Cervical Tracheostomy Research Articles

When tracheotomy was the only resort in paediatric tracheo-bronchial foreign body: case report

The pediatric individual is likely to present with an aspirated foreign body that maybe oriented as such that it may necessitate often an alternate route for removal. Rigid bronchoscopy with jet ventilation is the intervention undertaken at the earliest. In wide caliber foreign bodies a different approach has to be adopted. Tracheotomy, thoracotomy, bronchotomy and pneumonectomy are the next level procedures. A cervical tracheostomy had to be undertaken in a child with a week old impacted conical tail cap of a ball point pen.

Postoperative Complications Following Pharyngolaryngectomy With Total Esophagectomy: Comparison Between Cervical and Anterior Mediastinal Tracheostomy.

Pharyngolaryngectomy with total esophagectomy (PLTE) is associated with high morbidity and mortality rates. Cervical tracheostomy (CT) is the first choice of tracheostomy, whereas anterior mediastinal tracheostomy (AMT) is sometimes required due to tumor extension or insufficient blood supply to the tracheal tip. However, the differences in the outcomes between CT and AMT after PLTE remain unclear. We retrospectively reviewed 67 patients who underwent PLTE and compared the clinical features and postoperative complications between patients with CT and AMT. The characteristics and the outcomes were compared between the groups stratified by the causes of AMT. Of the 67 patients, 42 (62.7%) patients underwent PLTE with CT (CT group), whereas 25 (37.3%) underwent PLTE with AMT (AMT group). The AMT group included more cervicothoracic esophageal cancers and had showed an advanced T stage compared to the CT group (P < .01 and .01, respectively). The incidences of pneumonia and surgical site infection (SSI) were more frequent in the AMT group than in the CT group (P = .03 and .01, respectively). Surgery-related mortality was only observed in the AMT group. In the AMT group, 17 (68.0%) and 8 (32.0%) patients underwent AMT because of tumor extension and insufficient supply to the tracheal tip. The latter cases underwent transthoracic esophagectomy more frequently than former cases (P = .03). AMT after PLTE had more postoperative complications and mortality than CT. In cases that may need AMT, a transhiatal approach is preferable over transthoracic esophagectomy to avoid fatal complications when oncologically permissive.

Use of Retrograde Intubation as an Alternative Maneuver to Secure a Difficult Airway in a Spiny Soft-Shell Turtle (Apalone spinifera)

A spiny soft-shell turtle (Apalone spinifera) underwent coelioscopy after a 6 month history of anorexia and persistent leukocytosis. A laryngeal mass obstructed the glottis and prevented standard orotracheal intubation. Use of a red rubber catheter through a midventral cervical tracheostomy facilitated orotracheal intubation and maintenance by inhalant anesthesia. This method of intubation should be considered as an option for intubation in the chelonian if access to the glottis is impaired.

Posterior laryngofissure using a surgical contact diode laser: an experimental feasibility study.

To evaluate the feasibility of a 980-nm contact diode laser (CDL) as a method for creating a posterior laryngofissure in live pigs. Twenty-eight Landrace pigs (15-20kg) were anesthetized, intubated, ventilated, and submitted to a cervical tracheostomy. An anterior and posterior midline longitudinal laryngofissure incision was created according to randomization-control (n = 4), posterior laryngofissure with a scalpel blade; electrocautery (n = 12), posterior laryngofissure by electrocautery (10, 15, 20, 25W powers); CDL (n = 12), posterior laryngofissure by the CDL (10, 15, 20, 25W peak powers in pulsed mode). Larynx and proximal trachea were excised, prepared for histopathology, and digital morphometric analysis. Measurements in and within each group were analyzed (Kruskal-Wallis and Dunn test) with a level of significance of p < 0.05. Incision width was not different between the groups, as well as in the powers used in CDL (p = 0.161) and electrocautery group (p = 0.319). The depth of the incisions was smaller in the Laser group compared to control (p = 0.007), and in the electrocautery compared to control (p = 0.026). Incision area was smaller in CDL compared with the control (p = 0.027), and not different between laser and electrocautery groups (p = 0.199). The lateral thermal damage produced by electrocautery was the largest, with a significant difference between laser and electrocautery (p = 0.018), and between electrocautery and control (p = 0.004), whereas the comparison between laser and control showed no significant differences (p = 0.588). The posterior laryngofissure incision using a 980-nm CDL is feasible resulting in smaller incisional area and less lateral thermal damage.

Tracheostomy tape: more trouble than it's worth?

In many units where microvascular free-tissue transfer in the head and neck region is practised, tracheostomy is completed with the suturing of the tube in place and the removal of the supporting struts from the tube flange. The thinking is that in removing the struts the risk of occlusion of the vascular pedicle of the free flap, as it lies in the neck, is reduced as the cervical tape cannot be applied. The evidence base for vascular obstruction resulting from a correctly positioned tape is lacking. Presented here is a case in which potential flap failure, as a result of a cervical tracheostomy tape, was avoided by early detection of ischaemia using microdialysis.

Effect of upper airway cooling and CO2 on diaphragm and geniohyoid muscle activity in the rat.

Upper airway (UA) reflexes play an important role in regulating breathing and UA patency, but the effects of UA CO2 and cooling on ventilation and UA muscle activity are controversial. Diaphragm and geniohyoid electromyographic activities were recorded in anaesthetized rats, breathing spontaneously through a low-cervical tracheostomy. Warmed, humidified air containing 0 or 10% CO2 and cooled, room humidity air were applied at constant flow to the UA through a high- cervical tracheostomy. Spontaneous tracheal airflow, UA airflow and temperature, blood pressure, and rectal temperature were recorded. In all animals, the geniohyoid muscle had phasic inspiratory activity, which slightly preceded diaphragmatic activity. CO2 had no effect on mean peak integrated diaphragmatic activity and variable effects on geniohyoid activity. The coefficients of variation of these activities were unaffected by CO2. Similar results were obtained following bilateral mid-cervical vagotomy. Cool air decreased respiratory frequency (78+/-8%) (mean+/-SD % of control), peak inspiratory flow (78+/-5%) and diaphragmatic activity (77+/-4%), and increased geniohyoid activity (149+/-11%). Cutting the superior laryngeal nerves abolished these effects. In conclusion, whilst moderate upper airway cooling inhibits breathing and excites geniohyoid muscle activity, upper airway carbon dioxide has minimal effect.

Distribution of blood flow in the perfused tracheae of sheep: a search for arteriovenous anastomoses

The possible existence of arteriovenous anastomoses (AVAs) in the tracheobronchial circulation has been largely ignored; however, their presence would have many implications. Here we have searched for AVAs in the tracheal circulation of seven anesthetized sheep that were ventilated through a low cervical tracheostomy. Arteries to the midcervical trachea were isolated and perfused in situ at systemic blood pressure; blood flow was measured with an electromagnetic flow probe. A vein draining the perfused segment was cannulated. Radiolabeled microspheres (16 microns diam) injected into the arterial inflow of the perfusion indicated the distribution of blood flow (cervical trachea, 69.9 +/- 4.55% (SE); esophagus, 15.1 +/- 3.9%; connective tissue and blood vessels near trachea, 9.5 +/- 1.8%; lymph nodes, 4.0 +/- 2.2%; skeletal muscle, 0.17 +/- 0.07%; trachea below intubation, 0.00%; larynx, 0.00%; other tissues 0.81 +/- 0.32%). Less than 0.6% of the activity was detected in the tracheal venous blood and lungs, indicating little shunting via AVAs. Within the trachea, blood flow (per wet weight of tissue) to the mucosa overlying smooth muscle was approximately 25% of that to the mucosa overlying cartilage. Intra-arterial infusion of methacholine doubled perfusion blood flow without altering the proportion of shunted blood. Within the trachea, blood flow increased most to the mucosa overlying smooth muscle and to smooth muscle. In conclusion the contribution of AVAs to total blood flow in the cervical trachea is < 1%.

Afferent innervation and receptors of the canine extrathoracic trachea

The aim of this study was to establish the cranio-caudal distribution of slowly (SAR) and rapidly (RAR) adapting receptors of the extrathoracic trachea (ETT) as well as their innervation and response to water solutions of different compositions. Experiments were carried out on anesthetized dogs breathing spontaneously through a low cervical tracheostomy. Eighty percent of SARs and 76% of RARs with fibers in the superior laryngeal nerve (SLN) were found in the cranial third of the ETT. Fifty-seven percent of SARs and 45% of RARs with fibers in the cervical vagus and/or recurrent laryngeal nerve (RLN) were localized in the caudial third of the ETT. Instillation of water into the tracheal lumen had no effect on the activity of any SAR tested, but stimulated 41% of the RARs with fibers in the SLN and 23% of the RARs with fibers in the cervical vagus. Some of the RARs with fibers in the SLN (24%), but none of those with fibers in the cervical vagus/RLN, responded also to iso-osmotic dextrose solutions. Trachealis muscle contraction failed to stimulate the RARs tested. The blocking temperature for SAR and RAR fibers was similar and well within the range of myelinated fibers. We conclude that the SLN provides the innervation of the cranial ETT while the RLN has fibers for the caudal ETT with some overlap in the middle. The responses to water solutions indicate that tracheal RARs constitute a more heterogeneous group than laryngeal RARs.

Water-responsive laryngeal receptors in the dog are not specialized endings

The primary purpose of this study was to ascertain whether laryngeal receptors activated by water are specialized endings or whether they also respond to other stimuli, such as pressure, temperature and laryngeal motion as they occur during the breathing cycle. In 35 anesthetized mongrel dogs, breathing spontaneously through a lower cervical tracheostomy, water and other test solutions at approximately 37°C were injected into the functionally isolated larynx with a small catheter. Of the 130 receptors studied, none of the cold receptors (N = 13) responded to water, whereas approximately 60% of all laryngeal mechanoreceptors (72 of 117) responded with either a short delay, short duration or a long delay, long duration response. In general the former pattern of response was exhibited by nonrespiratory-modulated receptors, whereas the latter was typical of respiratory- modulated receptors. The specific nature of the stimulus (hypotonicity or lack of chloride ion) of the water response was further studied in 53 receptors with isoosmotic solutions of dextrose and sodium gluconate. The long delay, long duration response was dependent on a decreased osmolality, while the short delay, short duration response was dependent on the lack of chloride ion of the test solutions. All water-responsive receptors tested (N = 17) were blocked within 50 sec by topically applied 2% lidocaine and thus presumed to be superficial. However, 10 receptors which did not respond to water were also blocked within 50 sec, suggesting that not all superficial receptors are stimulated by water. Based on these observations, we propose that changes in osmolality or ionic composition of the laryngeal surface liquid could play an important role in modifying reflexes involved in the maintenance of upper airway patency.

Influence of upper airway sensory receptors on respiratory muscle activation in humans.

We reasoned that neural information from upper airway (UA) sensory receptors could influence the relationship between UA and diaphragmatic neuromuscular responses to hypercapnia. In this study, the electromyographic (EMG) activities of the alae nasi (AN), genioglossus (GG), and chest wall (CW) or diaphragm (Di) to ventilatory loading were assessed in six laryngectomized, tracheostomized human subjects and in six subjects breathing with an intact UA before and after topical UA anesthesia. The EMG activities of the UA and thoracic muscles increased at similar rates with increasing hypercapnia in normal subjects, in subjects whose upper airways were anesthetized, and in laryngectomized subjects breathing with a cervical tracheostomy. Furthermore, in the laryngectomized subjects, respiratory muscle EMG activation increased with resistive inspiratory loading (15 cmH2O X l-1 X s) applied at the level of a cervical tracheostomy. At an average expired CO2 fraction of 7.0%, resistive loading resulted in a 93 +/- 26.3% (SE) increase in peak AN EMG activity, a 39 +/- 2.0% increase in peak GG EMG activity, and a 43.2 +/- 16.5% increase in peak CW (Di) EMG activity compared with control values. We conclude that the ventilatory responses of the UA and thoracic muscles to ventilatory loading are not substantially influenced by laryngectomy or UA anesthesia.

Relaxation of tracheomotor tone by PEEP: influence of hypocapnia and acidemia.

The effect of PEEP on airway smooth muscle tone is difficult to assess using standard lung resistance and compliance techniques. In this study we isolated the extrathoracic trachea from lower airway pressure by performing a low cervical tracheostomy in dogs. We then measured the pressure (PTE) within a water-filled cuff of an endotracheal tube which was placed in the isolated extra-thoracic tracheal segment above the tracheostomy as a measure of tracheomotor tone. Sudden application of 10 cm H2O PEEP in normocapneic animals (PaCO2 = 5.6 +/- 0.2 kPa) caused an immediate dilation in this extrathoracic tracheal segment (PTE decreased from 5.7 +/- 0.3 kPa to 2.4 +/- 0.4 kPa). This decrease in tracheomotor tone was transient, returning to control level by four minutes in spite of 10 cm H2O PEEP maintained on the lower airway. With zero end-expiratory pressure the respiratory rate was increased from 9 to 19 breaths per minute and PaCO2 reduced to 3.9 +/- 0.2 kPa. No detectable tracheomotor dilation was observed after the application of 10 cm H2O PEEP to the lower airway. When exogenous CO2 was added to the inspired gas mixture at a respiratory rate of 19/min, the PaCO2 increased from 4.2 +/- 0.2 kPa to 6.7 +/- 0.4 kPa and a tracheomotor dilation in response to PEEP was again detectable. Finally, a 0.1 N infusion of HCl was infused into hypocapneic animals (PaCO2 = 3.7 +/- 0.3 kPa; pH = 7.47 +/- 0.02). After 30-70 minutes, pH decreased to 7.26 +/- 0.02 and PaCO2 remained 3.5 +/- 0.3 kPa.(ABSTRACT TRUNCATED AT 250 WORDS)

Reappraisal of Tracheal Injury From Cuffed Tracheostomy Tubes

Cervical tracheostomy with 72 hours of mechanical ventilation was performed in dogs to compare three techniques for reducing the hazard of tracheal injury from cuffed tracheostomy tubes. Hourly cuff deflation and the use of alternating sites of cuff pressure on the tracheal wall failed to prevent mucosal necrosis and cartilage injury. Careful inflation of the balloon cuff to allow an audible leak during inspiration eliminated significant tracheal injury. On the basis of these experiments, clinical techniques for management of cuffed tracheostomy tubes have been changed with satisfactory early results.