Symposium - ICU & Trauma Procedure Complications Access this article online Website: www.ijciis.org DOI: 10.4103/2229-5151.164994 Quick Response Code: An overview of complications associated with open and percutaneous tracheostomy procedures Anthony Cipriano, Melissa L Mao, Heidi H Hon, Daniel Vazquez1, Stanislaw P Stawicki, Richard P Sharpe, David C Evans1 ABSTRACT Department of Surgery, St. Luke’s University Health Network, Bethlehem, Pennsylvania, Tracheostomy, whether open or percutaneous, is a commonly performed procedure 1Department of Surgery, The Ohio State and is intended to provide long‑term surgical airway for patients who are dependent University College of Medicine, Columbus, on mechanical ventilatory support or require (for various reasons) an alternative airway Ohio, United States conduit. Due to its invasive and physiologically critical nature, tracheostomy placement Address for correspondence: can be associated with significant morbidity and even mortality. This article provides Dr. Stanislaw P. Stawicki, a comprehensive overview of commonly encountered complications that may occur St. Luke’s University Health Network, 801 Ostrum Street, Bethlehem, during and after the tracheal airway placement, including both short‑ and long‑term Pennsylvania ‑ 18015, United States. postoperative morbidity. E‑mail: [email protected] Key Words: Complications, open tracheostomy, percutaneous tracheostomy, review, tracheostomy INTRODUCTION tracheostomy complications are the focus of this review, the percutaneous tracheostomy shares many of the same Tracheostomy (stoma, Greek for “mouth”), denotes the risks, as well as some of its own unique complications.[12,13] formation of an artificial opening in the body’s dedicated conduit for air transit between the external atmospheric PREOPERATIVE CONSIDERATIONS air and the lung parenchyma. It is one of the oldest surgical procedures on record, dating back as far as 3600 Indications B. C. E. in Egypt.[1] Today, tracheostomy is one of the A surgical tracheostomy is one of the types of truly most frequently performed procedures in the critically‑ill “secure” artificial airways along with endotracheal patients, and is one of the cornerstones (in addition to intubation. As with all artificial airways, regardless of the surgically‑placed enteral feeding tubes) that help improve patient’s presenting diagnosis, there are four indications the lives of patients who are ventilator‑dependent or for placement: (a) Relieving airway obstruction or have lost their native airway (e. g., post‑laryngectomy circumventing the loss of native airway conduit; [2‑4] patients). (b) providing mechanical ventilation; (c) preventing As with any invasive procedure, there are numerous potential complications of tracheostomy. In general, This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, these complications can be categorized as perioperative, tweak, and build upon the work non-commercially, as long as the author is credited postoperative, procedural, those that occur or are and the new creations are licensed under the identical terms. identified after decannulation, as well as those that are temporally considered to be early (e. g., immediate) or For reprints contact: [email protected] late.[5‑11] In this review, we primarily organize tracheostomy complications as procedural‑related, maintenance‑related, Cite this article as: Cipriano A, Mao ML, Hon HH, Vazquez D, Stawicki SP, and those that occur after decannulation. We also briefly Sharpe RP, et al. An overview of complications associated with open describe the technique of open surgical tracheostomy and percutaneous tracheostomy procedures. Int J Crit Illn Inj Sci 2015;5:179-88. and percutaneous tracheostomy. While surgical © 2015 International Journal of Critical Illness and Injury Science | Published by Wolters Kluwer - Medknow 179 Cipriano, et al.: Complications of tracheostomy (or reducing) aspiration in the unprotected airway; Table 1: Characteristics of tracheostomy tubes [14] and (d) facilitating pulmonary toilet. Despite Types of Special considerations being a secure airway, tracheostomy should still be tracheostomy tubes considered an elective/semielective procedure that is Cannula Single performed after the airway is secured initially by way No inner cannula Can be used in patients where secretions are of endotracheal intubation, as the mortality rate is not a major concern higher for emergency tracheostomy when compared to Used for airway protection and positive [9] pressure ventilation endotracheal intubation (1–2% versus 0.05%). Although Narrowing outer diameter than dual cannulas there are no absolute contraindications to tracheostomy, Dual strong relative contraindications to elective tracheostomy Has inner cannula Used in patients with secretions include uncorrected coagulopathy, inability to tolerate Used for airway protection and positive the procedure (from medical perspective), certain pressure ventilation anatomic considerations (e. g., the presence of aberrant Cuffed Can be single or dual cannula Used in ventilated patients to create a seal vasculature, airway stenosis/obstruction, or tracheal Most commonly used in acute or short‑term fistula), recent instrumentation of the cervical spine, as intubation situations well as active local inflammation or infection. In addition, Cuffless Can be single or dual cannula Used in nonventilated patients some authors advocate an individualized approach to Long‑term tracheostomy, taking into consideration patient‑specific Patients able to swallow and technique‑specific factors for different surgical Patients able to speak [15] Patients have no aspiration risk approaches. Of note, the placement of cricothyrotomy, Used in the pediatric population although technically similar to tracheal airway procedures, Fenestrated Opening in back of outer cannula is characterized by a different (and somewhat unique) Patients breath and speak normally [16‑18] Used as a trial prior to tracheostomy removal set of indications and complications. Consequently, Special length Extra‑long cricothyrotomy will not be discussed in this manuscript. Considered for tracheomalacia, unusual General types of tracheostomy devices and specially anatomy, morbid obesity, thick necks, and copious secretions modified derivatives (e. g., for patients with neck obesity) are outlined in Tables 1 and 2. as early as possible in those patients who are expected Procedural timing to survive beyond the initial period of their acute illness The question of when to perform tracheostomy on a and will require long‑term airway access. patient with an endotracheal tube is a matter of debate in the literature. Sometimes the decision is straightforward, as in the case of permanent airway loss (e. g., total OVERVIEW OF SURGICAL TECHNIQUES laryngectomy). However, such situations are not the norm and the decision is left upon the biases, institutional Open tracheostomy standards of care, and personal preferences of the treating Prior to beginning the procedure, it is critical to position practitioner. One reason that the decision for when to the patient with optimal neck extension to aid in adequate perform tracheostomy may be difficult to make is that exposure. A shoulder roll may be placed underneath there are few randomized, prospective, controlled trials the patient’s shoulders to accomplish this. Appropriate comparing outcomes between early (defined as anywhere sterile technique is used, whether the procedure is from 3 to 10 days) to late (7 to 28 days) tracheostomies. performed in the operating room or at the bedside. The One study in the critical care setting showed that patients tracheostomy device should be tested prior to starting undergoing early tracheostomy (defined as tracheostomy the procedure to ensure that the cuff is functional and within 48 h) spent less time in the intensive care has no air leak. The choice of a horizontal versus vertical unit (ICU), had shorter duration of mechanical ventilation, skin incision depends upon surgeon preference. While experienced less ventilator‑associated pneumonia, and a horizontal incision allows for improved healing and were noted to have lower mortality compared with cosmesis, a vertical incision allows for extension of the late tracheostomy (defined as 14–16 days).[19] Other incision and avoidance of the anterior jugular veins. If a studies provide a relatively wide array of outcomes, horizontal incision is preferred, it is made approximately ranging from “no difference” to significant benefits of half‑way between the cricoid cartilage and sternal early tracheostomy.[20‑23] Although there is no universal notch (e. g., commonly two fingerbreadths above the consensus regarding timing of tracheostomy, the most sternal notch). Dissection is carried down through the important consideration appears to be the expected subcutaneous tissues and the platysma muscles. Smaller length of mechanical ventilatory support. How some vessels are cauterized, while larger vessels are ligated physicians or centers define “prolonged” or “late” is and divided. Once the strap muscles are encountered, variable, but the general agreement remains regarding the they are separated in the midline and retracted laterally. recommendation that tracheostomy should be performed Throughout this entire dissection, one should continue to 180 International Journal of Critical Illness and Injury Science | Vol. 5 | Issue