Tracheostomy

Abstract

Tracheostomy is a common procedure performed in the intensive care unit or operating room. The indications generally fall into three categories: respiratory failure with need for prolonged mechanical support, airway protection, and upper airway obstruction. The only absolute contraindications are overlying soft tissue infection and surgeon inexperience, although a variety of relative contraindications have been established, including high ventilator support settings and coagulopathy. Tracheostomy may be performed by either an open (surgical) or percutaneous technique. Surgical technique may be favored when patients have had prior neck surgery or lack the ability to extend the neck (i.e., after cervical fusion procedure). The only purported benefit of the percutaneous technique is a lower risk of stoma site infection. Complications of tracheostomy may be generally grouped as occurring early or late after the procedure. Early complications include hemorrhage, infection, aspiration, pneumothorax, and loss of airway. Late complications include tracheal stenosis, tracheoesophageal fistula, tracheoinnominate arterial fistula, dysphagia, dysphonia, and accidental decannulation. Physicians who perform this procedure must be prepared to recognize and treat both early and late complications. The timing of tracheostomy relative to the onset of respiratory failure has been the subject of considerable study, but a lack of any specific guidelines highlights the role of the surgeon in patient selection for and timing of the procedure. The decision to perform the procedure and specifically the timing should be individualized to the patient.