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Endotracheal intubation rather than tracheostomy is now used to establish an emergency airway. Even in difficult anatomic situations, intubation can usually be accomplished over a flexible intubating laryngoscope or bronchoscope. Failing this, a rigid bronchoscope is introduced. A ventilating bronchoscope may serve as an airway during tracheostomy, if necessary. A laryngeal mask airway may be considered. Tracheostomy is preferably done in an operating room with an airway already established by one of the methods noted. The patient is supine on the table with the neck moderately extended (see Figure 24-3B in Chapter 24, "Tracheal Reconstruction: Anterior Approach and Extended Resection"). An inflatable bag placed beneath the patient's shoulders is helpful. The table is flexed at hip level to elevate the head and neck, thus reducing pressure in the cervical veins. Brief general anesthesia is preferred, but local anesthesia may be used.

The incision is located with reference to the cricoid cartilage and not the sternal notch, since the trachea and larynx move independently of the sternum with flexion and extension of the neck (see Figure 1-4, in Chapter 1, "Anatomy of the Trachea"). A more cosmetic transverse incision is used since urgency is moderated by the inlying airway. A short incision is made 1 cm below the cricoid cartilage, which can usually be palpated, even in obese patients (Figure 22-1 A). It is carried through the platysma, the flaps elevated, and the strap muscles are separated in the midline. The thyroid isthmus overlies the second tracheal cartilage in most patients.

Dissection is begun at the lower border of the cricoid cartilage and the trachea is identified above and below the isthmus. Clamps are slipped beneath the isthmus, which is divided and suture ligated, providing a clean exposure of the upper trachea from the lower border of the cricoid cartilage down to the fourth ring or lower. The trachea is cleared of adventitial tissue and the thyroid isthmus is dissected laterally a few millimeters on either side to improve tracheal exposure. Occasionally, the pyramidal lobe must also be divided to improve access.

A vertical midline incision is made through the second and third rings, which are identified precisely (Figure 22-1B). The first ring is always left intact. In children, the third and fourth rings are selected. If rings are heavily calcified, straight scissors will crunch through them after an initial incision in the inter-annular space. Bleeding points may be touched with a cautery, but this must not contact an inlying plastic endotracheal tube or cuff since these can ignite and cause disastrous airway burns. The tracheal lumen is exposed. The endotracheal tube is withdrawn proximally to a point just above the incision in the trachea, but is not yet removed. Thyroid pole retractors are slipped into the tracheal lumen and the stomal edges retracted laterally (Figure 22-1C). If the opening is not large enough, part or all of the fourth ring may also be divided vertically.

The tracheostomy tube, with its previously tested cuff deflated, is slipped into the trachea using a small amount of water-soluble lubricant. With the tube in place, the cuff is inflated just enough to provide a seal and the volume noted. The tracheostomy tube should be no larger in diameter than is needed. Rarely does any patient require a tube larger than no. 7. A patient with small airways should not have a tube fitted snugly into the trachea. A swivel adaptor is attached to the tube and ventilation continued through the tracheostomy tube. Only when the tracheostomy tube is functioning satisfactorily, is the endotracheal tube removed. Traction sutures in the cartilaginous margins of the stoma are acceptable, but unnecessary. The skin is closed loosely with 3-0 nylon monofilament vertical mattress sutures. The flange of the tracheostomy tube is sutured to the skin with four additional sutures to prevent inadvertent extubation postoperatively. A tracheostomy tape is also tied, flexing the neck slightly as this is done so that the tape will be snug postoperatively.

Tracheostomy performed in this deliberate, unhurried way avoids postoperative hemorrhage from anterior cervical veins and the brachiocephalic vein or artery. It avoids pneumothorax, which, in the past, complicated tracheostomy, especially in children. Placement of the stoma with relation to the cricoid avoids an excessively low stoma that may later lead to erosion of the brachiocephalic artery. Division of the thyroid isthmus provides access to the proper level of the trachea and allows for enumeration of the rings so that there is no question about where the stoma is placed. Although there is no harm in excising a small amount of anterior tracheal wall for the placement of a tracheostomy tube, there is little to be gained by it. There is some hazard in teaching removal of any tracheal wall or the creation of flaps, since, if these are made excessively large, they may result in a large stoma, which tends to stenose as it heals by cicatrization. Interannular horizontal tracheostomy may lead to excessive lateral widening of the stoma by erosive pressure. In children, it has been found that vertical incision is safest since it destroys the smallest amount of tracheal wall. Pediatric tracheostomy tubes are also uniquely designed. Some tracheal wall will be damaged by necrosis due to pressure by the tube, regardless of incision. Sutures in the flange of the tube will prevent the tube from slipping out in the early period of healing before the stomal tract is well established. Sutures are removed when it is necessary to change the tube. By this time, the tract is well established. Loose closure of the incision around the tube will avoid subcutaneous emphysema.

Tracheostomy performed with such care avoids most early complications. Appropriate care of the tube from this point on avoids most later complications including stomal and cuff stenoses. Stomal stenosis is avoided by suspending the connecting tubing, thus eliminating leverage of the tube against the tracheal wall and its erosion. Cuff stenosis is avoided by scrupulously preventing overinflation of the large-volume cuff (see Chapter 11, "Postintubation Stenosis"). Semirigid esophagogastric tubes should be removed or replaced to avoid posterior erosion between the tube and the cuff, which can lead to tracheo-esophageal fistula (see Chapter 12, "Acquired Tracheoesophageal and Bronchoesophageal Fistula"). See Chapter 10, "Tracheostomy: Uses, Varieties, Complications," Chapter 38, "Tracheal Appliances," and Chapter 39, "Tracheal T Tubes" for further considerations regarding tracheostomy and tracheostomy devices. Cricothyroidostomy is not an acceptable alternative to tracheostomy for most purposes (see Chapter 10, "Tracheostomy: Uses, Varieties, Complications").

figure 22-1 Technique of tracheostomy. A, The patient is intubated so that tracheostomy, even if urgent, now becomes "elective." Incision (about 3 to 4 cm) is transverse and located 1 cm below the lower border of the cricoid cartilage, which is usually easily palpable. Skin and platysma are divided transversely, and upper and lower flaps are elevated to expose sternohyoid muscles. The incision frequently overlies the thyroid isthmus. B, The midline is opened between the sternohyoid and sternothyroid muscles. Their medial edges are elevated sufficiently to expose the lower border of cricoid, upper trachea, and thyroid isthmus. The isthmus is divided between clamps and sutures, and elevated sufficiently to expose the anterior surface of the trachea from just below the cricoid to approximately the fourth ring. C, The second and third rings are divided vertically, hemo-stasis obtained, and the tracheal walls retracted to expose the lumen. The endotracheal tube is retracted to a point just above the tracheotomy and the tracheostomy tube is inserted. In some, the fourth ring may also have to be divided. The balloon cuff of the tracheostomy tube is stripped back from the tube tip as shown, as the cuff is deflated. This facilitates passing the tube. This minor point of technique is generally useful for inserting cuffed tubes into tight stomas.

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