An overview of complications associated with open and percutaneous tracheostomy procedures

Abstract

Tracheostomy, whether open or percutaneous, is a commonly performed procedure and is intended to provide long-term surgical airway for patients who are dependent on mechanical ventilatory support or require (for various reasons) an alternative airway conduit. Due to its invasive and physiologically critical nature, tracheostomy placement can be associated with significant morbidity and even mortality. This article provides a comprehensive overview of commonly encountered complications that may occur during and after the tracheal airway placement, including both short- and long-term postoperative morbidity.

Keywords: Complications; open tracheostomy; percutaneous tracheostomy; review; tracheostomy.

Figure 1

Commonly utilized types of tracheal incisions

Figure 2

Open tracheostomy procedure. (a) Top row (left to right): After patient positioning with extended neck, sterile prep is applied, followed by surgical towel cushions on each side of the neck, and finally sterile drapes. (b) Second row from top (left to right): The surgical site is prepared, measured, and labeled; followed by assembly of all necessary surgical instruments. After the midline has been marked, the incision is made approximately two fingerbreadths above the sternal notch. The incision is extended down to the strap muscles. (c) Third row from top (left to right): The strap muscles are divided in the midline, and the incision is carried down towards the trachea. The thyroid isthmus may need to be divided, as shown in the middle photo, thus exposing the trachea. At this point, the cuff of the indwelling endotracheal tube is deflated, and an incision is made in the trachea using surgical blade (the use of cautery is prohibited due to oxygen fire risk). (d) Bottom row (left to right): The tracheal opening is now dilated, followed by the insertion of a blunt-tip obturator into the tracheostomy and the placement of assembled device into the trachea. This is followed by inflation of the tracheostomy cuff and verification of proper device placement (e.g., via confirmation of end-tidal CO₂ return). At the conclusion of the procedure, the tracheostomy is secured with both sutures and Velcro straps on either side of the device

Figure 3

Percutaneous tracheostomy procedure. (a) Top row (left to right): After patient positioning with extended neck, sterile prep is applied, followed by sterile drapes and injection of local anesthetic. Bronchoscopy is then performed to visualize the airway and to appropriately (partially) withdraw the existing tracheal tube to the point at which it is above the intended anatomic level (indicated by the finger), but still sufficiently below the vocal cords. (b) Second row from top (left to right): The wire introducer needle/sheath are placed into the trachea under endoscopic visualization, followed by removal of the needle and introduction via the sheath of the introducer wire. This is followed by the performance of a small skin incision around the wire and the initial dilation with a small caliber dilator. (c) Third row from top (left to right): The large dilator is then firmly, but carefully introduced in order to prepare the tracheostomy site for the placement of the intended tracheostomy device. (d) Fourth row from the bottom (left to right): The tracheostomy device, after being tested for balloon integrity, is then introduced into the trachea under endoscopic guidance. Once in the airway, the introducer and the wire are both removed from the inner tracheostomy device lumen and replaced by the inner tracheostomy cannula. Finally, the ventilator is connected to the newly placed device. (e) Bottom row (left to right): Endoscopic verification of airway placement is at times performed, followed by the removal of the endotracheal tube and securing of the new tracheostomy device with sutures and Velcro strap

Figure 4

Schematic representation of properly placed tracheostomy positioning