Chapter 45. Tracheostomy and Emergency Cricothyroidotomy

Tracheostomy

• Supralaryngeal obstruction.
• Secure airway access.
• Prolonged intubation and mechanical ventilation.
• Inability to control secretions.

Emergency Cricothyroidotomy

• Inability to obtain an oral or nasopharyngeal airway in a patient who requires emergent intubation.
• Severe facial or head and neck trauma.
• Acute loss of the airway due to supralaryngeal obstruction secondary to tumor, anaphylaxis, foreign body, trauma, or burn injury.

Tracheostomy

• Significant coagulopathy can be considered a relative contraindication because bleeding into the airway can be catastrophic.

Emergency Cricothyroidotomy

• There are few contraindications to cricothyroidotomy in the emergent setting with a patient in extremis.

• If possible, patient preparation should include the use of a folded sheet, sandbag, or other supporting device placed transversely under the shoulders; this helps in extending the neck and exposing the operative area.
• Endotracheal intubation is also extremely useful to maintain the airway during the procedure.
• In emergent situations when the patient is in respiratory distress, there may not be any time for such preparations.

• A replacement tracheostomy tube should be available at the patient's bedside at all times, and close monitoring is necessary in the first several days after tracheostomy.
• The inhaled air should be humidified since the upper airway is bypassed.
• Frequent endotracheal suctioning is often required to clear secretions.
• In the comatose patient, continuous pulse oximetry and frequent arterial blood gas monitoring may be needed.
• Delayed bleeding in the wound can often be difficult to visualize because the tracheostomy tube hinders exposure.
  • In such situations, packing of the wound with a long piece of hemostatic material (eg, Surgicel) may control the bleeding.
  • Packing with small pieces should be avoided to prevent aspiration into the airway.
• The initial tracheostomy tube is usually left in place for a minimum of 5–7 days, after which it may be removed and replaced.
• The polypropylene sutures in the tracheal flaps can be cut and removed at the time of the first tracheostomy tube change if the change goes smoothly.

• Tracheal stenosis.
• Subglottic stenosis.
• Tracheoesophageal fistula.
• Bleeding.