D

figure 10-2 Errors in location of the tracheostomy. A, Placement of the stoma below a cervical stenosis lengthens the extent of damaged trachea. A needed stoma should be located in the stenosis, an already damaged segment. In some patients, it is judicious or necessary to relocate a stoma correctly and allow the prior stoma to heal, in order to recapture usable trachea for reconstruction. B, An insufficiently long tube that fails to pass through a low stenotic lesion fails in its purpose. The solution is not to lower the stoma but to use a longer tube. In urgent cases, a modified endotracheal tube may be used. C, D, The stoma should not be located, whether by intent or error, in the cricothyroid membrane or through the cricoid cartilage. E, A stoma located just below the cricoid, especially in a kyphotic patient, may erode the central cricoid cartilage and result in a partly intralaryngeal subglottic stenosis.

largely eliminated with adequate exposure, good lighting, adequate anesthesia, and precise surgical technique. Pneumothorax during tracheostomy has become very rare. It tended to occur in small children. Obese, short-necked, kyphotic individuals may still present technical challenges.

Longer-term complications present chiefly as sepsis, hemorrhage, and obstruction. Additional complications include acquired tracheoesophageal fistula (TEF) and persistence of tracheal stoma. Sepsis of invasive or necrotizing type is surprisingly rare, even though all tracheostomies are soon contaminated, most often with Staphylococcus aureus (often a resistant strain) and Pseudomonas aeruginosa. Streptococcus and Escherichia coli are frequently present. This will occur despite sterile surgical technique and careful management of stoma, tubes, and suctioning. Antibiotics are not employed unless there is evidence of local invasion or pulmonary infection, to minimize overgrowth of other organisms. The contamination clears when the device is removed and the stoma is permitted to heal.

Hemorrhage, obstruction at the laryngeal and tracheal level due to granuloma, stenosis, and malacia, TEF, and persistent stoma are detailed in subsequent chapters, and their surgical treatment described (see Chapter 11, "Postintubation Stenosis," Chapter 12, "Acquired Tracheoesophageal and Bronchoesophageal Fistula," and Chapter 13, "Tracheal Fistula to Brachiocephalic Artery"). Prevention is also stressed.

Dysphagia and a tendency to aspiration, more pronounced in the elderly, may follow tracheostomy. Usually, this will ameliorate with time.

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