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Tracheostomy Techniques and Management

Tracheostomy Techniques and Management

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20TH ANNIVERSARYVol. 21, No. 1January 1999
FOCAL POINTKEY FACTS
5
The likelihood of suchcomplications as luminalstenosis, stomal stenosis, orocclusion occurring aftertracheostomy can be minimizedby using proper surgicaltechnique and following correctpostoperative management.
Tracheostomy Techniques andManagement
 Animal Specialty Group, Inc.
 Auburn University 
Patricia Colley, DVMRalph Henderson, DVM, MSMichael Huber, DVM, MS
ABSTRACT:
Tracheostomy is an important tool for managing critically ill patients or patientswith upper airway obstructions. Surgical techniques for temporary tracheostomy includetransverse flap; transverse (horizontal), vertical, and inverted ventral wall flaps; and percuta-neous (Seldinger) procedures. Serious complications can be prevented if practitioners applytheir knowledge of tracheal anatomy, physiology, and wound healing and follow proper surgi-cal technique and postoperative management procedures. Potential complications associatedwith permanent tracheostomy include skinfold occlusion and stomal stenosis.
C
ommon emergency situations can arise when a patient’s airway quickly becomes compromised or a critically ill patient requires long-term venti-latory support or even permanent bypass of the upper airways. In thesesituations, surgical access to the trachea (tracheostomy) and proper placement of a tracheostomy tube are essential. Life-threatening complications can, however,develop after the presenting problem has been resolved. This article reviews theindications and techniques for temporary and permanent tracheostomy, tra-cheostomy tube maintenance, and potential complications.
INDICATIONS
 A temporary tracheostomy may be of short duration (6 or fewer hours) or in-termediate duration (days to weeks). Short-duration tracheostomy is usually used during anesthesia for surgery of the oropharynx, especially if fracture repairrequires restoration of correct dental occlusion. Intermediate-duration tra-cheostomy is usually used to manage upper airway obstruction, injury, or tra-cheal disruption.
1
4
Tracheal obstruction may be secondary to stenosis, trauma,or neoplastic disease.
1
Torsion, vascular anomalies, and peritracheal abscesses arecauses of tracheal stenosis.
1
In addition, trauma from luminal foreign bodies, wounds, and previous surgery may result in second-intention healing and steno-sis. Laryngotracheal neoplasms are uncommon but may cause progressive ob-struction of the airways during growth. The more common laryngotracheal neo-plasms include mast cell tumor, oncocytoma, adenocarcinoma, chondrosarcoma,embryonic rhabdomyosarcoma, leiomyoma, lymphoma, osteochondroma, plas-macytoma, polyps, and squamous cell carcinoma.
5,6
Temporary tracheostomy 
V
s
Cuffed tracheostomy tubes areonly to be used for patients thatrequire mechanical ventilation.
s
The type of tracheal incision isnot a factor in the developmentof luminal stenosis.
s
The transverse flap techniqueis simple and allows easyremoval and replacement of atracheostomy tube.
s
Animals with permanenttracheostomies must avoidcontact with dust, dirt, smoke,and water-related activities.
s
Laryngeal aspiration of food,water, or saliva has not beenreported as a problem in animals.
Refereed Peer Review
CE
 
can be used to circumvent the upper airways whileawaiting remission of obstruction during radiationtherapy or during long-term ventilatory support of crit-ically ill patients.Indications for a permanent tracheostomy include la-ryngeal paralysis or collapse, radiation therapy of theupper airways or oropharynx, laryngotracheal resec-tions, staged laryngeal reconstruction, nasal neoplasia,or severe secretory respiratory disease.
7,8
Permanent tra-cheostomy can be either lifelong or surgically closed af-ter resolution of the primary disease.
NORMAL TRACHEAL ANATOMY
The trachea is a semirigid, flexible air conduit thatextends from the cricoid cartilage to the tracheal carina, where it divides to form the mainstem bronchi.
9
12
Thetracheal lumen is maintained by 35 to 45
C
-shapedhyaline cartilage rings (the actual number varies by species, breed, and individual).
12,13
The width of the av-erage canine cartilage is 4 mm at its thickest point ven-trally and tapers dorsally. The first tracheal ring, whichis complete in dogs, resembles and is partially coveredby the cricoid cartilage.
13
The remaining rings are unit-ed longitudinally by interspersed 1-mm-wide fibroelas-tic annular ligaments.
9,12
The tracheal rings are joined dorsally by the smoothtransverse fibers of the tracheal muscle and, together with the mucosa, submucosa, and adventitia, form thedorsal tracheal membrane.
9,10
The cervical trachea isbounded dorsally by the esophagus (cranially) and thelongus colli muscles (caudally) and ventrally by the ster-nohyoid muscles (cranially) and sternocephalic and ster-nothyroid muscles (caudally).
12,13
The trachea is bound-ed laterally on both sides by large neurovascular bundlesthat contain the vagosympathetic trunk, commoncarotid artery, internal jugular vein, and recurrent laryn-geal nerve (which lies outside the common sheath onthe left).
12
The cervical portion of the trachea ends at thecranial mediastinum and becomes the thoracic trachea.The tracheal mucosa is composed of pseudostratifiedciliated columnar epithelium, which contains basal, cil-iated columnar, goblet, and nonciliated columnarcells.
1,10,12,14
Mostof the epithelium contains a ratio of approximately five ciliated cells per goblet cell.
1,10
Thesubmucosa contains elastic fibers, fat cells, and seromu-cinous tubular glands,
10
the latter of which can secreteas much mucus as 40 goblet cells.
1
The hyaline cartilagerings, annular ligaments, and tracheal muscle form themusculocartilaginous layer, whereas the adventitia is aloosely enclosing sleeve of fascia that blends the muscu-locartilaginous layer to surrounding connective tissue.
1
The trachea is supplied by branches of the cranialthyroid, caudal thyroid, and bronchoesophageal arter-ies. The cranial and caudal thyroid arteries anastomosein the lateral pedicles and have branches that segmen-tally supply the ventral and lateral aspects of the tra-chea.
1
The dorsal tracheal membrane is supplied by branches of the bronchoesophageal arteries.
1
 After thearterial branches have penetrated the annular ligaments,they arborize in the submucosa and communicate witha dense capillary net beneath the epithelium.
13,15
Venousdrainage occurs through the thyroid and internal jugu-lar and bronchoesophageal veins.
16
Lymphatic drainagecontinues to the deep cervical, cranial mediastinal, me-dial retropharyngeal, and tracheobronchial lymphnodes.
1,17
The trachea is innervated by the sympathetic systemvia the sympathetic nerve trunk and the parasympa-thetic system via the recurrent laryngeal nerve.
12,13
Sym-pathetic stimulation inhibits tracheal muscle contrac-tion and glandular secretions, whereas parasympatheticstimulation has an opposing action.
10
NORMAL TRACHEAL PHYSIOLOGY
The primary purposes of the trachea are conductionof air to and from the lower airways and removal of particulate material from the bronchial tree.
11
Patentflexibility is achieved during normal cervical move-ments by joining rigid cartilage rings with flexible an-nular ligaments.
1,11
 Although tracheal diameter changesslightly during normal respiration, the diameter of thelumen decreases by 50% during coughing.
10
This dra-matic reduction results from tracheal muscle contrac-tion, which reduces dead space, increases the velocity of air, and is believed to aid in mucosal expulsion duringthe cough reflex.
13
Inhaled particulate material and excessive bronchialsecretions are cleared from the respiratory tract by themucociliary escalator (a continuous layer of mucus pro-duced by the goblet cells and seromucinous glands) andpropelled toward the larynx by the ciliated epithelialcells at approximately 12.6 mm/min.
1,10,11
The flow of mucus is most rapid in cats and younger dogs and is ac-celerated when warm, dry air is inspired.
2
TRACHEAL WOUND HEALING
Tracheal mucosa responds to irritation by increasingthe production of mucus.
10
Trauma to only the trachealmucosa heals by migration, mitosis, and differentiation, which lead to complete epithelial regeneration.
1,18
 Asearly as 2 hours after injury, marginal epithelial cellslose their cilia, flatten, and begin migrating across theinjury. These migrating epithelial cells, guided by theunderlying elastic lamina, secrete enzymes that dissolvethe fibrinous clot covering the denuded mucosa. Unlikein the epidermis, migration is limited to the marginal
Compendium 
January 199920TH ANNIVERSARYSmall Animal/Exotics
TRACHEAL RINGS
s
CHANGES IN TRACHEAL DIAMETER
s
INCREASED MUCUS PRODUCTION
 
ciliated columnar cells. Mi-tosis within the basal andcolumnar epithelia beginsafter cell migration; thus,the defect is covered withtransitional epithelium within 48 to 72 hours. Dif-ferentiation to ciliated orgoblet cells begins within 96hours. Development of ciliaor differentiation to gobletcells concludes mucosal re-generation.Linear full-thickness in- juries heal similarly if thetracheal mucosa remains inapposition; however, loss of mucosa leads to gaps beingfilled by granulation tissue, followed by wound con-traction and epithelialization (also known as second-in-tention healing).
3,10,19
 Wound contraction results in acertain degree of circular cicatrization. Therefore, heal-ing by second intention usually results in smaller lumi-nal diameters.Resection and anastomosis procedures and tra-cheostomy invariably result in a degree of stenosis. Fac-tors promoting tracheal stenosis include excessive ten-sion at the surgical site, poor anastomotic apposition,formation of granulation tissue, and infection.
1,19
21
Thetension exerted on an anastomotic suture line dependson the amount of trachea resected and the relative elas-ticity of the trachea.
1,19
The maximum tension beforetracheal disruption has been reported to be 1.7 kg forpuppies and 1.0 kg for adult dogs.
22
Healing has beenassociated with less inflammation and scar tissue if tra-cheal cartilages are not compromised.
23
25
Based on thedegree of luminal stenosis, many authors have conclud-ed that the type of tracheal incision (transverse flap,horizontal, or vertical) is not important in the develop-ment of stenosis.
24
27
TRACHEOSTOMY TUBESSelection and Placement
Proper selection and placement of tracheostomy tubes can affect the success of the procedure. Veterinar-ians can select from a variety of sizes available as single-or double-lumen and cuffed or noncuffed tubes.Single-lumen tubes must be removed and reinsertedeach time cleaning is required; double-lumen tubes areeasier to manage because the outer cannula remains inplace and the inner cannula can be removed, cleaned,and replaced. Mucus can, however, still accumulate justdistal to the inner cannula. Small tracheas cannot ac-commodate double-lumen tubes. For example, thesmallest Shiley 
®
double-lu-men tracheostomy tube
a
hasa 5-mm inner diameter anda 9.4-mm outer diameter.The smallest Shiley 
®
single-lumen tube
a
has a 3-mm in-ner diameter and 4.5-mmouter diameter.Noncuffed tubes are usedin patients that require a by-pass of the upper airways, whereas cuffed trache-ostomy tubes are only usedin patients requiring mech-anical ventilation. A trache-ostomy tube with a high-volume, low-pressure cuff can minimize damage to thetracheal mucosa and cartilage.The ideal tracheostomy tube should measure no larg-er than one half the diameter of the tracheal lumen, ex-tend approximately six to seven tracheal rings, and bemade of an autoclavable material (e.g., silicone, silver,or nylon) that is nonirritating to the trachea or be dis-posable.
4,28
The Shiley 
®
tracheostomy tube
a
meets all of these requirements and is available in various sizes (Fig-ure 1) as either single lumen (or cannula) or double lu-men and cuffed or noncuffed.Proper cuff inflation is very important to minimizepressure necrosis and subsequent tracheal stenosis. Prop-er inflation controls the amount of air in the cuff to al-low optimum sealing of the airway.
29
Such control, calledminimal occluding volume, is achieved in patients re-ceiving positive-pressure ventilation by gradually releas-ing small increments of air from the cuff (0.25 to 0.5 ml)until a small leak can be auscultated at the peak inspira-tory pressure. This point represents the minimal occlud-ing volume, and cuff pressure should not be altered un-less problems develop with positive-pressure ventilationand airway pressure cannot be maintained.
29
 After thetracheostomy tube has been positioned, it should be se-cured by tying umbilical tape around the patient
s neck.
Monitoring and Care
Tracheostomy tubes require intensive care and moni-toring to maintain patency and prevent life-threateningcomplications (e.g., tube dislodgment or occlusionfrom blood and mucus). In some patients, the tubemust be suctioned every 15 minutes during the imme-diate postoperative period whereas in others the tubecan be checked every 4 to 6 hours. Maintenance in-volves removing and cleaning the tube or inner cannu-la, suctioning the trachea, maintaining proper humidity 
Small Animal/Exotics20TH ANNIVERSARY
Compendium 
January 1999
TRACHEAL STENOSIS
s
TYPES OF TUBES
s
CUFF INFLATION
s
INTENSIVE CARE
Figure 1—
The Shiley 
®
tracheostomy tube (
left 
) meets the crite-ria for the ideal tracheostomy tube. (
Right 
) Shiley 
®
tracheosto-my tube with obturator (Mallinckrodt Medical TPI, Inc.).
a
Mallinckrodt Medical TPI, Inc., Irvine, California.

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