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1 January 1999
Tracheostomy
FOCAL POINT Techniques and
★The likelihood of such
complications as luminal
stenosis, stomal stenosis, or
Management
occlusion occurring after
tracheostomy can be minimized Animal Specialty Group, Inc. Auburn University
by using proper surgical Patricia Colley, DVM Ralph Henderson, DVM, MS
technique and following correct Michael Huber, DVM, MS
postoperative management.
ABSTRACT: Tracheostomy is an important tool for managing critically ill patients or patients
with upper airway obstructions. Surgical techniques for temporary tracheostomy include
KEY FACTS transverse flap; transverse (horizontal), vertical, and inverted ventral wall flaps; and percuta-
neous (Seldinger) procedures. Serious complications can be prevented if practitioners apply
■ Cuffed tracheostomy tubes are their knowledge of tracheal anatomy, physiology, and wound healing and follow proper surgi-
only to be used for patients that cal technique and postoperative management procedures. Potential complications associated
require mechanical ventilation. with permanent tracheostomy include skinfold occlusion and stomal stenosis.
C
ommon emergency situations can arise when a patient’s airway quickly
not a factor in the development becomes compromised or a critically ill patient requires long-term venti-
of luminal stenosis. latory support or even permanent bypass of the upper airways. In these
situations, surgical access to the trachea (tracheostomy) and proper placement of
■ The transverse flap technique a tracheostomy tube are essential. Life-threatening complications can, however,
is simple and allows easy develop after the presenting problem has been resolved. This article reviews the
removal and replacement of a indications and techniques for temporary and permanent tracheostomy, tra-
tracheostomy tube. cheostomy tube maintenance, and potential complications.
can be used to circumvent the upper airways while ies. The cranial and caudal thyroid arteries anastomose
awaiting remission of obstruction during radiation in the lateral pedicles and have branches that segmen-
therapy or during long-term ventilatory support of crit- tally supply the ventral and lateral aspects of the tra-
ically ill patients. chea.1 The dorsal tracheal membrane is supplied by
Indications for a permanent tracheostomy include la- branches of the bronchoesophageal arteries.1 After the
ryngeal paralysis or collapse, radiation therapy of the arterial branches have penetrated the annular ligaments,
upper airways or oropharynx, laryngotracheal resec- they arborize in the submucosa and communicate with
tions, staged laryngeal reconstruction, nasal neoplasia, a dense capillary net beneath the epithelium.13,15 Venous
or severe secretory respiratory disease.7,8 Permanent tra- drainage occurs through the thyroid and internal jugu-
cheostomy can be either lifelong or surgically closed af- lar and bronchoesophageal veins.16 Lymphatic drainage
ter resolution of the primary disease. continues to the deep cervical, cranial mediastinal, me-
dial retropharyngeal, and tracheobronchial lymph
NORMAL TRACHEAL ANATOMY nodes.1,17
The trachea is a semirigid, flexible air conduit that The trachea is innervated by the sympathetic system
extends from the cricoid cartilage to the tracheal carina, via the sympathetic nerve trunk and the parasympa-
where it divides to form the mainstem bronchi.9–12 The thetic system via the recurrent laryngeal nerve.12,13 Sym-
tracheal lumen is maintained by 35 to 45 C-shaped pathetic stimulation inhibits tracheal muscle contrac-
hyaline cartilage rings (the actual number varies by tion and glandular secretions, whereas parasympathetic
species, breed, and individual).12,13 The width of the av- stimulation has an opposing action.10
erage canine cartilage is 4 mm at its thickest point ven-
trally and tapers dorsally. The first tracheal ring, which NORMAL TRACHEAL PHYSIOLOGY
is complete in dogs, resembles and is partially covered The primary purposes of the trachea are conduction
by the cricoid cartilage.13 The remaining rings are unit- of air to and from the lower airways and removal of
ed longitudinally by interspersed 1-mm-wide fibroelas- particulate material from the bronchial tree.11 Patent
tic annular ligaments.9,12 flexibility is achieved during normal cervical move-
The tracheal rings are joined dorsally by the smooth ments by joining rigid cartilage rings with flexible an-
transverse fibers of the tracheal muscle and, together nular ligaments.1,11 Although tracheal diameter changes
with the mucosa, submucosa, and adventitia, form the slightly during normal respiration, the diameter of the
dorsal tracheal membrane.9,10 The cervical trachea is lumen decreases by 50% during coughing.10 This dra-
bounded dorsally by the esophagus (cranially) and the matic reduction results from tracheal muscle contrac-
longus colli muscles (caudally) and ventrally by the ster- tion, which reduces dead space, increases the velocity of
nohyoid muscles (cranially) and sternocephalic and ster- air, and is believed to aid in mucosal expulsion during
nothyroid muscles (caudally).12,13 The trachea is bound- the cough reflex.13
ed laterally on both sides by large neurovascular bundles Inhaled particulate material and excessive bronchial
that contain the vagosympathetic trunk, common secretions are cleared from the respiratory tract by the
carotid artery, internal jugular vein, and recurrent laryn- mucociliary escalator (a continuous layer of mucus pro-
geal nerve (which lies outside the common sheath on duced by the goblet cells and seromucinous glands) and
the left).12 The cervical portion of the trachea ends at the propelled toward the larynx by the ciliated epithelial
cranial mediastinum and becomes the thoracic trachea. cells at approximately 12.6 mm/min.1,10,11 The flow of
The tracheal mucosa is composed of pseudostratified mucus is most rapid in cats and younger dogs and is ac-
ciliated columnar epithelium, which contains basal, cil- celerated when warm, dry air is inspired.2
iated columnar, goblet, and nonciliated columnar
cells.1,10,12,14 Most of the epithelium contains a ratio of TRACHEAL WOUND HEALING
approximately five ciliated cells per goblet cell.1,10 The Tracheal mucosa responds to irritation by increasing
submucosa contains elastic fibers, fat cells, and seromu- the production of mucus.10 Trauma to only the tracheal
cinous tubular glands,10 the latter of which can secrete mucosa heals by migration, mitosis, and differentiation,
as much mucus as 40 goblet cells.1 The hyaline cartilage which lead to complete epithelial regeneration.1,18 As
rings, annular ligaments, and tracheal muscle form the early as 2 hours after injury, marginal epithelial cells
musculocartilaginous layer, whereas the adventitia is a lose their cilia, flatten, and begin migrating across the
loosely enclosing sleeve of fascia that blends the muscu- injury. These migrating epithelial cells, guided by the
locartilaginous layer to surrounding connective tissue.1 underlying elastic lamina, secrete enzymes that dissolve
The trachea is supplied by branches of the cranial the fibrinous clot covering the denuded mucosa. Unlike
thyroid, caudal thyroid, and bronchoesophageal arter- in the epidermis, migration is limited to the marginal
in the patient’s airways, and cleaning the stoma. ing ventilation.4 If air cannot flow around the tube and
Patients should undergo preoxygenation for at least 2 occlusion causes respiratory distress, a smaller tube
minutes before the procedure begins because tracheal should be inserted and the patient monitored. The tube
suctioning can cause hypoxemia, which can lead to myo- can then be removed when the patient is breathing nor-
cardial hypoxemia and premature ventricular contrac- mally with the occluded tube. The tracheostomy site
tions. In addition, because vagal stimulation from tra- should be allowed to heal by second intention and exu-
cheal irritation can cause bradycardia, patients should date cleaned from the site during healing.4
have electrocardiographic monitoring during suction-
ing. Vagal stimulation can also cause gagging or vomit- Associated Complications
ing; therefore, the trachea should not be suctioned im- Complications involving tracheostomy tubes include
mediately after a patient has eaten. Cats may require partial or complete obstruction, gagging and vomiting
more frequent monitoring of the tube because they re- during suctioning, subcutaneous emphysema, and tra-
portedly have more problems with the formation of cheal infection and necrosis.31 Acute complications also
thick mucus. include hemorrhage, damage to peritracheal neurovas-
During suctioning, the inner cannula of the tra- cular structures, subcutaneous emphysema, pneumo-
cheostomy tube or the entire single-lumen tube should thorax, and pneumomediastinum.11,26,30 Tracheal irritation
be removed and soaked in 2% chlorhexidine solution caused by the tube can lead to the formation of tracheo-
and after suctioning, rinsed with sterile saline before esophageal fistulas in the dorsal tracheal membrane
being replaced. Using aseptic technique, a small, sterile and/or vascular erosions and hemorrhages.32
suction catheter should be gently inserted through the Luminal stenosis can cause a 5% to 75% reduction
outer cannula. Suctioning should not begin until the of the tracheal cross-sectional area. The tracheal mu-
catheter is properly positioned within the tracheal lu- cosa is extremely sensitive to injury; mucosal erosions
men and should continue for no longer than 10 to 12 leading to ulceration and stricture can result after only
seconds. The catheter should then be rotated and with- a few hours if the endotracheal tube cuff is over-
drawn and oxygen immediately supplied to the patient. inflated.33 Circumferential stenosis results from damage
The procedure can be repeated if necessary but should to the tracheal mucosa caused by inserting a trache-
never be continued in patients that show excessive dis- ostomy tube that is too large or overinflating the cuff.
comfort or respiratory or cardiac changes. Stenosis can also result from excessive tube movement
A low-friction catheter made from soft pliable tubing within the tracheal lumen, which allows the tip of the
(e.g., suction catheter or red rubber catheter) should be tube to damage the tracheal mucosa or cartilage rings at
used. All catheters are measured as 6, 8, 10, 12, 14, 16, the stoma. Several studies have shown that the type of
or 18 Fr, which correspond to 2.0, 2.7, 3.3, 4.0, 4.7, tracheal incision plays a minor role in the development
5.3, or 6.0 mm, respectively. of luminal stenosis.24,26,27,34 The major factors contribut-
The airways can be humidified by instilling sterile ing to luminal stenosis are the number of cartilage rings
saline (0.2 ml/kg) into the tracheostomy tube every damaged or removed, amount of tube motion, length
hour or by nebulization. Periodic forceful bilateral com- of time the tracheostomy tube was in place, and exces-
pression of the chest (coupage) is beneficial in clear- sive cuff pressure.25,33,35 Tracheal resection and/or anas-
ing the lower airways of patients with excessive bron- tomosis is indicated to correct severe luminal stenosis.
chial secretions.
The bandage should be changed at least once a day TEMPORARY TRACHEOSTOMY
and the site inspected for signs of infection. The area Temporary tracheostomy procedures involve the
around the tube should be cleaned with a dilute solu- transverse flap34,36; transverse (horizontal),10,11,30,37,38 ver-
tion of povidone–iodine or chlorhexidine and the ban- tical,10,11,26,38 and inverted ventral wall flap26,38; and per-
dage (soft roll gauze) replaced to minimize tube move- cutaneous (Seldinger)38 techniques. The lack of a per-
ment. manent stoma with these techniques necessitates the
use of a tracheostomy tube to maintain airway patency.
Removal The tracheostomy tube itself acts as a foreign body and
The tracheostomy tube should be removed as soon as causes inflammatory edema, increased mucus produc-
a normal airway has been established or when ventilation tion, and decreased ciliary movement—all of which can
therapy is no longer required.30 Whether the patient can lead to postoperative complications.10,12,13,32,37 In addi-
ventilate adequately without the tube can be determined tion, partial or complete occlusion and dislodgment of
by deflating the cuff (if present), occluding the tube to the tracheostomy tube are common life-threatening
allow airflow to resume its normal passage, and monitor- complications.30
Philadelphia, WB Saunders Co, 1984, pp 438–484. to ventilatory assistance through cuffed tubes: A pathologic
22. Lau RE, Schwartz A, Buergelt CD: Tracheal resection and study. Ann Surg 169(3):334–348, 1969.
anastomosis in dogs. JAVMA 176(2):134–139, 1980. 34. Huber ML, Henderson RA, Finn-Bodner S, et al: Assess-
23. Mendez-Picon G, Ehrlich FE, Salzberg AM: The effect of ment of current techniques for determining tracheal luminal
tracheostomy incisions on tracheal growth. J Ped Surg 11(5): stenosis in dogs. Am J Vet Res 58:1051–1059, 1997.
681–685, 1976. 35. Andrews MJ, Pearson FG: Incidence and pathogenesis of
24. Natvig K, Olving JH: Tracheal changes in relation to differ- tracheal injury following cuffed tube tracheostomy with as-
ent tracheostomy techniques. J Laryng Otol 95:61–68, 1981. sisted ventilation: Analysis of a two year prospective study.
25. Bardin J, Boyd AD, Hirose H, et al: Tracheal healing fol- Ann Surg 173(2):249–263, 1971.
lowing tracheostomy. Surg Forum 25:210–212, 1974. 36. Macintire DK, Henderson RA, Wilson E, et al: Transverse
26. Bryant LR, Mujia D, Greenberg S, et al: Evaluation of tra- flap tracheostomy: A surgical technique for temporary tra-
cheal incisions for tracheostomy. Am J Surg 135:675–679, cheostomies of intermediate duration. J Vet Emerg Crit Care
1978. 5:25–31, 1995.
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tion tracheostomy in dogs. J Oral Maxillofac Surg 53:289– 77–82, 1982.
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