Although Egyptian tablets depict use of tracheotomy for medical applications nearly 5600 years ago,1 initial descriptions of the procedure in Western literature did not appear until the middle of the sixteenth century.2 By 1718, “tracheotomy” became accepted terminology for the surgical technique that was then primarily used for relief of airway obstruction and removal of aspirated foreign bodies. Typically gruesome clinical results relegated tracheotomy to a reviled role in airway management and gained it a designation as the “scandal of surgery.”3 The diphtheria epidemics of the nineteenth century popularized tracheotomy.4 Tracheotomy did not become widely accepted, however, until 1909, when Chevalier Jackson standardized surgical techniques and decreased the operative mortality from 25% to less than 1%.5
Advances in tube design during the 1960s and 1970s and improved management techniques further promoted acceptance of tracheotomy for long-term airway access for critically ill, ventilator-dependent patients. The advent of percutaneous dilational tracheotomy (PDT) further widened the application of tracheotomy by allowing the procedure to be performed in the intensive care unit (ICU) by nonsurgeons.6 Up to 24% of patients undergoing mechanical ventilation and 6% of critically ill patients in general have a tracheotomy performed.6–12 In North Carolina, nearly a threefold increase in the application of tracheotomy for prolonged mechanical ventilation was observed from 1993 to 2002.9 Although only 7% of ventilated patients underwent tracheotomy in that study, they accounted for 22% of all mechanical ventilation patient charges.
Four indications exist for a tracheotomy in critically ill patients: (a) maintenance of airway patency for patients with functional or mechanical upper airway obstruction, (b) provision of airway access for suctioning retained airway secretions, (c) prevention or limitation of aspiration in patients with glottic dysfunction, and (d) management of patients who require long-term airway access for ventilator support.13 Acceptable outcomes from tracheotomy remain dependent on the skill of the operator who performs the procedure and expertise of interdisciplinary teams charged with managing patients from the critical care phase of their illnesses through transitions to hospital wards and long-term care facilities until successful decannulation occurs.14,15
Standard Surgical Tracheotomy
A standard surgical tracheotomy provides tracheal access through a temporary incisional tracheostoma between cartilaginous rings (Fig. 40-1). The stoma spontaneously closes after removal of the tracheotomy tube.
Anatomic location of stoma placement for different forms of surgical airway access.
Standard surgical tracheotomy is a well-tolerated procedure with an operative mortality of less than 1% when performed as an elective procedure in stable, ventilator-dependent patients. In contrast, most,16 but not all,17 centers report a higher complication rate when surgical tracheotomy is performed as an emergency procedure. Some groups report successful emergency tracheotomy when performed on awake patients.18 Most centers, however, have replaced emergency surgical tracheotomy ...