8-31: Cricothyrotomy & Tracheostomy

The three main approaches to secure an airway include endotracheal intubation, cricothyrotomy, and tracheostomy. In an acute airway emergency where the airway above the trachea is blocked (ie, due to trauma, mass, or bleeding), cricothyrotomy secures an airway more rapidly than tracheotomy, with fewer potential immediate complications (eg, pneumothorax and hemorrhage). Depending on the airway emergency, a cricothyrotomy may need to be converted to a tracheostomy after the airway has been secured.

There are two primary indications for tracheotomy: airway obstruction at or above the level of the larynx and respiratory failure requiring prolonged mechanical ventilation. Tracheotomies may be performed via an open or percutaneous approach. In experienced hands, the various methods of percutaneous tracheotomy have been documented to be safe for carefully selected patients. Simultaneous videobronchoscopy can reduce the incidence of major complications. The major cost reduction comes from avoiding the operating room. Bedside tracheotomy (in the ICU) achieves similar cost reduction and is advocated by some experts as slightly less costly than the percutaneous procedures.

The most common indication for elective tracheotomy is the need for prolonged mechanical ventilation. There is no firm rule about how many days a patient must be intubated before conversion to tracheotomy should be advised. The incidence of serious complications, such as subglottic stenosis, increases with extended endotracheal intubation. As soon as it is apparent that the patient will require protracted ventilatory support, tracheotomy should replace the endotracheal tube. Less frequent indications for tracheostomy are life-threatening aspiration pneumonia, the need to improve pulmonary toilet to correct problems related to insufficient clearing of tracheobronchial secretions, and obstructive sleep apnea.

Posttracheotomy care requires humidified air to prevent secretions from crusting and occluding the inner cannula of the tracheotomy tube. The tracheotomy tube should be cleaned several times daily. The most frequent early complication of tracheotomy is dislodgment of the tracheotomy tube. Surgical creation of an inferiorly based tracheal flap sutured to the inferior neck skin may make reinsertion of a dislodged tube easier. It should be recalled that the act of swallowing requires elevation of the larynx, which is limited by tracheotomy. Therefore, frequent tracheal and bronchial suctioning is often required to clear the aspirated saliva as well as the increased tracheobronchial secretions. Care of the skin around the tracheostoma is important to prevent maceration and secondary infection.