Anesthesiology

Tracheostomy / Standard and Bedside

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What the Anesthesiologist Should Know before the Operative Procedure

Tracheostomy, or direct surgical opening of the trachea, is a common procedure performed in critically ill patients. The most common indication for tracheostomy is respiratory failure with ventilator dependency and the need for prolonged mechanical ventilation. Other common indications are upper airway obstruction, protection of tracheobronchial tree in patients at risk of aspiration, management of secretions, or as an elective procedure in patients undergoing major head and neck surgery to facilitate surgical exposure and ventilation.

Several advantages of tracheostomy include: decreased work of breathing, ability to facilitate weaning from mechanical ventilator support, improved patient comfort and decreased intensive care unit (ICU) and hospital length of stay.

The vast majority of patients are critically-ill in the ICU under mechanical ventilation for an elective procedure. Often, these patients have significant comorbidities and multisystemic organ dysfunction which will require identification and stabilization (specifically coagulopathy and high PEEP requirement) before the procedure takes place.

What is the risk of delay in order to obtain additional preoperative information?

In the case of elective tracheostomy for long term mechanical ventilation, it is mandatory to clearly assess the presence of coagulopathy and the risk of bleeding. The presence of clinically significant coagulopathy and poor oxygenation or gas exchange with high ventilatory pressures are contraindications to proceed. These particular issues should be corrected before an elective procedure.

Patients with deteriorating hemodynamics must first be stabilized. Most patients are on established doses of vasoactive medications, which does not constitute a contraindication.

Emergent:Emergent tracheostomy should not be delayed for any reason. Airway control should take precedence with special attention to intraoperative optimization associated with medical conditions. The emergent indications for tracheostomy are acute respiratory failure due to critical upper airway obstruction or collapse with subsequent asphyxia. Likewise, acute upper airway compromise (acute epiglottitis, croup, Ludwig's Angina) can be life-threatening conditions. In these cases, the procedure should not be delayed in order to obtain diagnostic procedures. The procedure should ideally be performed in the OR or where appropriate equipment is located to maximize the chance of procedural success.

Urgent: Depending upon the degree of airway compromise and the anticipated respiratory collapse, there may be time to correct other issues, such as hemodynamic instability, while the patient is rapidly prepared for the procedure.

Elective: In patients undergoing tracheostomy as part of a separate elective surgical procedure, the usual considerations should be made. Most patients will receive an elective tracheostomy for prolonged mechanical ventilation and are probably relatively stable in the ICU.

2. Preoperative evaluation

A complete preoperative assessment is required. Emphasis should be made on determining the presence of coagulopathy and the requirement of high peak inspiratory pressures and/or PEEP in order to maintain an acceptable oxygenation level. Also, it is important to assess if there is a stable hemodynamic status, including the presence of unstable arrhythmias.

The surgeon should determine the technical suitability and appropriate location (OR vs. bedside) of the procedure. This decision is made considering the presence of contraindications for percutaneous dilational tracheostomy (PDT) such as anatomical abnormalities, previous tracheostomy or neck surgery, history of neck irradiation, or extensive scarring/fibrosis, limited neck mobility, aberrant blood vessels. Morbid obesity is no longer an absolute contraindication for a percutaneous/bedside procedure.

The ICU team will help determine if the patient is suitable for transfer to the OR. Increased risk of clinical deterioration during transport will mandate a bedside procedure or delay surgery. The anesthesia team should have a complete understanding of the patient management and care goals to optimize the anesthetic plan.

  • Medically unstable conditions warranting further evaluation include: Significant coagulopathy and/or active bleeding (including clinically significant or worsening thrombocytopenia), high ventilatory settings or hypoxemia, hemodynamic instability, active myocardial ischemia, or unstable arrhythmias.

  • Delaying surgery may be indicated if: There are significant coagulation abnormalities, the use of high PEEP or ventilatory settings with hypoxemia or marginal oxygenation, or a high risk of clinical deterioration during transfer to the OR if the procedure cannot be done at the bedside.

a. Cardiovascular system

Preoperative evaluation

Acute/unstable conditions:

If there is clinical suspicion of myocardial ischemia, its presence must be established by EKG, cardiac biomarkers, or echocardiogram. Significant myocardial ischemia may be aggravated during tracheostomy, given the important sympathetic stimulation during airway manipulation. Deteriorating or unstable hemodynamics may be worsened by transient hypercarbia or hypoxemia.

If available, review all hemodynamic data. Pulmonary hypertension and RV dysfunction are particularly susceptible to acute changes in ventilation/oxygenation. In some situations, the use of temporary preoperative pacemakers or cardioverter/defibrillator is warranted to treat unstable arrhythmias. The baseline degree of systolic and diastolic dysfunction will be also major determinants of the specific anesthetic technique/considerations.

Baseline coronary artery disease or cardiac dysfunction- Goals of management:

Generally patients with a CAD diagnosis at time of surgery are optimized. Otherwise, patients with no acute ischemia who are in stable clinical condition will not benefit from further work up or intervention. Perioperative optimization of myocardial oxygen balance should be pursued.

Perioperative risk reduction strategies

Most patients have already undergone continuous invasive monitoring. Therefore, establishing new monitoring is usually unnecessary. If possible, optimize hemodynamics preoperatively. Many patients are on pharmacologic hemodynamic support already. Anticipate transient vasodilation upon induction and significant hypertension/tachycardia with airway manipulation.

The procedure is short with minimal bleeding, and transfusion is rarely essential. Increase FiO2 before the procedure to maximize the margin of safety against hypoxemia. Short-acting beta blockers may be useful for controlling the sympathetic response during critical points of the procedure.

b. Pulmonary

Tracheostomy patients have respiratory failure with mechanical ventilation, and frequently have marginal oxygenation on high PEEP and/or inspired oxygen concentration. Determine the specific ventilatory settings used and define the alternatives for ventilatory support during discontinuation of ventilation for the tracheostomy.

PEEP should be maintained during transport, and whenever possible. Perform endotracheal aspiration of excessive secretions using the closed endotracheal suction system in order to optimize gas exchange and ventilatory mechanics prior to starting the procedure. Remember, excessive aspiration can cause derecruitment/atelectasis and desaturation; recruitment manoeuvres may be necessary afterwards.

In patients whose tracheostomy is done for airway obstruction/control, a careful assessment of the airway should be done and alternative means of airway access have to be discussed with the surgeon prior to the procedure. All tracheostomy patients are at risk of pulmonary aspiration as a result of pharyngeal pooling of secretions above the airway cuff in combination with impaired airway reflexes. Many have had recent aspiration episodes. Carefully suction all oropharyngeal secretions above the ETT cuff to avoid further aspiration upon ETT manipulation and cuff deflation.

i. COPD:

Most patients have significant chronic and/or acute pulmonary disease as a contributor to their respiratory failure. COPD and smoking are highly prevalent in this population. Assess the baseline CXR and ABGs, if available, pulmonary function tests should be reviewed. Many patients with borderline oxygenation and/or hypercarbia are already on stable treatments and are unlikely to improve acutely before the procedure.

ii. Reactive airway disease (Asthma):

Assess the severity of the disease and the likelihood of further decompensation in order to plan preoperative interventions. Minimal airway manipulation can trigger episodes of severe airway reactivity in susceptible patients. Preventive management may help avoid bronchospasm by achieving deep anesthetic levels and minimizing the sympathetic response. Topicalization of the tracheal mucosa with short /intermediate acting local anesthetics before airway manipulation may be indicated in high-risk patients. If there is active bronchospasm before the procedure, use nebulizer therapy and a pulmonary toilet to improve patient status.

d. Renal-GI:

Preoperative evaluation

Renal

Patients have often varying degrees of chronic kidney disease and/or acute kidney injury contributing to their respiratory failure. In many instances, patients are being managed by forced diuretic therapy with the goal of achieving a negative total body fluid balance. These patients may be intravascularly volume contracted, and are more susceptible to significant hemodynamic changes with vasodilation.

Assess the fluid balance, urine output, and electrolytic status of the patient. Review the available renal function tests and electrolytes. Determine the ICU team's goals of management and tailor the fluid/electrolytes management strategy to the same effect.

GI

Patients are at high risk of pulmonary aspiration of gastric contents. Many patients have advanced enteral feeding and/or TPN due to GI dysfunction/failure. Assess the GI status of the patient and the presence of conditions that increase the risk of aspiration, such as ileus, gastric feeding, or high output gastric tube drainage.

Perioperative risk reduction strategies

Renal:

Optimize hemodynamics and avoid hypotension, which can cause additional ischemic injury and worsen a preexisting chronic kidney disease. Patients with severe/acute anemia are at high risk of perioperative acute kidney injury and could benefit from preoperative transfusion in selected cases, even though the procedure is short and blood loss is usually minimal. Most patients do not require intervention. Anticipate hemodynamic changes and avoid infusing significant volume of fluids in a patient who is being diuresed.

GI:

Most patients are already NPO. In any case, make sure gastric feeding had been stopped more than 6-8 hours before the procedure and that the stomach is empty by suctioning the gastric tube, which in most cases is already present. Although there are not clear guidelines, advanced post-pyloric/jejunal feeding do not need to be stopped more than 4-6 hours in advance. Some advocate continued feeding in this later circumstance, given the low risk of aspiration, if there are not other risk factors. Most patients have pharmacologic GI prophylaxis already in place.

e. Neurologic:

The main population of critically-ill patients that benefit the most from early tracheostomy are patients with severe traumatic brain injury and low GCS. An important indication for tracheostomy is severely compromised neurologic status with inability to maintain and protect the airway. In patients with respiratory failure, neurologic dysfunction, such as generalized neuropathy, neuromuscular diseases, or phrenic nerve paralysis, are triggers or significant contributors to respiratory failure.

i. Acute issues:

Acute neurologic changes and the presence of a new CVA are acute medical issues that need to be fully diagnosed and resolved prior to an elective tracheostomy. Undiagnosed acute intracranial hypertension and/or hemorrhage can be aggravated during a short procedure such as a tracheostomy. Assess the baseline neurologic status and diagnosis. Review radiologic, studies if available. Determine goals of care accordingly (i.e., stroke patients may have further secondary injury/ischemia with minimal hemodynamic changes; significant hypertension can facilitate hemorrhagic conversion of ischemic CVAs).

ii. Chronic disease:

Many patients have advanced cardiovascular disease. If there is history of carotid artery disease, patients will benefit from higher perfusion pressures, and minimal hypotension can be catastrophic. Some patients may have varying degrees of chronic illness, weakness, and/or myopathy. In these instances, avoid neuromuscular blockers. Avoid long-acting muscle relaxants in chronically-ill patients.

f. Endocrine:

Most critically-ill patients have stress response and/or multifactorial hyperglycemia. The benefits of blood sugar control in critically-ill patients have been advocated for several years. Specific populations, such as cardiac surgical patients, have shown the highest outcome benefits. Therefore, most patients in the ICU have insulin therapy.

Continue to monitor blood glucose and insulin therapy in the same way. Short periods with no feeding usually do not cause significant hypoglycemia. Keep the patients under continuous monitoring and protocols that allow for adjustments in insulin levels accordingly. Beware of stopping TPN abruptly, because it will cause rapid, severe rebound hypoglycemia.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Most critically-ill tracheostomy patients have some degree of anemia of chronic disease. In most instances, there is no need for transfusion because there is minimal blood loss. Consider perioperative blood transfusion only in cases of symptomatic anemia with possible acute myocardial ischemia or target organ dysfunction (renal and/or cerebral ischemia).

Assess the presence of coagulopathy. Review baseline coagulation tests. Usually PT/INR, PTT, and platelets are sufficient. Ideally there should not be any level of coagulopathy. Some studies have shown that it is safe to perform PDT in patients with mild-to-moderate coagulopathy.

Avoid the use of long-acting neuromuscular blockers because they increase the risk of weakness and myopathy in critically-ill patients. In most cases, it is possible to avoid the use of neuromuscular blockers by providing deep anesthetic levels and local anesthetics. Otherwise, it is feasible to use low single doses of short- or intermediate-acting neuromuscular blockers.

4. What are the patient's medications and how should they be managed in the perioperative period?

Most patients are already in a fully established medication regimen. It is rarely necessary to change or stop medications pre- or intraoperatively, except for the management of coagulation and/or hemodynamics.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Cardiac medications

Many patients can be on vasoactive medications and/or inotropes. Consider adjusting them to improve perfusion pressures and to avoid hemodynamic instability. Aim to return to baseline doses whenever possible. Most patients are already on beta blockers, which decrease the incidence of perioperative cardiac adverse events. Use short-acting beta blockers to manage hemodynamic/sympathetic responses during the procedure.

Pulmonary

Most patients in respiratory failure are on a maintenance or control medication regimen usually consisting of a combination of inhalation and/or oral/IV therapy. Consider the use of additional inhalation therapy to improve respiratory status or to manage or prevent bronchospasm.

Hematologic

If the patient is already on aspirin, there is usually no contraindication to proceed. Aspirin, even at high doses, will not significantly increase the risk of surgical bleeding or complications. In most cases, patients are on aspirin for the management of coronary stents. Otherwise, aspirin has little application in critically-ill patients and is generally avoided due to the risk of GI bleeding.

Other antiplatelet agents (IIB/IIIA receptor antagonist agents) may increase the risk of surgical bleeding significantly, and delaying the procedure may be advisable. If coronary stents are present, determine the implantation date and recommended therapy in order to balance the risk of surgical bleeding vs. the potential risk of stent thrombosis or stenosis.

The consequences of surgical bleeding or vascular complications in this procedure can include stent thrombosis or stenosis. Consult with cardiology, if necessary. Ask the surgeon about the risk of bleeding and make a joint decision, if possible.

i. What should be recommended with regard to continuation of medications taken chronically?

  • Cardiac: See above.

  • Pulmonary: Consider supplementary use of inhaled bronchodilators before staring the procedure.

  • Renal: Avoid the use of nephrotoxic agents. Antibiotics are usually not indicated.

  • Neurologic: Many patients have undiagnosed delirium or are being actively treated for delirium. Avoid the use of benzodiazepines, which can worsen delirium.

  • Anti-platelet: See above.

  • Psychiatric: Continue the established regimen. Determine if antipsychotics are being used to manage agitation and/or delirium. Potential psychoactive medications that can cause acquired prolonged QT intervals are phenothiazines, tricyclic antidepressants, typical and atypical antipsychotics, and SSRIs. Other possible agents are antibiotics/antifungals. If there is QT prolongation or risk, avoid using medications that can further increase this risk. In general, ketamine and volatile anesthetics (in particular halothane and enfluorane) are considered "sensitizing" agents. Adequate anesthetic levels and control of sympathetic responses prevents significant arrhythmias. Otherwise, anesthetics and neuromuscular blockers are not an issue.

j. How to modify care for patients with known allergies

Most allergies are related to antibiotics. Prophylactic antibiotics are not indicated for this procedure. If patients are already on antibiotics, continue the established regimen. There are rarely allergies related to anesthetic agents with the exception of neuromuscular blocking drugs.

k. Latex allergy - If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

N/A

l. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics

N/A

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia is only of concern when succinylcholine and/or inhalational anesthetics are used. For bedside tracheostomy, there is no use of inhalational agents because there is typically no access to them outside of the OR. This procedure is usually performed using intravenous anesthetic agents. Otherwise, succinylcholine should be avoided whenever possible given the potential side effects, not only of malignant hyperthermia, to which critically-ill patients can be more susceptible.

5. What laboratory tests should be obtained and has everything been reviewed?

Patients in the ICU generally have basic laboratory work up daily. Those should be sufficient for the procedure with the exception of coagulation studies. Be aware of PT/INR, PTT, and platelet count results from the same day.

These patients usually have long standing metabolic derangements which will not likely be corrected in an acute basis before the procedure. In some instances, it may be even dangerous to correct some abnormalities acutely (i.e. hyper- or hyponatremia, hypokalemia, etc.). Common laboratory normal values will be same for all procedures, with a difference by age and gender.

Hemoglobin levels: Most critically-ill patients have chronic anemia. Hemoglobin levels of 7-9 g/dL are usually acceptable in most patient populations, unless they are at high risk or show evidence of end organ damage. Other considerations are the presence of signs of hypoperfusion (acidemia, base deficit, lactic acidosis) even with apparently acceptable hemoglobin levels. Usually blood loss is minimal during the procedure and transfusions are rarely necessary.

Electrolytes: Patients may have varying degrees of chronic kidney disease and/or acute kidney injury. Therefore, electrolytic abnormalities are common. Hypernatremia may suggest a hypovolemic state with volume contraction (with increased risk of hypotension and/or hemodynamic instability during the procedure). Patients on diuretics may have hypokalemia. Remember that hypo- and hyperkalemia predispose one to significant ventricular arrhythmias.

Coagulation panel: Have recent platelet count, PT/INR, and PTT. Review the trends and assess for the presence of clinical coagulopathy. Usually normal PTT, INR < 1.5 and platelet count of at least 80,000 /mm3 with a stable or improving trend is advisable in order to avoid increased risk of surgical bleeding.

Imaging: Review available imaging in the context of the specific patient pathologic conditions. Include stress tests, renal imaging tests, etc. New imaging is not required unless indicated by specific surgical needs or patient issues (anatomic abnormalities or variants, etc.).

Other tests: Review available tests. New tests are usually not needed. Include thyroid tests, etc.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

The procedure can be performed under general or local/regional anesthesia. General anesthesia is the preferred technique for elective procedures. For urgent/emergent procedures, airway protection makes a local/regional anesthesia the technique of choice.

a. Local anesthesia

is used for emergent or urgent procedures where the goal is to gain access to the airway. In this instance, airway protection takes precedence. Therefore, sedation is avoided in most cases.

  • Neuraxial

    • Not an option for this procedure.

  • Peripheral Nerve Blocks

    • Bilateral blockade of the lingual and pharyngeal branches of the glossopharyngeal nerve, combined with bilateral superior laryngeal nerve block and transtracheal block, may be used in some elective procedures to gain access to the airway by awake fiberoptic intubation. This occurs before the tracheostomy is performed in cases where it is considered safer for the patient or necessary for the specific surgical procedure. This approach may be indicated when tracheostomy is part of another elective procedure, such as radical airway/neck surgery and/or maxilofacial surgery. Otherwise, performing regional anesthetic techniques is not indicated in emergent situations. An emergent/urgent tracheostomy can be performed with local anesthesia only if it is considered advantageous or necessary. An alternative to airway peripheral nerve blocks is airway nebulization of local anesthetics.

      • Benefits: Airway control before the tracheostomy. Decreased requirement of general anesthetics. Decreased sympathetic response.

      • Drawbacks: Time consuming procedure. Potential risk of neurovascular injury and/or bleeding and hematoma formation. Risk of local anesthetic toxicity by overdose or inadvertent intravascular injection. Low potential risk of distorting patient's anatomy.

      • Issues: Significant edema can obscure anatomic landmarks in critically-ill patients. Calculate the maximal total dose of local anesthetic before proceeding. Have resuscitation equipment available in case of local anesthetic toxicity.

b. General Anesthesia

Most procedures are performed under general anesthesia, both in the OR or at bedside in the ICU. In the OR, an anesthesia machine/gas delivery system is available. At the bedside, the usual option is to use intravenous agents, such as propofol, narcotic analgesics, and medium-acting neuromuscular paralytics agents, based on the patient’s clinical condition. In the majority of cases, the patient has an endotracheal tube in place and a stable sedation regimen. General anesthesia is consequently the technique of choice.

  • Benefits: Easy to perform by continuing the same sedation regimen or increasing doses. Provides a still patient with stable hemodynamic status. Ideal in agitated or restless patients. No need to manipulate the airway before the procedure. Potentially faster and technically easier to perform than a local/regional anesthetic.

  • Drawbacks: Abolishment of patient respiratory effort and mechanics. Ventilatory weaning needs to start after recovery from general anesthetic.

  • Other issues: The use of neuromuscular blockers can facilitate the procedure by providing a still patient. But it may also delay the ventilation weaning process after the tracheostomy by further impairing the patient's respiratory mechanics.

  • Airway concerns: During tracheostomy there is always the potential risk of airway loss, which can be more significant in a patient with abolished respiratory effort. There should always be alternate airway management devices and technical expertise available.

c. Monitored Anesthesia Care

- is the technique of choice for access to the airway under local anesthesia.

  • Benefits: Provides a patient that is awake with preserved airway protective reflexes and respiratory effort and mechanics.

  • Drawbacks: Potentially uncomfortable and anxiety provoking for the patient. Requires high level of surgical expertise. Minimal airway manipulations can cause more significant autonomic responses as compared to general anesthetic techniques.

  • Other Issues: The use of MAC requires a very cooperative patient. Lack of a motionless surgical field can increase the risk of unintended surgical injuries or complications.

6. What is the author's preferred method of anesthesia technique and why?

The preferred anesthetic technique depends on the type of procedure being performed. As discussed above, regional anesthesia techniques with airway peripheral nerve blocks and/or topical mucosal airway anesthesia are indicated in elective situations where an awake fiberoptic intubation needs to be performed before tracheostomy.

For emergent or urgent tracheostomies, the technique of choice is monitored anesthesia care with local anesthesia. Judicious intravenous sedation can be used if considered essential and safe. In patients with borderline airway control and in emergent situations, the use of even minimal sedation may decrease airway protective reflexes and cause airway loss, which is catastrophic and should be avoided.

For elective tracheostomy (both standard and bedside) in patients with respiratory failure with need of prolonged mechanical ventilation, the technique of choice is general anesthesia. Bedside tracheostomy should be performed with intravenous agents, whereas in the OR inhalational agents may be used. In any case, it is preferable to keep the sedation regimen established for the patient and supplement the anesthetic with small intermittent boluses of a short-acting opioids (such as fentanyl) and a short-acting anesthetic agent (such as propofol) in small titrated doses.

Benzodiazepines increase the risk of delirium, which is significant as this population is already at high risk. It is always beneficial to supplement with local anesthetic infiltrated in the incision site and surgical area as well as with nebulizer in the tracheal mucosa, which can be done via the endotracheal tube or by using fiberoptic bronchoscopy. The procedure can be performed without the use of neuromuscular blocking agents.

Use of neuromuscular blockers should be avoided whenever there is spontaneous respiratory effort. Neuromuscular blockade should be used only when needed to avoid unsafe surgical conditions. Use short-acting medications at low doses. The goal is to have the patient back to his/her baseline level of consciousness and respiratory mechanics as soon as possible after the procedure and not to delay the process of weaning sedation and mechanical ventilation. In most instances, the use of infusion (i.e. propofol and/or remifentanil) is not required, given the short duration of the procedure.

a. What prophylactic antibiotics should be administered?

Tracheostomies are not specifically listed in the SCIP initiative. Therefore, there is no open SCIP recommendation regarding the use of prophylactic antibiotics. Prophylactic antibiotics should be use for tracheostomies as part of a different procedure. Cefazolin is the antibiotic of choice in these cases. Also depending on the extension of the oropharyngeal cavity involvement, coverage for anaerobes (with metronidazole or clindamycin) should be added. There is not clear consensus about antibiotic prophylaxis for tracheostomies for critically-ill patients with need of prolonged mechanical ventilation. In the past, cefazolin had been used (mostly for standard tracheostomies) with inconclusive support in the literature, but practice still varies by institutions. There is no clear evidence that the use of prophylactic antibiotics is beneficial for PDT, and they are not recommended in those cases.

b. What do I need to know about the surgical technique to optimize my anesthetic care?

  • "Open" surgical tracheostomy: A vertical or horizontal 2-3 cm incision is made over the 2nd to 3rd tracheal ring. Blunt dissection parallel to the trachea allows separation of the platysma and submuscular tissues. This approach may require partial or total division of the thyroid isthmus. The main characteristic of this procedure is that access to the trachea requires either resection of the anterior part of the 2nd tracheal ring or creation of a tracheal flap that is ostomized to the skin.

  • Percutaneous dilational tracheostomy: is performed via a 1-2 cm horizontal skin incision and blind, blunt dissection for identification of the anterior tracheal surface between the 2nd and 3rd tracheal ring. The identified area is punctured with a large bore needle and a J guidewire is introduced to the trachea distally using a modified Seldinger technique. The entire procedure is performed under direct bronchoscopic guidance through the in-situ endotracheal tube, which has already been placed proximally above the puncture site in order to avoid cuff rupture. After appropriate dilations the tracheostomy tube is inserted into the trachea. The presence of the bronchoscope makes effective ventilation more difficult during this approach. Bronchoscopy decreases the rate of complications, including posterior tracheal wall injury, improving patient safety. Ultrasound scan guidance can also be used for identification of anatomical structures.

c. What can I do intraoperatively to assist the surgeon or proceduralist and optimize patient care?

  • Proper positioning can improve surgical access and decrease the possibility of complications. Upper body elevation to 20-30 degrees helps to reduce venous pressure and bleeding. Patient's shoulders should be placed on a transverse roll with slight head extension (contraindicated in cervical spine injury), elevating the larynx and exposing the upper trachea. Head overextension can compress the trachea and bring the innominate artery cephalad, exposing it to potential injury.

  • Suction the endotracheal tube before starting the procedure to avoid pushing secretions distally into the tracheobronchial tree. Suction the oropharynx completely to avoid aspiration of secretions upon endotracheal cuff deflation.

  • During a standard tracheostomy, it is advisable to carefully advance the endotracheal tube just above the carina (usually 24-25 cm from the teeth) right before the surgeon enters the trachea to avoid cuff rupture and significant air leak. After the trachea is open, withdraw the endotracheal tube under direct vision until the tip is just above the tracheotomy site. Do not withdraw the tube further and be prepared to advance it into the trachea again if there are any problems with cannula insertion. The endotracheal tube in the larynx also can be used to visualize the tracheostomy site and cannula with a bronchoscope after placement.

  • During PDT, bronchoscopy can also be used to assist the surgeon in finding the entry site by tracheal transillumination. The downside is that the endotracheal tube cuff must be deflated and the tube withdrawn to the larynx before the needle puncture, increasing the possibility of desaturation, hypoxemia, and difficult ventilation.

d. What are the most common intraoperative complications and how can they be avoided/treated?

  • The most feared complication is airway loss, which can happen any time during the procedure, even during transport before and after the procedure. There should always be an anesthesiologist/airway expert present and equipment, such as a bag for positive pressure ventilation, bronchoscope, and intubating LMAs, available. A plan should be established preoperatively in difficult cases, such as obese patients or patients with altered anatomy. Helpful maneuvers include placement of a tube exchange catheter via the endotracheal tube before removal or a suction catheter via the ostomy site to direct cannula placement.

  • The presence of a significant air leak can be managed by increasing tidal volumes, occluding the oropharynx with gauze, or intermittently occluding the ostomy site while ventilation is attempted and the cannula inserted.

  • Airway fire is always a possibility. Do not use nitrous oxide and avoid 100% oxygen mixtures. Coordinate with the surgeon in advance to decrease FiO2 to < 30 % before electrocautery use (make sure ETO2 is < 30 %). Be prepared to manage an airway fire. The endotracheal tube cuff could be reinflated with normal saline if necessary.

  • False passage or cannula malposition should be suspected whenever there is difficulty during insertion or high airway pressures upon reinstating ventilation. Use of a suction catheter to verify patency or bronchoscopy (either through the cannula or via the endotracheal tube) are useful to confirm the diagnosis. Re-intubate if necessary.

  • Significant or major bleeding with or without hematoma formation are always a possibility. The most devastating source of bleeding is innominate artery injury, which is very uncommon given the low anatomical position over the trachea. Other more common sources are the anterior jugular vein or the thyroid gland blood supply. This complication can be more frequent in patients with previous neck surgery and/or tracheostomy and patients with a difficult or abnormal anatomy.

i. Cardiac complications

Intra- and postoperative myocardial ischemia and arrhythmia can occur given the important sympathetic stimulation with airway manipulation. Use appropriate anesthetic levels and local/topical lidocaine. Optimize oxygen supply by increasing FiO2 when it is possible and safe. Transfuse if necessary. Continue to use beta blockers as needed. Follow high risk patients for possible perioperative myocardial infarction.

ii. Pulmonary

Bronchospasm is a common occurrence. Otherwise, tracheal injury with laceration or perforation can happen with both types of procedures. Tracheal perforation can cause various degrees of barotrauma, from subcutaneous emphysema to pneumothorax or pneumomediastinum. Aspiration with or without aspiration pneumonia is most prevalent the first few days after the procedure. Cannula obstruction due to mucus or a clot or against the tracheal wall can happen at any time, from the intra- to the early postoperative period.

iii. Neurologic

Peripheral nerve injury is possible during the open surgical procedure.

a. Neurologic:

There is probably a higher incidence of short-term complications with dilational tracheostomy. The incidence of stoma infection and better cosmetic results are associated with these last procedures. The incidence of long-term issues, such as tracheal stenosis and tracheocutaneous fistula, appears to be higher after standard surgical procedures.

Injuries specific to surgical tracheostomy include peripheral nerve, esophageal, and thyroid injuries. For percutaneous tracheostomies, injuries include tracheal ring fracture, lateral stoma placement, and posterior tracheal wall injury. The frequency of complications, particularly tracheal wall injury, is decreased with bronchoscopy guidance.

b. If the patient is intubated, are there any special criteria for extubation?

Extubation is not applicable to this procedure. The patient should undergo a planned sedation-ventilation weaning protocol after tracheostomy.

c. Postoperative management

1. What analgesic modalities can I implement?

The patient should continue the same sedation/analgesia protocol as before. There is no need for additional changes, as the procedure is usually well tolerated.

2. Which level of bed acuity is most appropriate?

After a tracheostomy, the patient should stay in the ICU or be placed in a high-acuity setting given the risk of decannulation/lost airway. The stoma will not mature until 7-10 days after the procedure. The patient should be closely monitored during this time.

3. What are common postoperative complications, and ways to prevent and treat them?

  • Bleeding: Is common and usually minor (5 % of cases) and can be controlled by tracheal cannula cuff inflation or manual packing. Major bleeding is an emergency and requires reoperation.

  • Infection: Wound infection is rare and usually requires local therapy. Surgical treatment is required only in cases of deep necrotizing infections.

  • Tracheal stenosis: Is precedent by granulation tissue formation secondary to local chondritis. It is usually symptomatic if > 50 % only. It can be prevented by small stoma sizes, avoiding mechanical irritation in the tracheal, avoiding infection by optimal wound care, and a tracheal cannula cuff pressure < 20 mmHg.

  • Tracheomalacia: It is caused by cartilage necrosis and causes expiratory airway collapse. The mechanisms and prevention are the same as for tracheal stenosis.

  • Tracheoesophageal fistula: It is caused by posterior tracheal wall erosion due to cannula movement, overinflation, or nasogastric tube damage. It requires surgical repair.

  • Persistent stoma: It occurs due to the prolonged presence of tracheal cannula with epithelization of the stoma tract. It is recognized when the stoma does not close after more than 3 months of cannula removal. It may require surgical closure.

  • Tracheo-arterial fistula: It is the most lethal complication, with only a 20-25% survival rate. It can occur at any time, although usually within several weeks of the procedure. Diagnostic clues are sentinel bleeding and a pulsatile tracheal cannula. It occurs commonly at the innominate artery. Other possible sites involved are the left innominate vein, right common carotid artery, and the aortic arch. It occurs due to erosion from the anterior tracheal wall (usually by excessive tube movement and cuff overinflation). It can be prevented by avoiding low placement of the stoma in the trachea and limiting neck extension, head movement, and excessive weight of the ventilatory circuit.

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