway management. However it is not always possible to have the requisite expertise and advanced equipments required for the airway management. Also, there are several instances where the placement of a surgical airway is recommended, especially in the setting of large tumors of the upper aerodigestive tract, laryngotracheal injuries that preclude intubation, inflammatory swelling of the upper airway, bleeding in the airway, maxillofacial trauma, bilateral vocal cord immobility, and so on. Furthermore, in settings of known difficulty with intubation or certain facial dysmorphisms, an elective surgical airway is ideal [2]. Therefore it is not only necessary to have a thorough knowledge of the anatomy of the neck and procedural technique but it is also equally essential to know the unusual challenging situations one can face during this procedure to avoid complications and be better prepared.

This chapter aims to draw the attention to likely challenges in tracheostomy which can help the surgeon be better prepared in such situations and it can help one to be fore warned prior to the procedure in order to avoid likely complications.

2. History of tracheostomy

Tracheostomy is a procedure that has been performed as early as in 100 BC with documentation by the Greek physicians. It has gone through the mentioned 5 periods-

1. Period of legend- 2000 BC to 1546 AD

2. Period of fear - 1546 AD to 1833 It was performed only by a brave few at the risk of their reputation

3. Period of drama – 1833 to 1932 Gradually it came to be considered as the preferred means to secure airway in emergency situations in acutely obstructed patients.

4. Period of enthusiasm – 1932 to 1965 where the adage, “If you think of tracheostomy………do it!!” became popular.

5. Period of rationalization – 1965 to till date where the merits of tracheostomy and intubation have been debated for good.

However with the advancements in technology and use of it in early diagnosis of airway lesions it has become possible to plan the definite treatment early and avoid unnecessary tracheostomies. The bronchoscopic guided intubation has further eased the procedure even in difficult scenarios. Therefore we now enter an era of dealing with challenges in the procedure; “period of challenges” as we prepare ourselves to be aware of the challenges and tackle them reducing mortality and morbidity.

3. Challenges during tracheostomy

The neck dissection can be challenging in many situations like advanced laryngeal, hypopharyngeal malignancies, thyroid malignancies, deep neck space abscess, post radiation recurrence in neck etc. It is essential to ascertain the site of obstruction and evaluate the pulmonary status prior to the procedure. Tracheostomy would be futile in case of obstructions below the level of the planned stoma in the trachea. Based on the site; tracheostomy is classified as: High, Mid and Low tracheostomy. Usually it’s the mid tracheostomy that is done at the level of the isthmus of the thyroid gland i.e. between 2nd and 3rd or 3rd and 4th tracheal rings. The low tracheostomy done below the level of the isthmus does carry the risk of injury to great vessels or damage to the pleura thereby resulting in pneumothorax and hence one must be careful. Usually the opinion of cardiothoracic surgeon is taken where sternotomy is required to approach the trachea like in enlarged thyroid with retrosternal extension or anaplastic thyroid carcinoma with stridor. The ideal timing (early vs. late) and techniques (percutaneous dilatational, other new percutaneous techniques, open surgical) for tracheostomy have been topics of considerable debate. Based on evidence from 2 recent large randomized trials, it is reasonable to wait at least 10 d to be certain that a patient has an ongoing need for mechanical ventilation before consideration of tracheostomy [3]. However emergency tracheostomy is a life saving procedure required to be done within minutes with high complication rate as one does not have the luxury of time to ensure adequate preparation. This is where one must be well versed and equipped to deal with challenges.

4. Relevant anatomy

The anatomy of the trachea must be understood with its relations to other relevant structures in the neck. The trachea is a 10 to 15 cm long fibro cartilaginous tube that begins at the inferior border of the cricoid cartilage at the level of the sixth cervical vertebra (C6), about 5 cm above the jugular notch. The inspection of the neck is important as patients with short neck, contractures post burns, post irradiated necks, severe cervical spondylosis, enlarged thyroid gland can pose difficulties during tracheostomy (Figure 1). The proper positioning of the patient ensuring good extension of neck is necessary to make the trachea more prominent and superficial to help in easy location and faster dissection especially during emergency tracheostomy. It is needless to emphasize the importance of good lighting in the field of dissection with an equally efficient assistant during the procedure as the structures must be well retracted to help locate the trachea in the midline. Midline dissection especially during emergencies can help one remain in the relatively avascular plain but this is not always true. The identification of the thyroid gland with appropriate dissection away from the plane of surgery by either hooking it up or in difficult cases ligating and dividing the isthmus can help reach the trachea faster. The pretracheal fascia is identified and confirmation of trachea done by aspirating air into a syringe with 4% lignocaine which can then be injected in case of procedures being done under local anesthesia. Once identified the inter cartilginous incision with or without removal of a part of the anterior tracheal wall is carried out to then introduce the tracheostomy tube of appropriate size while keeping the lumen open using the Trousseau’s tracheal dilator. The selection of the tracheostomy tubes either protex or metal depends on the indication for tracheostomy and the present clinical condition of the patient (Figure 2). All patients requiring prolonged ventilation, ICU stays with patient non responsive, anticipating need for positive pressure ventillation will require the cuffed portex tubes of proper size. In case of adult male patients its either 7.5 or 8 sized portex tube whereas in females its 7.5 or 7. However the Jackson’s metal tracheostomy tube may be inserted in advanced laryngeal malignancy patients presenting with stridor where it is likely to be a permanent tracheostomy and patient requires to be sent home with the same after educating him and his relative on how to clean and use the inner tube. The requirement of suctioning can be avoided with cleaning by removing inner tube and reinserting it. However the metal tube can be an impediment in cases where there is bleeding with granulations around the stoma site, when an MRI is required etc. The selection of tracheostomy tube of appropriate size is important. Usually in intubated patients it is easy to ascertain the size but during emergency tracheostomy ensure that the tube with larger diameter is inserted so that chances of tube block in the early post operative period is minimized. Usually it’s the cuffed portex tube that is used in adult patients with instructions to deflate the cuff at regular intervals. Now the portex tubes do come with the inner tube and hence is preferred over the metal tubes to avoid skin corrosion and granulations with better tolerability among patients. The maintenance of personal hygiene around the stoma site and cleaning of the tube must be explained well to avoid infection and stomal problems.

Figure 1.

Neck findings that can pose difficulties during tracheostomy (a) scar post burns, (b) short neck and (c) post irradiated neck.

5. Salient features of a few of the challenges during tracheostomy

1. Pediatric Tracheostomy – This is definitely a challenging area considering the tracheostomy technique. It was primarily indicated for inflammatory diseases (epiglottitis, abscesses or laryngotracheobronchitis) or trauma prior to early 1960s. At present, almost two-thirds of pediatric tracheostomies are performed in infants less than 1 year of age, the main indications been congenital or acquired laryngotracheal stenosis, prolonged ventilator support and regular pulmonary toileting for persistent aspiration in cases of pharyngotracheal discoordination. However severe anterior neck burns, vascular anomalies of lower neck and the need for high peak inspiratory pressures that may cause pnuemomediastinum/pnuemothorax are all contraindications to performing it.

   Infant larynx is located at the levels of third to fourth cervical vertebra and it starts to descend by age of two to reach adult levels. The challenges in an infant larynx are based on its anatomy wherein up to ten tracheal rings lie in the neck in infants, it’s one-third the size of adult larynx and thyroid notch lie behind the hyoid bone. The technical difficulties in performing a peadiatric tracheostomy is mainly due to the pliable cartilages of infant trachea which can make it difficult to identify from other tubular structures in the neck, thus increasing the possibility of injuring the major structures nearby like recurrent laryngeal nerve, esophagus etc. For peadiatric tracheostomies most palpable landmark is cricoid cartilage, unlike thyroid notch in adults. The location of tracheotomy in children for aspiration or prolonged ventilator support, is made at third or fourth tracheal rings. When indicated for incipient laryngotracheal stenosis (LTS) due to prolonged intubation, it must be at first tracheal ring to preserve as many normal tracheal rings distally as possible or low in the neck at sixth or seventh tracheal rings so as to spare sufficient number of normal rings between the stenosis and tracheostoma. The surgery is performed under general anesthesia with the airway secured where ever possible with an endotracheal tube or a rigid ventilating broncoscope. For cosmetic reasons a small horizontal incision is preferred which is then deepened through subcutaneous fat plane to strap muscles and bipolar diathermy used to cauterize small vessels in the surgical field. The anterior surface of trachea is exposed over 3 to 4 tracheal rings. The debate is still ongoing whether a vertical or horizontal tracheal incision, with or without flap should be made. However the vertical incision seems safer and preferred during all the procedures done at our institute. However tracheal stay sutures are placed or either sides and secured to either sides of chest or an inferiorly based Bjork flap transecting a single tracheal ring maybe taken and sutured to the inferior edge of skin to facilitate reinsertion of the tracheostomy tube while it is being changed or during accidental extubation. In infants accidental dislodgement of the tracheostomy tube is something that one must be careful about and hence the immediate post tracheostomy period is important with the infant requiring utmost care if possible by staff trained to do so. The smallest tracheostomy tube that ensures specifically adapted gas exchange in relation to child’s age is selected. The postion of distal tip of tracheostomy tube, which should rest at least two to three rings above the carina, must be ensured hence the availability of appropriate sized tracheostomy tubes for infants is important. One ring Bjork flap is one of the ways to prevent anterior accidental subcutaneous dislodgement of the cannula.

2. Percutaneous Dilatational tracheostomy (PDT) - The improvement in technique with adoption of percutaneous tracheostomy in the ICU patients has further revolutionized the procedure. Percutaneous dilatational tracheostomy (PDT) over a guidewire was invented by Ciaglia in 1985. This procedure has gained popularity owing to the easy execution of the same at the patients’ bedside avoiding unnecessary and at times high risk transfers to the operation theaters and due to the cost- effectiveness. A recent meta-analysis of Putensen et al. in 2014 included 14 RCTs with 973 patients and found PDT to be associated with less incidence of stomal inflammation and infection but higher incidence of technical difficulties when compared to the conventional surgical tracheostomy [4]. This procedure as an emergency intervention requires an experienced surgeon and at any moment of time if required one must be prepared to convert to open procedure. There are definite contraindications as shown in Table 1 which makes the patient selection process crucial. Proper patient selection and the wide use of ultrasound or bronchoscope can decrease failure rates and complications [5]. Though there are various techniques one should stick to the technique with maximum individual comfort as there is no evidence of superiority among various techniques.

S No.	Absolute contraindications	Relative contraindications
1	Inability to extend neck (Post trauma or otherwise)	Obesity
2	Severe Coagulopathy	Limited neck mobility
3	Infection on the neck wall	Distorted anatomy of neck
4		Previous neck surgeries
5		High ventilator support
6		Bleeding diathesis
7		Hypotension

Table 1.

Contraindications of percutaneous tracheostomy.

6. Conclusion

Tracheostomy is a procedure that has revolutionized recovery of critically ill patients especially those requiring prolonged ventilation. The knowledge of likely difficulties is essential to be able to circumvent them and provide a secure airway as early as possible. It is only in patients who cannot be intubated or in whom it is difficult to intubate that this procedure becomes valuable. The advances in technology and procedures have made intubation possible in almost all patients though it calls for need of expertise and right equipments. Tracheostomy has its challenges in indications, timing, procedure and post procedural care. After the mentioned five periods we are probably into the, “period of challenges” wherein the possibility of tackling the encountered difficulties is being dealt with. It is the beginning of the journey as we move over the uncharted sea and this is an attempt to highlight a few common difficulties encountered.

A case report below highlights one such challenging situation likely during an emergency tracheostomy. The importance of early recognition and timely meticulous management can help avoid serious complications and morbidity. The foresight to secure an airway, as intubation was not possible and avoid an incision and drainage helped diagnose a pseudoaneurysm. Pseudoaneurysms of the internal carotid artery (ICA) are rare and harbor potential risk of life threatening hemorrhage.

7. Case presentation

History – A 62 year old lady with right side neck swelling having stridor was referred to our hospital. The patient a known diabetic, hypertensive with coronary artery disease was on medications for past 10 years. She gave history of dental pain with fever 10 days ago for which she consulted a doctor and was given medications. The fever and pain subsided but she developed a gradually progressive neck swelling on the right side with breathlessness that progressed to noisy breathing. She did not give history of blunt or penetrating neck injuries, voice change or dysphagia.

Examination – The patient had inspiratory stridor. Neck examination revealed a 5 cm x 3 cm firm to hard, tender swelling on the right side extending from just above the supraclavicular region to 1 cm lateral to the thyroid cartilage, laterally reaching upto the posterior border of the sternocleidomastoid. The examination of the oral cavity and oropharynx were unremarkable except for a carious right lower premolar tooth. On direct laryngoscopy the laryngeal inlet was found obstructed by a smooth bulge obstructing the glottis. The other clinical examination was found to be normal.

Investigations & treatment – The blood investigations were all within normal limits except for a raised total WBC count with neutrophilia. The primary concern was to secure an airway and hence an emergency tracheostomy was mandatory. The patient was shifted immediately to the operation theater and under local anesthesia tracheostomy was done. During the procedure after retracting the strap muscles the thyroid gland was found to be pushed by an unusually large mass on the right side. An attempt to retract or hook was futile with bleeding from the surface of the mass. The possibility of a vascular lesion in the region of the carotid sheath was suspected and hence meticulous and careful dissection was carried out to separate the mass. The thyroid gland was retracted medially and the mass held laterally for the visualization of the trachea. After confirming the position of the trachea the stoma was made between the third and fourth tracheal rings and 7.5 portex tracheostomy tube was introduced. The patient was comfortable post procedure and stridor relieved. USG neck was done which reported the possibility of a right internal carotid artery (ICA) pseudoaneurysm with a heteroechoeic collection compressing the right internal jugular vein (IJV). A CT angiogram was done which showed two pseudoaneurysms involving the right ICA with a peripherally enhancing hyperdense collection noted in the right carotid space surrounding the ICA and the distal common carotid artery, possibly a hematoma (Figure 3). Saccular pseudoaneurysms measuring 0.6 & 0.7 cm respectively causing complete airway compromise at C5 vertebral body level were noted (Figure 4). The opinion of the cardiovascular and thoracic surgeon was sought and endovascular stenting was advised as the definitive treatment option.

Figure 2.

Tracheostomy tubes (i) Portex tube with inner tube and obturator & (ii) Jackson’s metal tracheostomy tube with inner tube and obturator.

This case highlights one of the many challenges likely to be encountered during a tracheostomy especially when it is required to be performed as an emergency. “The eyes see what the mind knows” therefore awareness of this possibility helps the surgeon to be better prepared and avoid an on table catastrophe. The rupture of the pseudoaneurysm during the procedure can be life threatening and meticulous dissection can help avert an unusual adversity.

Discussion- The earliest known references to tracheostomy are made in the Rigveda published around 2000 BC. The term ‘tracheotomy’ was first published in 1649 by Thomas Fienus, and referred to the creation of an opening into the anterior tracheal wall to secure the airway. However, in 100 BC, Asclepiades of Bithynia was noted to be the first surgeon to perform an elective tracheotomy, but the first documented successful case dates back to 1546 and is accredited to Antonio Musa Brassavola, as the patient was thought to have an ‘abscess of the windpipe’. Traditionally, the use of a tracheotomy was reserved for cases of airway obstruction [5]. The evolution of tracheostomy can be divided into five stages; the period of legend, fear, dramatization, enthusiasm and rationalization. In the early 19th century, tracheotomy was employed in the treatment of diphtheria and other infectious causes which lead to airway obstruction. In the 1930s, tracheotomy was performed in patients with bulbar poliomyelitis to facilitate access to the airway for the removal of secretions [6]. In the late 1940s to the early 1950s, many began trialing the application of positive pressure ventilation through a tracheotomy [7]. Also, in the 1950s, this surgical procedure was extended to multiple neurologic disorders including coma, brain tumors, multiple sclerosis, and so on. The growing use of tracheostomy led it to be considered as a routine procedure that was both effective and relatively safe, which sharply contrasts much of the previous thought equating tracheotomy to a ‘pronouncing sentence of death’ [8].

Special patient populations may benefit from early tracheostomy, including (1) high likelihood of prolonged mechanical ventilation (ARDS, COPD, failed primary extubation), (2) spinal cord injury and chronic neurologic disorders, and (3) traumatic brain injury patients and other patients with need for airways [9]. The operative technique of tracheostomy was refined by Chevalier Jackson. Studies have reported morbidity of 4–10% and mortality of less than 1% [10]. Though we have come a long way, the procedure is still with some hurdles. One such problem faced is that of an Internal Carotid artery (ICA) pseudoaneurysm which can make the procedure challenging. Pseudoaneurysms of the ICA are generally caused by trauma, with at least part of the aneurysm wall composed only of the adventitial layer or just by hematoma. It has a variety of causes including inflammation, trauma and various iatrogenic causes [11]. The age of presentation usually varies between 16 and 68 years. It may be asymptomatic and detected incidentally. Symptomatic pseudoaneurysms manifest with local or systemic signs and symptoms. Local effects of pseudoaneurysm (whether it is infected or not) are secondary to mass effect on adjacent structures causing compromise of function. This condition may manifest as a palpable thrill, audible bruit or pulsatile mass. Ischemia of the surrounding tissues due to vascular compromise may lead to necrosis of the overlying skin and subcutaneous tissues. Neurologic symptoms may develop secondary to nerve compression or ischemia. The compression of the adjacent vein may lead to edema and deep vein thrombosis. Thromboembolism is also a potential complication. The pseudoaneurysm may rupture leading to hemorrhage with its potential clinical sequel of life threatening shock. Pseudoaneurysm and deep neck space infection both present with posterior pharyngeal wall swelling, drooling, neck lump, hoarse voice or stridor. Clinically difficult to differentiate imaging modalities are required for the same. Investigations aiding in the diagnosis of pseudoaneurysm include Color Doppler sonography, contrast-enhanced CT (CECT), or MRI, and cervical angiography. Color Doppler shows swirling of blood flow within the pseudoaneurysm with a communicating channel to the parent artery (Yin Yang phenomenon) [12]. Ultrasonography (USG) is a valuable diagnostic tool for the detection of pseudoaneurysm. This modality is portable, readily available, inexpensive, fast, involving no ionizing radiations or renal toxic contrast material and non invasive. However it has limitations in assessing pseudoaneurysms of the deep arteries, moreover evaluations of vessels in fracture and hematoma may be difficult. Gray scale USG demonstrates hypoechoeic cystic structure adjacent to a supplying artery. CT angiography has advantage over other imaging modalities as it is not much operator dependant and has shorter acquisition time (<1 minute). Three dimensional CT angiography allows visualization of the lesion from all angles. It has high sensitivity and specificity in detecting arterial injuries. The MRI appearance of this lesion will vary depending on their size, age, extent of thrombosis and presence or absence of arterial occlusions. It shows flow void in a patent aneurysm and variable signal intensity in a thrombosed aneurysm [13]. A pseudoaneurysm generally appears on sectional MR images as small mass lesion that is closely contiguous with the patent artery but which projects outside its normal confines. The various treatment options for pseudoaneurysms include USG-guided compression, percutaneous thrombin injection, coil embolization, endovascular stent graft insertion, and surgery [14]. Lately, endovascular management has proven to be advantageous over surgical management. It is less invasive and is helpful especially when surgery is contraindicated due to various reasons [15]. It also reduces hospital stay, and has eliminated the need for surgical procedures under general anesthesia. The case discussed here is of pseudoaneurysm masquerading itself as a neck abscess causing airway compromise. Our patient presented with a gradually progressive neck mass associated with fever without any history of recent trauma or surgeries. The clinical picture along with the raised total WBC count made us suspect a deep neck abscess. There are reported cases of pseudoaneurysms mimicking neck abscess. The mass effect caused by the pseudoaneurysm was to such an extent that the laryngeal inlet was not at all visualized depriving the possibility of airway restoration by endotracheal intubation. Therefore the need to resort to emergency tracheostomy. This report underlies the need to treat neck swellings with caution and emphasizes the fact that though tracheostomy has evolved over centuries it’s not without any challenges even in expert hands.

Figure 3.

CT angiogram showing pseudoaneurysms involving right ICA.

Figure 4.

CECT scan showing airway compromise due to the pseudoaneurysm (Rt).

Conclusion: Tracheostomy is a common critical care procedure performed by surgeons with the otorhinolaryngologist called in for management of patients in stridor or with a neck mass. In emergency setting the risk is even more and hence it is necessary to be aware of likely conditions that could result in a catastrophe. Pseudoaneurysm of the ICA is definitely one such possibility that must be kept in mind as it can mimic a neck abscess and fatal rupture into the airway can be catastrophic. The knowledge of such a possibility with meticulous dissection would be required to secure an airway following which patient may be investigated and definitive treatment provided.