Introduction

Placement of a tracheostomy tube is a procedure considered as a lifesaving intervention. This technique allows air to bypass the glottis and nasal cavity to improve respiratory tract function. Appropriate management is essential.

Tracheostomy patients require constant monitoring while the tube is in place. Associated complications are common and may lead to death if they are unrecognized and untreated.⁴

Tracheostomy is a common procedure performed in the emergency room (ER), therefore it is crucial that ER clinicians understand how to perform a tracheostomy urgently without needing to review the procedure in the event of an airway occlusion.⁵

Indications

Tracheostomy tube placement is indicated for potentially life-threatening upper airway obstructions (when orotracheal route is unavailable), oral or pharyngeal surgery or long-term positive pressure ventilation (PPV) in critically ill patients. With tracheostomy, accessing the trachea distal to the nose, mouth, pharynx and larynx allows oxygen flow to enter distal to obstructions and decreases the risk of damage to the oral cavity during long-term intubation.¹

Tracheostomy is also indicated for the following:

• Preoperatively in patients with upper airway obstructions before definitive treatment is implemented (e.g., allowing referral or processing of biopsy specimens).
• Transient soft tissue obstructions such as swelling after upper respiratory tract surgery, trauma, laryngeal/pharyngeal oedema or inflammation.
• As part of elective surgery when orotracheal intubation is unavailable (e.g., when the patient is unable to open its mouth, or in oral or pharyngeal surgery.⁴

Contraindications

There are several contraindications to performing a temporary tracheostomy. These include coagulopathies (e.g., vitamin K antagonist rodenticide intoxication), masses or tracheal obstruction distal to the recommended site of tracheostomy and tracheal collapse distal to the site of tracheostomy or previous tracheal stent placement.³

Tracheostomy Tube Selection

Several types of tracheostomy tubes are available. They can be cuffed or uncuffed and with or without an inner cannula. Placing a tube with or without a cuff depends on individual patient factors. To reduce the risk of tracheal damage, an uncuffed tube should be used or the tube cuff should be kept deflated. Even on patients under PPV, uncuffed tubes may also be feasible. A removable inner cannula is considered desirable allowing for easy and effective tube maintenance. This can be briefly removed for cleaning whilst avoiding the risk of disrupting airway integrity. In the absence of an inner cannula, the entire tracheostomy tube should be replaced at least every 24 hours to prevent occlusion with accumulated secretions.¹

The most appropriate tracheostomy tube size is debatable, but the larger the relative size of the tube to the trachea, the less air can flow around it in the event of tube obstruction, so patients with larger tubes should be more closely monitored. However if the upper airway tract obstruction is marked or complete, bypassing airflow will be minimal, meaning a larger tube will benefit the patient. Larger tubes may predispose to site damage.

With better airflow a less negative intrathoracic pressure is achieved during inspiration, consequently, there is less risk of gastro-oesophageal reflux and regurgitation, which is believed to decrease the aspiration risk.⁴ Extra tube length may help to avoid tube dislodgement. It is suggested to use the largest internal diameter tube that will fit into the tracheal lumen without any effort, or as a rule of thumb one that is approximately 75% of the internal tracheal diameter. Tubes vary according to their material, external and internal diameters, length, and presence/absence of cuff. An uncuffed tube is used, unless PPV is required, when a low-pressure cuffed tube is necessary. This tube requires special care to avoid pressure necrosis on the internal tracheal mucosa.⁴

Tracheostomy tubes can also be fenestrated to allow airflow through the upper airway if the external opening is occluded. However, the utility in veterinary medicine is questionable and this kind of tube cannot be used with PPV. If a tracheostomy tube is not available, an endotracheal tube can be shortened and used as an effective substitute.⁶

Equipment

In addition to the tracheostomy tube itself, essential equipment for performing a temporary tracheostomy includes instruments for a surgical approach to the trachea, suture, and material to secure the tube in place.²

Essential equipment to perform a tracheostomy includes:

• Hair clippers
• Endotracheal or tracheostomy tube
• Skin preparation solutions (povidone iodine or chlorhexidine)
• Sterile drape
• Towel clamps
• Scalpel blades (10 and 15)
• Mosquito haemostats
• Scissors
• Needle drivers
• Suture scissors
• Small Gelpi retractors
• Umbilical tape
• 3/0 or 4/0 nonabsorbable suture
• 3/0 or 4/0 absorbable suture

Technique

Tracheostomies can be percutaneous or surgical (transverse or vertical incision).

Percutaneous tracheostomy (Seldinger technique) is a good technique for emergent patients and can be done rapidly. A small transverse incision is made at the desired location for tube insertion. A small-gauge needle is inserted into the tracheal lumen, a guidewire is introduced via the needle into the lumen. Then a dilator is passed over the guidewire. The guidewire and dilator are than removed and the tube is secured in place.¹

Advantages of this technique include smaller skin incisions, less tissue trauma and a lower incidence of complications.²

Surgical tracheostomy, is best performed in a controlled manner with the patient under general anaesthesia and with an orotracheal tube placed. The animal is placed in dorsal recumbency with the neck extended for exposure the incision site. Surgical preparation of the ventral cervical region should be performed.

Several techniques for tracheostomies have been described, none of which have been shown to be superior with respect to functionality or complication rate.² The two common surgical approaches for tracheostomy are transverse and vertical incisions.

Transverse Incision

In this approach the incision is made between the 3rd and 4th or 4th and 5th tracheal rings. The incision should be extended for no more than 50% of the tracheal circumference. Care should be taken to avoid left recurrent laryngeal nerve injury. To reduce tracheal irritation or inflammation, a small ellipse of cartilage adjacent to the incision can be made. Long loops of suture are placed around the tracheal rings adjacent to the incision to facilitate retraction of the trachea and future replacement of the tube after cleaning.¹

Figure 1. Transverse incision tracheostomy

Vertical Incision

A ventral midline vertical incision is made through 2nd to 4th tracheal rings. Long stay sutures may be place encircling the cartilage rings lateral to the incision to aid in continued manipulation of the trachea and future tube replacement. Segmental lateral tracheal collapse may be a long-term complication of this procedure.¹

Figure 2. Vertical incision tracheostomy

After Care and Management

Tracheostomy tubes are commonly associated with several complications but at the same time with a good outcome in most patients. Continuous monitoring is always required.

Major aims of tracheostomy tube management are preventing tube obstruction, facilitating removal of airway secretions and minimizing the risk of airway trauma or nosocomial pneumonia.⁶

All staff working in ER should be trained in recognizing a tube occlusion or dislodgement.⁵

Suctioning Protocol

Care of the tracheostomy tube requires frequent monitoring and suctioning as necessary to remove mucous and blood clots that can cause tube obstruction. To humidify the tracheal mucosa and remove debris within the trachea and tracheostomy tube, instillation of sterile saline and a tracheostomy tube suction are performed at regularly scheduled intervals.³

This procedure should be performed frequently to remove secretions and reduce the risk of tube occlusion:

• Preoxygenate the patient with 100% oxygen 3–5 minutes prior to suctioning.
• Remove the inner cannula for cleaning.
• Humidify airway for 20 minutes before performing suctioning.
• Insert a sterile suction catheter to the level of the carina and apply suction intermittently using a circular motion (no longer than 10 seconds).
• Repeat the suctioning 3–4 more times.
• Administer 100% oxygen for 3–5 minutes after each suctioning episode.
• Replace the cleaned inner cannula.
• Clean the incision site surrounding the tracheostomy tube and ensure that the tube is still in position.⁶

Tracheostomy Site Care

Tracheostomy technique implies that a tube bypasses the normal defense mechanisms of the upper airway. Therefore, sterile technique must be used all times while caring for the tracheostomy site and the tracheostomy tube itself, in order to avoid iatrogenic nosocomial infection.³

Removal of the Tracheostomy Tube

When airway obstruction has resolved, the tracheostomy tube should be removed within 48 hours and the site should heal by second intention. Closing the skin increases the risk of subcutaneous emphysema.⁵

Complications

There are several complications associated with temporary tracheostomy and correct management of the tube is essential. Possible complications include tube occlusion or dislodgment, subcutaneous emphysema, pneumothorax, aspiration of fluids and foreign bodies, pneumonia and incision site infection,⁶ damage to the laryngeal nerve, pneumomediastinum, tracheal collapse and some others.

References

1.  Fudge M. Endotracheal intubation and tracheostomy. In: Silverstein D, ed. Small Animal Critical Care Medicine. 2nd ed. Elsevier; 2009.

2.  Lam N. In: Aronson L, ed. Small Animal Surgical Emergencies. Wiley Blackwell; 2015:263–269.

3.  Mazzaferro E. Temporary tracheostomy. Top Companion Anim Med. 2013;28:74–78.

4.  Nicholson I, Baines S. Indications, placement and management of tracheostomy tubes. In Pract. 2010;32:104–113.

5.  Rozanski E. Airway management. In: Drobatz K, Hopper K, Rozanski E, Silverstein D, eds. Textbook of Small Animal Emergency Medicine. New Jersey: Wiley Blackwell; 2019:1173–1176.

6.  Silverstein D. Small Animal Critical Care Medicine. 2nd ed. EUA: Elsevier; 2015.