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Tracheostomy: from insertion to decannulation
In this paper, the authors make an update on the different technical modalities
for making a tracheostomy, the appropriate time for it and the complications.
Introduction
The reports on surgical underwriting of the airway date back to antiquity [1]. However,
Chevalier Jackson is credited with performing the first clear description of open surgical
tracheostomy (TQA) in 1909 [2] and Ciaglia's first percutaneous dilatation tracheostomy
(DPT) in 1985 [3].
A procedure that previously required an operating room is now commonly performed in
the intensive care unit (ICU) [4,5]. Knowledge of tracheostomy is, therefore, still very
important for surgeons; however, it is equally important for those responsible for patient
care in the ICU.
This review will focus on tracheostomy as a non-emergency procedure in stable ICU
patients with mechanical ventilation. The authors outline insertion techniques, review
the literature comparing TQA and TPD techniques and explore the optimal timing for
insertion [4,6,7]. They also summarize the potential complications and their treatments
and the types of tubes and their optimal handling.
Finally, they discuss when removal can be considered (ie, decannulation). The review
was based on a search in the Medline database using the MeSH terms " tracheostomy "
(tracheostomy) or " percutaneous tracheostomy " (percutaneous tracheostomy), from
1999 to 2007 and collected additional references from the bibliographies of these
articles.
Procedures
Both TQA and TPD require similar anesthesia, analgesia, positioning and sterile
preparation. The patient is placed supine with a cushion placed transversely behind the
shoulders to extend the neck and provide optimal exposure (unless the patient requires
cervical spine precautions). The head of the bed is typically elevated 15º-20º to
decrease venous engorgement. Antibiotics are not usually given prior to the procedure
[8].
Open Surgical Technique
A vertical or horizontal skin incision of 2-3 cm is made in the midline between the sternal
fork and the thyroid cartilage (approximately at the level of the 2nd tracheal ring)
[9,10]. After dividing the skin and the underlying platysma, it is continued longitudinally
with blunt dissection. The separation of the infrahiodeos (eg, sternohyoid, sterno-

thyroid) muscles and lateral retraction exposes the trachea and the overlying thyroid
isthmus. The isthmus can be mobilized and retracted up or divided [11].
Nearby vessels may bleed substantially and hemostasis is achieved with electrocautery
or ligatures. The pretracheal fascia and the fibroadiposal tissue are dissected in a blunt
form, the tracheal rings 2 to 5 can be visualized. A cricoid hook can provide traction up
the trachea, improving the exposure. Lateral tracheal support sutures on the 3rd or 4th
rings can provide lateral retraction and stabilization and help define the stoma [9].
Once haemostasis and exposure have been optimized, the trachea is opened vertically
or transversally with the scalpel (the electrocautery is now contraindicated - see next
section for complications) [10,11]. A distal base flap of the tracheal wall (Bjork flap) may
be created, or a section of the anterior tracheal wall may be removed.
Polar separators in the stoma maintain the opening and the endotracheal tube is
withdrawn under direct vision. An aspiration catheter placed within the open area can be
used as a guide for insertion of the tracheostomy tube. The correct location is confirmed
by direct visualization, CO2 concentration at the end of expiration, ease of ventilation
and adequate oxygen saturation [9]. Flexible video-bronchoscopy offers adjuvant
confirmation and helps bronchial cleansing.
Percutaneous dilation technique
There are several techniques recorded, but all employ a modified Seldinger technique
[12]. Concomitant bronchoscopy adds a "tracheal vision" that helps the replacement of
the endotracheal tube (TET) above the incision and helps visualize the site of the
needle and subsequent dilatation of the stoma. The bronchoscopy may also reduce
the damage to the posterior tracheal wall, confirm the location of tube and help clean
the air. Therefore, it is strongly recommended [13-15].
The cricoid is palpated and a transverse incision in the skin of 2 cm is made at the level
of the second tracheal ring. Vertical blunt dissection is followed by tracheal puncture
with a 22G "needle finder" and then an adjacent 14G needle attached to a syringe filled
with saline solution [3]. The aspiration of bubbles suggests an appropriate tracheal
puncture. Continued insertion of a guidewire and removal of the needle.
There are now subtle differences that distinguish forms of stoma creation. The Ciaglia
technique uses sequential tracheal dilators (Cook Critical Care, Inc.) on the
guidewire. Variations of this include the percutaneous Per-fit introducer set (Smiths
Medical) and the Percu-Twist (Meteko Instrument).
Alternatively, the Blue Rhino technique (Cook Critical Care, Inc.) employs a single large,
tapered dilator. The Portex Griggs technique (Smiths Medical) employs dilating forceps
on the guidewire. The Fantoni translaaryngeal technique (Mallinckrodt) requires the
retrograde passage of a wire parallel to the TET.

The tube is then attached to the wire and, by pulling the wire and using digital
backpressure, the tube is inserted orally and placed through the anterior wall of the
trachea [8]. Regardless of the technique, recent observational data suggest that routine
radiography has poor performance and rarely modifies p16 management].
Moment of the tracheostomy
In 1989, Chest's consensus guidelines recommended trans-laryngeal mechanical
ventilation when we anticipated an artificial airway of less than 10 days and
tracheostomy when anticipated lasting more than 21 days [24]. Otherwise, a daily
assessment was recommended.
Subsequently, several small clinical trials have attempted to elucidate the optimal
duration of the tracheostomy. Studies have included patients with burns [28] or trauma
[31], those admitted to the medical ICU [27] or in the mixed medical / surgical ICU 5].
Rumbak et al. [27] underwent a multicenter, prospective and randomized trial of 120
patients assigned to early TPD (<48 hours after admission to ICU) or late TPD (> 14
days). They found that early tracheostomy was associated with significantly less
mortality, nosocomial pneumonia, unplanned extubation, oral and laryngeal trauma, and
a shorter duration of mechanical ventilation and ICU admission.
Prospective studies by Rodríguez [26], Bouderka [25] and Arabi [30] and their
respective colleagues showed a decreased duration of mechanical ventilation with early
tracheostomy, although they did not report differences in mortality.
To collect data from such small heterogeneous assays, Griffiths et al. [5] performed a
systemic review and meta-analysis of 5 randomized trials comparing early to late
tracheostomy in the ICU. There was no difference in mortality rates or nosocomial
pneumonia. However, early tracheostomy was associated with 8.5 fewer days of
mechanical ventilation and 15 days less in the ICU.
In a similar meta-analysis comparing early to late tracheostomy in ICU patients,
Dunham et al. [31] found no differences in mortality, nosocomial pneumonia, duration of
mechanical ventilation or ICU stay. However, in the subgroup of patients with traumatic
brain injury, early tracheostomy was again associated with a shorter duration of
mechanical ventilation and ICU stay.
It is surprising that, given the putative benefits of subglottic ventilation, the scientific
evidence is not even more in favor of early tracheostomy. Overall, current evidence
suggests consistent benefits in morbidity but not mortality; however, more research is
needed. For example, elucidating which ICU patients require long-term mechanical
ventilation might well identify those most likely to benefit from early tracheostomy
training.

In addition, it is unclear whether innovations in the translaryngeal tubes [32] (eg, high
volume / low pressure cuffs, subglottic aspiration ports) have made prolonged
translaryngeal mechanical ventilation safer and therefore less beneficial to the early
tracheostomy. The availability of TPD has played a role in the promotion of
tracheostomy.
However, this could mean that patients who previously would not have received a
tracheostomy now do so. Finally, it must be remembered that the tracheostomy, despite
the technique, is still not risk-free. There are several ongoing clinical trials to clarify the
optimal timing of tracheostomy [33-35].
Until such data are available, the authors of this paper recommend that tracheostomy
be performed in those patients who anticipate a duration of more than 10 days of translaryngeal mechanical ventilation, performing the procedure as soon as said clinical
course is identified
Weakness of the tracheostomy
As with TET extubation, the most reliable indication for tracheostomy decannulation is
when there is no need for airway protection or mechanical ventilation. Over time,
patients may have decreased the size of their tracheostomy tubes or switched to
fenestrated or non-cuffed tubes.
These measures increase the flow of air through or around the tube, respectively. This,
in turn, enables sufficient airflow to allow the external tracheostomy to be plugged and
to facilitate speech [32]. Speech in patients can increase motivation and speed
recovery. This can also be promoted by placing a unidirectional valve on the
tracheostomy to allow airflow over the throat during expiration. The most common
example is the Passy-Muir tracheostomy valve (Passy-Muir, Inc.).
Specific strategies for weaning and decannulation often depend on the institution. Some
consider them once the patient has had the tube covered for 48 hours or more, while
others consider them when a valve for speech is tolerated [50].
Closure is usually attempted after confirming the air passage around the deflated
cuff. This is assessed by listening at neck level or by measuring the difference between
volume at the end of inspiration and expiration [48]. Importantly, a non-fenestrated tube
should never be capped without deflating the cuff, nor should a speech valve be applied
to a tracheostomy with an inflated cuff: this causes complete obstruction of the airway.
The change of tracheostomy tubes is usually direct but requires trained personnel. Lifethreatening complications include rupture of the innominate artery (massive
hemorrhage) and displacement of the tube (loss of airway) [51].
A common error is to make the caudal gyrus prematurely with the risk of pretracheal
emplacement, airway occlusion, pneumomediastinum and cardiorespiratory arrest

[51]. When a tracheostomy tube is changed, the patient should be placed supine with
the neck in extension. The "classical technique" simply consists of removing and
inserting a new tube. The "train track technique" uses a guide, historically an aspiration
catheter and a modified Seldinger technique. There are commercial tube exchange
products that include a central light to allow ventilation during the process [51].
Decanulation before a mature tract has formed is potentially disastrous. Rapid loss of
airway by stoma closure may occur. In addition, blind reintegration attempts have the
potential to deviate pre-fetally.
If inadvertent decannulation occurs before maturation of the tract (typically 7-10 days
post-procedure), immediate preparations for orotracheal mechanical ventilation should
be made. This is categorically the first and safest approach after accidental
decantation. Only if there is an appropriate backing can a reinsertion of the tube be
attempted briefly.
The patient's neck should be extended and skin sutures and adhesive tapes cut for
better exposure. If the sutures of support are present, a gentle traction of the same can
expose the tract and stabilize the trachea to try a recanulación. A laryngoscope with a
pediatric sheet offers a lighted retractor to explore the wound.
Placing the leaf in the trachea and raising it can help reinsertion under direct
vision. Alternatively, digital scanning and insertion of a suction catheter or directing a
bronchoscope through the stoma, may facilitate tracheostomy reinsertion by the railroad
method [51]. Again, trans-pharyngeal mechanical ventilation is recommended.
.


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