Tracheotomy
Tracheotomy | |
---|---|
ICD-10-PCS | 0B110F4 |
ICD-9-CM | 31.1 |
MeSH | D014140 |
MedlinePlus | 002955 |
Tracheotomy (
Etymology and terminology
The etymology of the word tracheotomy comes from two Greek words: the root tom- (from Greek τομή tomḗ) meaning "to cut", and the word trachea (from Greek τραχεία tracheía).[2] The word tracheostomy, including the root stom- (from Greek στόμα stóma) meaning "mouth", refers to the making of a semi-permanent or permanent opening and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma (hole) at the time it is created.[3]
Indications
There are four main reasons why someone would receive a tracheotomy:[3]
- Emergency airway access
- Airway access for prolonged mechanical ventilation
- Functional or mechanical upper airway obstruction
- Decreased/incompetent clearance of tracheobronchial secretions
In the acute (short term) setting, indications for tracheotomy include such conditions as severe facial trauma, tumors of the head and neck (e.g., cancers, branchial cleft cysts), and acute angioedema and inflammation of the head and neck. In the context of failed tracheal intubation, either tracheotomy or cricothyrotomy may be performed.[citation needed]
In the chronic (long-term) setting, indications for tracheotomy include the need for long-term mechanical ventilation and
In extreme cases, the procedure may be indicated as a treatment for severe obstructive sleep apnea (OSA) seen in patients intolerant of continuous positive airway pressure (CPAP) therapy. The reason tracheostomy works well for OSA is because it is the only surgical procedure that completely bypasses the upper airway. This procedure was commonly performed for obstructive sleep apnea until the 1980s, when other procedures such as the uvulopalatopharyngoplasty, genioglossus advancement, and maxillomandibular advancement surgeries were described as alternative surgical modalities for OSA.
If prolonged ventilation is required, tracheostomy is usually considered. The timing of this procedure is dependent on the clinical situation and an individual's preference. An international multicenter study in 2000 determined that the median time between starting mechanical ventilation and receiving a tracheostomy was 11 days.[5] Although the definition varies depending on hospital and provider, early tracheostomy can be considered to be less than 10 days (2 to 14 days) and late tracheostomy to be 10 days or more.
Alternatives
Biphasic cuirass ventilation is a form of non-invasive mechanical ventilation that can — in a small subset of cases — allow people to avoid a tracheostomy.[6]
Components
A tracheostomy tube may be single or dual lumen, and also cuffed or uncuffed. A dual lumen tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The obturator is used when inserting the tracheostomy tube to guide the placement of the outer cannula and is removed once the outer cannula is in place. The outer cannula remains in place but, because of the buildup of secretions, there is an inner cannula that may be removed for cleaning after use or it may be replaced. Single-lumen tracheostomy tubes do not have a removable inner cannula, suitable for narrower airways. Cuffed tracheostomy tubes have inflatable balloons at the end of the tube to secure them in place. A tracheostomy tube may be fenestrated with one or several holes to let air through the larynx, allowing speech.[7]
Special tracheostomy tube valves (such as the Passy-Muir valve[8]) have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound.[9]
Surgical procedure
Open surgical tracheotomy (OST)
The typical procedure done is the open surgical tracheotomy (OST) and is usually done in a sterile operating room. The optimal patient position involves a cushion under the shoulders to extend the neck. Commonly a transverse (horizontal) incision is made two fingerbreadths above the suprasternal notch. Alternatively, a vertical incision can be made in the midline of the neck from the thyroid cartilage to just above the suprasternal notch. Skin, subcutaneous tissue, and strap muscles (a specific group of neck muscles) are retracted aside to expose the thyroid isthmus, which can be cut or retracted upwards. After proper identification of the cricoid cartilage and placement of a tracheal hook to steady the trachea and pull it forward, the trachea is cut open, either through the space between cartilage rings or vertically across multiple rings (cruciate incision). Occasionally a section of a tracheal cartilage ring may be removed to make insertion of the tube easier. Once the incision is made, a properly sized tube is inserted. The tube is connected to a ventilator and adequate ventilation and oxygenation is confirmed. The tracheotomy apparatus is then attached to the neck with tracheotomy ties, skin sutures, or both.[10][11]
Percutaneous dilatational tracheotomy (PDT)
The first widely accepted percutaneous tracheotomy technique was described by Pat Ciaglia, a New York surgeon, in 1985.[12] The next widely used technique was developed in 1989 by Bill Griggs, an Australian intensive care specialist.[13] In 1995, Fantoni developed a translaryngeal approach of percutaneous tracheostomy.[14] The Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison studies have been undertaken between these two techniques with no clear differences emerging[15] An advantage of PDT over OST is the ability to perform the procedure at the patient's bedside. This significantly decreases costs and time/people-power needed for an operating room (OR) procedure.[11] Contraindications for percutaneous tracheostomy include infection at the site of tracheostomy, uncontrolled bleeding disorder, unstable cardiopulmonary status, patient unable to stay still, abnormal anatomy of the tracheolaryngeal structures.[2]
Risks and complications
As with most other surgical procedures, some cases are more difficult than others. Surgery on children is more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open.[16] There are other difficulties with patients with irregular necks, the obese, and those with a large goitre.
The many possible complications include
Early complications include infection, hemorrhage,
A 2013 systematic review (published cases from 1985 to April 2013) studied the complications and risk factors of percutaneous dilatational tracheostomy (PDT), identifying major causes of fatality to be
A potential risk factor identified in a 2013 systematic review of the percutaneous technique was the lack of bronchoscopic guidance. Use of the bronchoscope, an instrument inserted through a patient's mouth for internal visualization of the airway, can help with proper placement of instruments and better visualization of anatomical structures. However, this can also be dependent on the skills and familiarity of the surgeon with both the procedure and the patient's anatomy.[18]
There are a multitude of potential complications related to the airway. The main causes of mortality during PDT include dislodgment of the tube, loss of airway during procedure and misplacement of the tube.[18] One of the more urgent complications include displacement or dislodgment of the tracheotomy tube, either spontaneously or during a tube change. Although uncommon (< 1/1000 tracheostomy tube days), the associated fatality is high due to the loss of airway.[21] Due to the seriousness of such a situation, individuals with a tracheotomy tube should consult with their healthcare providers to have a specific, written, emergency intubation and tracheostomy recannulation (reinsertion) plan prepared in advance.
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and a procedural mortality of 0%,[23] which is comparable to those of other series reported in the literature from the Netherlands[24][25] and the United States.[26][27] A 2013 systematic review calculated procedural mortality to be 0.17% or 1 in 600 cases.[18] Multiple systematic reviews identified no significant difference in rates of mortality, major bleeding, or wound infection between the percutaneous or open surgical methods.[22][19]
Specifically a 2017 systematic review calculated the most common causes of death and their frequencies, out of all tracheotomies, to be hemorrhage (OST: 0.26%, PDT: 0.19%), loss of airway (OST: 0.21%, PDT: 0.20%), and misplacement of tube (OST: 0.11%, PDT: 0.20%).[19]
A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases.[28] The comparative study above also identified ring fractures in 9 of 30 live patients[15] while another small series identified ring fractures in 5 of their 20 patients.[29] The long term significance of tracheal ring fractures is unknown.[citation needed]
History
Ancient history
Tracheotomy was first potentially depicted on Egyptian artifacts in 3600 BC.[30] Hippocrates condemned the practice of tracheotomy as incurring an unacceptable risk of damage to the carotid artery. Warning against the possibility of death from inadvertent laceration of the carotid artery during tracheotomy, he instead advocated the practice of tracheal intubation.[17]
Despite the concerns of Hippocrates, it is believed that an early tracheotomy was performed by
Medieval world
The 7th century Byzantine physician
16th–18th centuries
The European Renaissance brought with it significant advances in all scientific fields, particularly surgery. Increased knowledge of anatomy was a major factor in these developments. Surgeons became increasingly open to experimental surgery on the trachea. During this period, many surgeons attempted to perform tracheotomies, for various reasons and with various methods. Many suggestions were put forward, but little actual progress was made toward making the procedure more successful. The tracheotomy remained a dangerous operation with a very low success rate,[quantify] and many surgeons still considered the tracheotomy to be a useless and dangerous procedure. The high mortality rate[quantify] for this operation, which had not improved, supported their position. From the period 1500 to 1832 there are only 28 known reports of tracheotomy.[35]
In 1543,
Towards the end of the 16th century, anatomist and surgeon
In 1620 the French surgeon Nicholas Habicot (1550–1624), surgeon of the Duke of Nemours and anatomist, published a report of four successful "bronchotomies" which he had performed.[37] One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a pediatric patient. A 14-year-old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a highwayman. The object became lodged in his esophagus, obstructing his trachea. Habicot suggested that the operation might also be effective for patients with inflammation of the larynx. He developed equipment for this surgical procedure which displayed similarities to modern designs (except for his use of a single-tube cannula).[citation needed]
19th century
In the 1820s, the tracheotomy began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician Pierre Bretonneau employed it as a last resort to treat a case of diphtheria.[44] In 1852, Bretonneau's student Armand Trousseau reported a series of 169 tracheotomies (158 of which were for croup, and 11 for "chronic maladies of the larynx")[45] In 1858, John Snow was the first to report tracheotomy and cannulation of the trachea for the administration of chloroform anesthesia in an animal model.[46] In 1871, the German surgeon Friedrich Trendelenburg (1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia.[47] In 1880, the Scottish surgeon William Macewen (1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform.[48][49] At last, in 1880 Morell Mackenzie's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary.[17]
20th century
In the early 20th century, physicians began to use the tracheotomy in the treatment of patients affected by paralytic
Society and culture
Notable individuals who have or have had a tracheotomy include
Across movies and TV shows, there are many situations where an emergency procedure is done on an individual's neck to re-establish an airway. An example is in the 2008 horror film, Saw V, in which a character being drowned from the neck up performs a manual tracheotomy, stabbing his neck with a pen to create an airway to breathe through. The most common procedure is a cricothyrotomy (or "crike"), which is an incision through the skin and cricothyroid membrane. This is often confused or misnamed as a tracheotomy (or "trach") and vice versa. However, they are quite different based on location of the opening and length of time the alternate airway is needed.
References
- ^ Molnar, Heather (11 April 2023). "Types of Tracheostomy Tubes".
- ^ a b Romaine F. Johnson (6 March 2003). "Adult Tracheostomy". Houston, Texas: Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine. Archived from the original on 17 May 2008.
- ^ a b Jonathan P Lindman; Charles E Morgan (7 June 2010). "Tracheostomy". WebMD.
- ^ Eberhardt, Lars Karl (2008). Dilatational Tracheostomy on an Intensive Care Unit (Dissertation). Universität Ulm.
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- ^ "Translaryngeal Tracheostomy- TLT Fantoni method". www.translaryngealtracheostomyfantoni.it. Archived from the original on 11 September 2017. Retrieved 21 December 2018.
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- ^ Steven E. Sittig; James E. Pringnitz (February 2001). "Tracheostomy: evolution of an airway" (PDF). AARC Times: 48–51. Archived from the original (PDF) on 1 April 2017. Retrieved 5 June 2008.
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- ^ a b Goodall, E.W. (1934). "The story of tracheostomy". British Journal of Children's Diseases. 31: 167–76, 253–72.
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- ^ a b Nicholas Habicot (1620). Question chirurgicale par laquelle il est démonstré que le Chirurgien doit assurément practiquer l'operation de la Bronchotomie, vulgairement dicte Laryngotomie, ou perforation de la fluste ou du polmon (in French). Paris: Corrozet. p. 108.
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- ^ Julius Casserius (Giulio Casserio) and Daniel Bucretius (1632). Tabulae anatomicae LXXIIX ... Daniel Bucretius ... XX. que deerant supplevit & omnium explicationes addidit (in Latin). Francofurti: Impensis & coelo Matthaei Meriani.[permanent dead link]
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- ^ Georges Detharding (1745). "De methodo subveniendi submersis per laryngotomiam (1714)". In Von Ernst Ludwig Rathlef; Gabriel Wilhelm Goetten; Johann Christoph Strodtmann (eds.). Geschichte jetzlebender Gelehrten, als eine Fortsetzung des Jetzlebenden. Zelle: Berlegts Joachim Undreas Deek. p. 20.
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- ^ Armand Trousseau (1833). "Mémoire sur un cas de tracheotomie pratiquée dans la période extrème de croup". Journal des connaissances médico-chirurgicales. 1 (5): 41.
- ^ Armand Trousseau (1852). "Nouvelles recherches sur la trachéotomie pratiquée dans la période extrême du croup". In Jean Lequime and J. de Biefve (ed.). Annales de médecine belge et étrangère. Brussels: Imprimerie et Librairie Société Encyclographiques des Sciences Médicales. pp. 279–288.
- ^ Snow J (1858). "Fatal cases of inhalation of chloroform, Treatment of suspended animation from chloroform". In Richardson BW (ed.). On chloroform and other anaesthetics: their action and administration. London: John Churchill. pp. 120–200, 251–62.
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- ^ Trendelenburg, F (1871). "Beiträge zu den Operationen an den Luftwegen" [Contributions to airways surgery]. Archiv für Klinische Chirurgie (in German). 12: 112–33.
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- ^ "Biography (Christopher Reeve Homepage)". www.chrisreevehomepage.com. Retrieved 19 December 2018.
- ^ Day, Nate (3 August 2020). "Val Kilmer says he's doing great after tracheotomy: 'I feel a lot better than I sound'". Fox News. Retrieved 14 June 2022.
- ^ "Famous people who have or have had Tracheostomies". www.tracheostomy.com. Archived from the original on 24 December 2018. Retrieved 19 December 2018.
Further reading
- Plotnikow GA, Roux N, Feld V, Gogniat E, Villalba D, Ribero NV, Sartore M, Bosso M, Quiroga C, Leiva V, Scrigna M, Puchulu F, Distéfano E, Scapellato JL, Intile D, Planells F, Noval D, Buñirigo P, Jofré R, Nielsen ED (October 2013). "Evaluation of tracheal cuff pressure variation in spontaneously breathing patients". International Journal of Critical Illness and Injury Science. 3 (4): 262–8. PMID 24459624.
External links
- Tracheotomy Info (A community for tracheotomy-wearers and the people who love them) at tracheotomy.info
- Tracheostomy Products and Support (Online resource for tracheostomy products, supplies and support) at trachs.com
- Aaron's tracheostomy page (Caring for a tracheostomy) at tracheostomy.com
- (Pictures with video clipping) at drtbalu.com
- Translaryngeal tracheostomy Archived 11 September 2017 at the Wayback Machine
- "Tracheotomy" at Dorland's Medical Dictionary
- Smiths Medical Tracheostomy Training Videos
- A Video of Rescue Breathing for Laryngectomees and Neck Breathers
- "Book of Simplification Concerning Therapeutics and Diet", is a manuscript from 1497 that discusses tracheotomies
- An all inclusive resource about tracheostomy including articles and courses for medical professionals, caregivers and patients
- Site and blog with information about tracheostomies
- Global Tracheostomy Collaborative. International collaborative with resources for hospitals, caregivers, and patients about tracheostomies, including international research
- Dilatational Tracheostomy On An Intensive Care Unit