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400 PART 4: Pulmonary Disorders

perform. Other devices are available that dilate via a screwing motion, as tissue planes within the neck shift in relation to one another. Blindly
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again to theoretically reduce the amount of posterior force required. replacing the tracheostomy tube in these situations risks the creation of
These devices may still result in a greater incidence of posterior wall a false passage, subcutaneous emphysema and increased difficulty with
injury, however. The Griggs’ guidewire dilating forceps is a sharp-tipped subsequent attempts to replace the tube, complications that have all been
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forceps which is threaded over a percutaneously introduced guidewire associated with case fatalities. After surgical tracheostomy, replacement
and used to dilate the pretracheal tissues and anterior tracheal wall. of a dislodged tube may sometimes be facilitated by anterior traction
47
Overall, the incidence of complications of Griggs’ technique appears on the trachea with the stay sutures that are often left in situ. However,
similar to Ciaglia’s, 48,49 although the potential for over-dilation of the tra- the safest method of achieving an airway in a patient with a dislodged,
cheal stoma and an increased risk of hemorrhage have been described. 50 fresh tracheostomy is to reintubate via the oropharynx or nasopharynx
The Ciaglia technique is performed with the patient positioned supine using an endotracheal tube. The tracheal stoma can then be covered
and with the neck in extension using a roll behind the scapulae. The cri- with an occlusive dressing and the tracheostomy tube replaced in a
coid ring and sternal notch are identified. The area of the skin incision is more controlled setting. Permanent tracheostomies, generally created in
infiltrated with local anesthetic containing epinephrine. A 2- to 3-cm skin conjunction with operative procedures such as laryngectomy, are most
incision is made horizontally or vertically midway between the cricoid often formed by marsupializing the tracheal mucosa to the skin, thus
ring and the sternal notch. Our preference is to do a certain amount of providing a reliable passage for replacement of the tracheostomy tube
blunt dissection with a mosquito clamp at this point, to separate the pre- even in the first few days postprocedure, since intubation from above
tracheal tissues in the midline and allow a more accurate palpation of the would obviously be an impossibility.
tracheal rings. At this point, the endotracheal tube is loosened from its ties A more mature tract typically forms by 7 days, and so the first tube
and the flexible bronchoscope introduced. Under direct bronchoscopic change is generally delayed until at least 1 week after creation of the tra-
vision the endotracheal tube is withdrawn to a position just above where cheostomy. There is little evidence to suggest that routine tracheostomy
the tracheostomy will be performed. Palpation of the anterior tracheal tube changes are helpful, but removal and reinsertion is often required
wall with the tip of a clamp or with a finger helps to identify the appropri- due to a complication, such as cuff rupture, or when changing to a differ-
ate level. Transillumination with the bronchoscope is also a useful method ent type or size of tracheostomy tube. Anticipated difficult tube changes
to identify when the tip of the endotracheal tube has been withdrawn to are ideally performed by the physician who initially performed the tra-
beyond the skin incision. At this point the endotracheal tube is generally cheostomy procedure and with personnel and equipment available for
sitting just at the level of the vocal cords and a major cuff leak may ensue. endotracheal intubation. We recommend that tracheostomy tube changes
Patients may experience interruptions in the applied level of positive be facilitated with an airway exchange catheter or other tube (such as a
end-expiratory pressure (PEEP) at this point, which occasionally requires nasogastric tube), used as a stent to guide the reinsertion.
that the procedure be abandoned. The trachea is entered with the access One of the most commonly encountered complications of tracheos-
needle between the 2nd and 4th tracheal rings. Bronchoscopic visualiza- tomy is tube obstruction by mucus, blood, or tissue. Most tracheosto-
tion of this step in particular is recommended to avoid posterior wall mies will have an inner cannula that can be emergently removed in these
injury. The guidewire is advanced caudad down the trachea. The needle situations, restoring airway patency. The cannula can then be replaced
is withdrawn and the dilator is advanced into the trachea, through the without risking a complete tracheostomy tube change. All patients with
anterior tracheal wall. Once dilation is complete, the tracheostomy tube, tracheostomies having inner cannulas should have replacement cannu-
mounted on a tapered introducer, is advanced under direct bronchoscopic las easily accessible; we routinely tape a replacement cannula to the wall
vision into the trachea. The introducer and guidewire are removed and the behind the patient’s bed.
tracheostomy tube position verified with end-tidal CO detection and via The formation of a tracheo-innominate fistula (TIF) is a dreaded but
2
bronchoscopy through the tracheostomy itself. The cuff is then inflated rare complication, with reported rates ranging from 0.1% to 1% of surgi-
and the tracheostomy tube secured in place. cal tracheostomies. The incidence of TIF from percutaneous dilational
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■ EMERGENCY CRICOTHYROIDOTOMY AND TRACHEOSTOMY tracheostomy is likely similar. Although a low-lying neck tracheostomy
incision has been implicated in the causation of TIF, leading to direct
Critically ill patients who require establishment or maintenance of a erosion of the angled portion of the tracheostomy tube into the innomi-
patent airway and who cannot be endotracheally intubated require an nate artery, TIF more commonly occurs from erosion of the tracheal
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emergency surgical airway. Most of the time, this should be a crico- tube tip or cuff through the anterior tracheal wall. Erosion from the
thyroidotomy, achieved either by percutaneous Seldinger technique cuff or tip of the tracheostomy tube may occur even with a standard 2nd
or open surgical incision. The cricothyroid membrane is generally an or 3rd ring tracheotomy. Poor fit of the tracheal tube may be a contribut-
easily palpable landmark and is located very superficially in the neck, ing factor, resulting in excessive pressure on the tracheal wall. Patients
with essentially no overlying structures. This makes cricothyroidotomy with previous neck irradiation or significant stomal site infections are
a much safer emergency surgical airway than tracheostomy. Most crico- also likely at increased risk for this complication. The presentation of
thyroidotomies will require conversion to a formal tracheostomy in an TIF is most often delayed, occurring at least 72 hours postprocedure,
urgent, but not emergent, manner. Conversion to tracheotomy allows for as it depends on erosion of the tube through the tracheal wall, rather
use of a larger tube, with consequently lower airway resistance, greater than direct trauma to the innominate artery. TIF can also develop as a
comfort, and likely decreased laryngeal and subglottic complications. 51,52 very late complication, with cases being described up to several years
Emergency tracheostomy (instead of cricothyroidotomy) is very rarely postprocedure, but the majority of cases (70%) will manifest in the first
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indicated. Patients with trauma or tumour obstructing the larynx and 3 weeks. In contrast, early posttracheostomy bleeding is generally the
cricoid ring or the subglottic trachea may require urgent tracheostomy. result of local trauma to veins, smaller arteries or the thyroid gland.
Ideally, this procedure is performed under local anesthetic and with the TIF typically presents as either peristomal bleeding or hemoptysis.
patient breathing spontaneously. Notably, up to half of patients with TIF will have a self-limited sentinel
bleed prior to the development of massive hemorrhage. Management
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of TIF depends on the hemodynamic and respiratory stability of the
MANAGEMENT OF TRACHEOSTOMIES patient. A patient who has had a sentinel bleed can be investigated with
■ MANAGEMENT OF SELECTED COMPLICATIONS bronchoscopy or possibly with angiography or computed tomogra-
phy angiography. Bronchoscopy may help to identify other sources of
In the early postprocedural period, a mature tract will not yet have formed hemorrhage, such as granulation tissue, as well as assessing the degree
between the tracheal stoma and the skin incision, and dislodgement of the of pulmonary soiling. If suspicion of TIF is high, bronchoscopic exami-
tracheostomy tube can result in obscuration of the tracheotomy incision nation should occur in the operating room with resources available

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