Tracheostomy Basics

Introduction

• Tracheostomies are artificial airways that allow for protected, unobstructed access to the trachea through the neck for ventilation.
• Tracheostomies are commonly performed for patients with a variety of indications, both emergent and elective.¹
  • Emergent indications commonly include acute upper airway obstruction due to laryngeal trauma, angioedema, anaphylaxis, infection, obstructive mass, or stenosis. Other indications for emergent tracheostomy include patients in whom endotracheal intubation is unsuccessful or an emergent cricothyrotomy is performed.
  • Elective indications include patients who need prolonged mechanical ventilation or those with poor airway protection who require ventilation or secretion control.
• The surgical procedure creating a tracheostomy is called a tracheotomy and is typically performed between the second and third tracheal rings.²

• Tracheostomies have many benefits, including reduced work of breathing, improved comfort, and swallowing, but require careful maintenance and support to reduce morbidity and mortality.
• Laryngectomies are not the same as tracheostomies and are not discussed in this summary. Of note, the only way to access the airway in a patient with a laryngectomy is via the laryngectomy stoma.

Components

• The most common type of tracheostomy device is a tracheostomy tube with a flange and may contain other components such as an inner tube and a cuff. These tubes are often compatible with the standard 15 mm connector for attachment to a ventilator or anesthesia circuit.⁴

• Standard tracheostomy tubes are available in cuffed or uncuffed variants, but cuffed tubes are generally more common and preferred.⁶
  • Cuffed tubes completely seal the airway, which is essential for patients requiring positive pressure ventilation. The cuff also prevents aspiration, thereby protecting the airway, unlike uncuffed tubes.
  • Uncuffed tubes are used more often in patients who no longer require positive-pressure ventilation and can protect their own airway but who continue to require direct access to the trachea.⁷
• Tracheostomy tubes may have a single or double cannula. Generally, double cannula tubes are preferred because they allow removal of the inner cannula for suctioning while keeping the airway and stoma patent.
  • Single-cannula tubes are simpler than double-cannula tubes but are generally used only temporarily. Occlusion of a single cannula tube usually requires removing the entire tube to clear the occlusion, making them less desirable.
  • Double cannula tubes contain an outer cannula and a smaller inner cannula that can be removed for cleaning. Some inner cannulas are disposable, while others are reusable after cleaning.
  • A special consideration for double cannula tubes is that some may require the inner cannula to be inserted prior to connection to a breathing circuit.⁶
• There are alternative types of tracheostomy devices, such as T-tubes and stoma maintenance devices, that require special considerations and will not be discussed in this summary.²

Anesthetic Considerations

Preoperative Considerations⁷

• As a part of the preoperative evaluation, all patients with tracheostomies should be thoroughly assessed for the following information:
  • Why was the tracheostomy placed? Tracheostomies placed in patients with neuromuscular weakness often have a patent upper airway, allowing for oral intubation in case of obstruction or dislodgement. Tracheostomies placed in patients with laryngectomies will not have a patent upper airway, making ventilation from above the tracheostomy impossible.
  • When was the tracheostomy placed and by whom? Recently placed tracheostomies may still have an immature (unstable) stoma, which increases the risk of complications associated with a potential tube change.⁴ The service that created the tracheostomy should be consulted for information regarding tube changes.
    • Tube changes should not be routinely performed in patients who have recently undergone tracheotomy due to an immature stoma unless surgically indicated or in an emergency.⁸
  • What type of tracheostomy tube is in place? Uncuffed tracheostomies are acceptable for patients not requiring pressure support who are undergoing monitored anesthesia care. If patients require ventilation or pressure support, it is recommended to exchange for a cuffed tube to ensure adequate ventilation without leaking air or anesthetic gases.
  • How patent is the tracheostomy? Tracheostomies should be assessed for patency. Any stridor or increased work of breathing is a sign that there may be an airway obstruction, which should prompt further evaluation for suctioning or a tube change.
• Tracheostomy kits containing supplies such as an extra tracheostomy tube (same size + 1 size smaller), suction equipment, and a syringe for cuff inflation should always be kept at the bedside in case of a dislodged tracheostomy tube or an obstruction that can not be cleared to allow for rapid tube replacement.⁸

Intraoperative Considerations

• Preoxygenation should be performed in all patients prior to the induction of anesthesia.⁷
• Induction may be performed with either intravenous or inhalational agents. Inhalational agents should generally be avoided when an uncuffed tracheostomy tube is in place, due to the potential for leakage of anesthetic gases.
• When sedating patients with uncuffed tubes, you should be prepared to exchange for a cuffed tracheostomy tube of the same size or one size smaller, or for an endotracheal tube if required.
• Monitoring ventilation with end-tidal CO₂ is important in patients with tracheostomies to quickly detect and correct airway obstruction or other airway anomalies.

Postoperative Considerations

• Following anesthesia, patients with new tracheostomies (generally less than 14 days old) should be transferred to units staffed by trained, familiar personnel for the management of new tracheostomies.
• As described above, a tracheostomy kit with suctioning and tube-exchange equipment should always be available at the bedside in case of obstruction or dislodgement of the tube.