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INTRODUCTION

Tracheostomy is one of the most commonly performed procedures in surgical practice. An intervention dating back to 1500 bc,13 tracheostomy, until recently, was used solely to relieve acute upper airway obstructions. Polio and the advent of modern ventilators in the 20th century made tracheostomy largely a routine elective procedure for patients dependent on ventilatory assistance. This chapter describes the techniques and associated risks and benefits of the procedure.

INDICATIONS

Tracheostomy continues to be indicated for relief of upper airway obstruction, including intermittent obstructions such as those occurring in sleep apnea, although cricothyroidotomy is preferred in an emergency situation. Most tracheostomies today, however, are performed electively in the critical care setting to facilitate pulmonary toilet and ventilatory support for chronically ventilated patients. Tracheostomy is superior to prolonged translaryngeal intubation in many ways (Table 55-1). Tracheostomy improves patient comfort, leading to decreased requirements for analgesia, thereby facilitating ventilatory weaning. It provides a more secure airway, which in turn permits greater patient mobilization because the risk of inadvertent extubation is decreased. It reduces the incidence of vocal cord injury and subglottic stenosis, as well as the rate of sinusitis. Airway resistance is also reduced over the short tracheostomy in comparison to the longer endotracheal tube. Pulmonary toilet and oral hygiene are improved, and it permits the use of fenestrated devices that provide the potential for speech.48 Despite these advantages, considerable debate remains over the ideal timing of tracheostomy. In principle, tracheostomy should be considered for any critically ill, intubated patient in whom extubation is not immediately foreseeable, after the patient has spent a “reasonable” length of time on the ventilator. Defining reasonable, however, forms the basis of the controversy. In the 1960s, a reasonable length of time was considered to be as few as 3 or 4 days because of the high rate of complications associated with the use of rigid, low-volume, high-pressure endotracheal cuffs during prolonged translaryngeal intubation. After the introduction of high-volume, low-pressure endotracheal cuffs in the 1970s, complication rates decreased, and it became reasonable to keep patients with endotracheal intubation for longer periods. Translaryngeal or endotracheal intubation now may be appropriate for periods up to 3 weeks, particularly if the patient objects to a tracheostomy or if there are contraindications or other risks.46,912 A recent meta-analysis examining the optimal length of time to tracheostomy was inconclusive, as there were too few publications with comparable patient populations. The debate is likely to continue.13

Table 55-1MAJOR RISKS AND BENEFITS OF TRACHEOSTOMY

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