Tracheostomy Management in the Chronically Ventilated Patient

PROLONGED CRITICAL ILLNESS: MANAGEMENT OF LONG-TERM ACUTE CARE

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TRACHEOSTOMY MANAGEMENT IN THE CHRONICALLY VENTILATED PATIENT John E. Heffner, MD, and Dean Hess, PhD, RRT

Patients who require long-term mechanical ventilation typically have progressed through multiple phases of an illness, each of which needs thoughtful decisions regarding airway support. Most ventilator-dependent patients first undergo respiratory stabilization with a translaryngeal endotracheal tube in a critical care setting. At some time during the course of their disease, translaryngeal tubes are converted to a tracheostomy to provide longterm airway access for ventilatory support. Once patients achieve stabilization of their critical illnesses sufficient to allow transfer to a chronic ventilator setting, the importance of expert care in airway support does not diminish. In fact, as critically ill patients improve and achieve higher levels of mentation, their need for skilled airway management to enhance comfort, mobility, and an ability to communicate increases. Such patients benefit from a systematic approach to airway management that provides the greatest opportunity for a high degree of psychologic wellbeing and a successful outcome of weaning from ventilatory support. This article reviews approaches to managing artificial airways for patients who require long-term mechanical ventilation.

TRACHEOSTOMIES-GENERAL OVERVIEW

Tracheotomy provided assistance with airway support long before the era of modernday respiratory care. The application of tracheotomy has varied during the past several decades. In the 1960s, the rigid design of translaryngeal endotracheal tubes and a high frequency of airway injuries encouraged placement of tracheostomies in ventilatordependent patients within the first 3 days of respiratory failure.62In the early 1980s, case series studies suggested that tracheotomy was associated with a high incidence of tracheotomy-related airway complication^.^^^ These observations, combined with the advent of better-tolerated endotracheal tubes fabricated from pliable materials, altered practices toward delaying tracheotomies, often into the third or fourth week of intubation. More recently, case series more accurately have profiled tracheotomy as a well-tolerated procedure with acceptable rates of complication.6,lZ8 Many intensivists now place a surgical airway earlier in the course of ventilator-dependent patients when the benefits of the procedure outweigh its disadvantages and the risks for prolonging translaryngeal i n t u b a t i ~ n . ~ ~

From the Department of Medicine, Medical University of South Carolina, Charleston, South Carolina (JEH); Harvard Medical School; and Massachusetts General Hospital, Boston, Massachusetts (DH)

CLINICS IN CHEST MEDICINE ~

VOLUME 22 NUMBER 1 MARCH 2001

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A tracheostomy provides several potential benefits compared with prolonged translaryngeal intubation: Increased patient mobility More secure airway Increased comfort Improved airway suctioning Early transfer of ventilator-dependent patients from the intensive care unit (ICU) Less direct endolaryngeal injury Enhanced oral nutrition Enhanced phonation and communication Decreased airway resistance for promoting weaning from mechanical ventilation Decreased risk for nosocomial pneumonia in patient subgroups Mentally alert patients tolerate a tracheostomy better than an endotracheal tube and experience less facial and oral discomfort.6 Enhanced comfort may decrease the need for sedation that has been associated with an increased risk for nosocomial pneumonia.80Tracheostomy also allows greater mobility, including moving to a chair. Early transfer from the ICU is facilitated with performance of a tracheotomy for patients who are not ready for weaning from mechanical ~entilation."~ Ventilator-dependent patients have opportunities for articulated speech after placement of a tracheostomy. Speech and an ability to communicate spontaneously enhance patients' well-being and sense of control.47, 86 The inability to communicate has been identified by patients as one of their most significant sources of psychologic stress during ventilator dependency.'O, 44, 73, 88,Io3 Recent studies suggest that mechanically ventilated patients who receive a tracheostomy have a lower risk for nosocomial pneumonia. A randomized trial that enrolled 107 trauma patients to early tracheotomy (7 or fewer days of mechanical ventilation) or delayed tracheotomy (> 7 days) observed an 81% relative risk for pneumonia in the early tracheotomy group compared with the delayed tracheotomy group.llS A retrospective study by Kluger and c o - ~ o r k e r ssimilarly ~~ detected a lower incidence of pneumonia in 118 trauma patients converted to a tracheostomy during the first week of mechanical ventilation compared with later in their hospital course. It has not been demonstrated that these benefits exist for patients with causes of respiratory failure unrelated to trauma.

Tracheostomy tubes present spontaneously breathing patients with lower airway resistance than translaryngeal endotracheal tubes. Endotracheal tubes have a higher resistance in vivo than predicted by their manufactured caliber because inspissated secretions decrease the luminal diameter and promote turbulent airflow?, 141 Lower airway resistance with a tracheostomy decreases ventilatory load and provides an opportunity for accelerating weaning from mechanical ventilation in patients with borderline lung function. Lower airway resistance may explain why trauma patients who undergo early tracheotomy have a shorter period of mechanical ventilation and ICU stay than patients managed with prolonged translaryngeal intubation and delayed tra~heotomy.''~ TRACHEOSTOMY TUBE CARE

Proper tracheostomy care begins with the selection of an appropriate tube for a patient's needs. Standard tracheotomy tubes have a C-shaped curve that may not accommodate patients with thick necks or long tracheostomy stoma tracks. In such instances, specialized tubes with angulations placed at different points of the tube's length (Fig. 1)or tubes made from flexible, kink-resistant material (Fig. 2) can be used. Tracheostomy tubes traditionally have been secured with twill tape around the neck. Commercially available equipment for securing tracheostomy tubes consists of padded tape with a hook and loop fabric fastener that is passed around the patient's head and through the slits in the neck plate of the tube. This approach is quick and easy to apply. The tape is easily adjustable, and the elastic properties of the foam permit stretching to accommodate swelling of the neck or movement of the patient. The fenestrated tracheostomy tube has an opening on its cephalad side. With the inner cannula removed and cuff deflated, the patient can breathe through the upper airway. To ensure that the patient breathes only through the upper airway, a decannulation plug is used to occlude the external opening of the tube. Several precautions are necessary before the tracheostomy tube is plugged. The inner cannula should be removed, the fenestrations must be free of tissue or granulation, and the cuff must be deflated. There is no evidence to guide the frequency of tracheostomy tube changes. It is a common

TRACHEOSTOMY MANAGEMENT IN THE CHRONICALLY VENTILATED PATIENT

Figure 1. Shiley specialized tracheostomy tubes with differing tube lengths and positioning of the tube angulation. Manufacturers provide consultative services for patients with diff icult-to-fit airways. (Courtesy of Mallinckrodt Medical, St. Louis, MO.)

Figure 2. A and B, Examples of TTS Fixed Neck Flange Hyperflex Tracheostomy Tubes. The tube is made of soft, flexible, compliant and kink-resistant, wire-re-enforced material that allows placement into anatomically complicated airways. (Courtesy of Bivona Medical Technologies, Gary, IN.)

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practice to change the tracheostomy tube when it is grossly soiled, if it malfunctions (e.g., cuff rupture), or if a tube of another design is needed (e.g., fenestrated tube). Changing the tracheostomy tube is not a benign procedure. Complications include inability to insert the replacement tube, insertion of the replacement tube into a false passage74 (soft tissue of the neck or mediastinum), bleeding, and patient discomfort. The risk for these complications decreases with the age of the tracheal stoma. For this reason, it is recommended that changing the tracheostomy tube be avoided for at least 1week after surgical creation of the stoma and that the first tube change is performed by the surgeon who performed the tracheotomy. If a difficult tracheostomy tube change is anticipated (e.g., obese patient, airway anomaly, short and thick neck), a clinician experienced in endotracheal intubation should be present.

system compliance are at particular risk for experiencing airway complications from excessively high cuff pressures when these techniques are used. Estimation of cuff pressure by finger palpation of the external inflation bulb does not provide a reliable substitute for cuff pressure measurement^.^^ Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube.15 Cuff pressures are most accurately measured using a syringe with a manometer connected to the cuff tubing by a stopcock. The stopcock setup must communicate simultaneously with the syringe, manometer, and cuff to allow real-time pressure monitoring during cuff inflation.32Commercial devices simplify frequent monitoring of cuff pressures (e.g. Digital P-V Gauge, Mallinckrodt Medical, St Louis, MO). Physicians should examine chest radiographs to determine whether the cuff has a width greater than the caliber of the CUFF MANAGEMENT trachea, which suggests the presence of a hyperinflated cuff and tracheal overdistention4 (Fig. 3). Tracheostomy tube cuffs require monitorAmbient conditions can alter tracheostomy ing to maintain their inflation pressures in a cuff pressures. High airway pressures during range of 20 to 25 mm Hg. Overly low cuff the inspiratory cycle in mechanically ventipressures, below 18 mm Hg, may cause the cuff to develop longitudinal folds, promote lated patients with low respiratory system microaspiration of secretions collected above compliance are transmitted to the cuff and the cuff, and increase the risk for nosocomial increase cuff pressure and the tension of the pneumonia.l', 12, 110 Excessively high cuff prescuff against the tracheal m ~ c o s aThe . ~ ~corresures above 25 to 35 mm Hg exceed capillary lation between peak airway pressure and inperfusion pressure and can result in comprestracuff pressure is linear; a peak airway pression of mucosal capillaries, which promotes sure of 35.3 mm Hg (48 cm H,O) has been mucosal ischemia and tracheal s t e n ~ s i s .lZo ~ ~ , shown to correspond to an intracuff pressure Many respiratory therapy departments accept of 25 mm Hg (34 cm H,O) in critically ill 25 mm Hg (34 cm H,O) as the upper limit for patients ventilated with translaryngeal endoacceptable intracuff pressure. tracheal The minimal occlusion or minimal leak Cuff pressures also can increase when patechniques are two methods for inflating tratients undergo anesthesia with volatile gases. cheostomy tube cuffs.33The minimal occluDiffusion of volatile gases into a cuff inflated sion technique entails inflation of the cuff to with air increases cuff pressures to critical the lowest volume that extinguishes end-inlevels above mucosal capillary perfusion spiratory leaks around the cuff during posipressure within 2 hours of a surgical procetive-pressure ventilation. The minimal leak dure.Il2Anesthesiologists should monitor cuff technique is performed by inflating the cuff pressures during prolonged procedures or inuntil a slight airleak exists during end-inspiflate cuffs with the anesthetic gas mixture at ration. the start of surgery. The latter approach reThe authors do not depend on either of quires reinflation of the cuff with air at the these techniques because caregivers cannot end of the procedure. assume that application of the minimal occluOccasionally, the pilot tube that transmits sive or minimal leak technique ensures inflapressure to the cuff is severed accidentally. To tion of a tracheostomy cuff to a safe pressure correct this problem, a short, blunt needle can range.7*90 Patients who require high airway be passed into the pilot tube and a stopcock inflation pressures because of low respiratory attached to the needle hub to add and main-

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Figure 3. Evidence of a hyperinflated tracheostomy tube cuff that is overdistending the trachea.

circuit remains dry. Further, many HMEs have filtration properties. This factor leads to the naive assumption that HMEs are associated with a lower ventilator-associated pneumonia (VAP) rate than active humidification. There is substantial evidence, however, that the ventilator circuit per se is relatively unimportant in the development of VAP. Although HUMIDIFICATION a single study76reported a lower VAP rate with passive humidification compared with Humidification of the inspired gas is a standard of care for tracheostomized patients.21 active humidification, this finding is not supported by the preponderance of evidence Active humidifiers pass the inspired gases from other studies.19,22, 41, 82 The accumulated over a heated water bath to humidify the gas evidence suggests no relationship between by evaporation. A heated circuit may be used VAP and the type of humidification used. to maintain a constant temperature and huHeat and moisture exchangers traditionally midity of the gas as it is delivered to the have been changed on a daily basis and more patient. This action decreases condensation frequently if they become partially occluded within the circuit. A passive humidifier, with airway secretions. Multiple studies have sometimes called an artificial nose or heat and demonstrated that ventilator circuitsM,43, 63, 83, 94 moisture exchanger (HME), traps a portion of and inline suction catheterss1 changed at 1 the heat and humidity from the patient's exweek or longer intervals rather than shorter pired gas and returns it to the patient on the intervals are associated with lower incidence subsequent inspiration. Although the temperof VAP. These observations suggest that it ature and humidity output of active humidimay be safe to change HMEs less frequently fiers exceed that of HMEs, passive humidification is adequate for many patients.lo0 than daily. Recent data35,36 suggest that HMEs can be used safely for as long as 3 days (and Hygroscopic HMEs provide a higher humidity output than hydrophobic H M E s , ~ the ~ , ~ ~perhaps , ~ ~ ~ longer). Adopting this practice seems to have little risk but is associated with conimplications of which may be important siderable cost savings. when selecting an HME. Clinical concerns limiting the use of HMEs With passive humidification, the ventilator tain air in the cuff until the tube can be rep l a ~ e d . Cuff ~ ~ ,leaks ~ ~ also can occur and a continuous flow of gas into the cuff can be used to temporarily maintain cuff inflation until the tube can be changed.132

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are that they add additional deadspace and resistance7l and their humidity output is less than that of active h~midifiers.~~, 137 This situation raises the concern of dried secretions and tracheostomy tube occlusion with the HME. The humidity output of some HMEs is inadequate'" and a fatal endotracheal tube obstruction has been reported with the use of an HME.97Similar issues have been raised with incorrectly used active humidifiers and heated wire circuits, however.99The risk for tracheostomy tube occlusion during HME use can be decreased by (1) choosing a hygroscopic HME with adequate moisture output, (2) selecting appropriate patients for use of HMEs, and (3) observing the proximal endotracheal tube for the presence of condensation. Patients appropriate for HMEs have minimal airway secretions.22, 23 Whether using an active or a passive humidifier, the presence of condensation in the flex tube of the circuit and proximal endotracheal tube indicates adequate h~midification.'~, 114 The additional deadspace and resistance of the HME should be considered during weaning assessments. A low level of pressure support may be useful to offset these effects.lo9The deadspace of the HME also should be considered in patients with an elevated arterial partial pressure of carbon dioxide (Paco,). A decrease in Paco2 with removal of the HME from the circuit has been reported.7o For the spontaneously breathing tracheostomized patient (i.e., not mechanically ventilated), humidification often is provided using a heated or cool aerosol applied to the proximal tracheostomy tube. Although a heated aerosol traditionally has been used for this purpose, there is no evidence that this is superior to the use of a cool mist. Furthermore, the use of heated aerosol complicates humidification efforts and adds expense. Aerosols for humidity should be avoided in patients with reactive airways disease, because inhaled aerosols can trigger bronchospasm in some patients with a history of bronchospasm. In such patients, an active passover humidifier should be used. Patients who require long-term tracheostomy also may benefit from an artificial nose that increases humidity and serves as a filter to prevent the inhalation of airborne debris. The use of HMEs in these patients reduces sputum production and the number of coughing episodes per day,', 53, 66 which can be important to the patient's quality of life.

CLEARANCE OF SECRETIONS

Patients with tracheostomies should be suctioned whenever physical examination reveals the presence of secretions in the airwayz1, Because suctioning is uncomfortable, it should be performed only when indicated and not at a fixed frequency13oThe upper airway also should be suctioned periodically to remove oral secretions. Hyperinflation and hyperoxygenation generally are recommended before suctioning to prevent suction-related hypoxemia. In some critical care units, a manual ventilator (resuscitator) is used to generate hyperinflation and hyperoxygenation. Manual ventilators may be inferior, however, to hyperinflation and hyperoxygenation using the venti1at0r.l~~ It also has been shown that manual ventilators found at the bedside of mechanically ventilated patients can be a source of contamination of the lower respiratory tract.138One of the difficulties related to use of a manual ventilator during suctioning is that tidal volume delivery and airway pressure usually are not measured. Lung hyperinflation frequently is not achieved by manual v e n t i l a t i ~ n 'and ~~ adverse hemodynamic sequelae may result if vigorous efforts are applied to manual resuscitators to achieve hyperinflation. Glass and co-workers46reported that the mean fractional concentration of oxygen in inspired gas (FIo,) approximated 0.7, the mean respiratory rate 30/minute, and the mean tidal volume, 625 mL when nurses used a manual ventilator during airway suctioning. Closed suction systems in which the catheter becomes part of the ventilator circuit are also available for tracheostomy patients (shorter catheters). The effectiveness of secretion clearance is similar for closed-system catheters and that of the conventional suction technique.140 Closed suction technique maintains adequate oxygenation during suctioningM,65 The incidence of patient contamination and environmental contamination also has been reported to be less with the use of closed suction Because closed suction catheter systems do not need to be changed until they malfunction or become grossly soiled, they may provide cost savings compared with open The instillation of saline to facilitate airway suctioning is controversial. Ackerman, reported transient hypoxemia during airway suctioning after the instillation of saline. Hagler and T r a ~ e reported r~~ that a 5-mL sa@

TRACHEOSTOMY MANAGEMENT IN THE CHRONICALLY VENTILATED PATIENT

line instillation dislodged large numbers of bacteria from the endotracheal tube lumen, potentially increasing the likelihood of washing organisms from the endotracheal tube into the lower respiratory tract. Saline instillation may be useful to loosen and remove thick secretions in selected patients. This practice should be used judiciously and should not be a routine procedure each time a patient is suctioned. SPEECH

Experienced caregivers can take advantage of a tracheostomy’s potential for promoting articulated ~peech.4~. Available techniques depend on different levels of patient cooperation and require individualization of care. Patients who fail a particular technique may successfully master this technique later in their clinical course.1o4Language therapists should be included in plans for assisting chronically ventilated patients with their efforts to communicate.’” Ventilator-dependent patients who require low minute ventilations may accomplish whispered speech during periods of partial deflation of the tracheostomy tube cuff. Brief speaking sessions can be initiated by SUCtioning through the patient’s mouth the region above the cuff to remove retained secretions. The cuff is deflated slowly until a sufficient leak of air around the cuff allows whispered speech during the ventilator’s inspiratory cycle. Patients are observed for signs of hypoventilation, and the cuff is reinflated after the speaking session.17,57, Patients may be able to speak throughout the ventilator cycle if a small amount of positive end-expiratory pressure is added that produces a continued airleak after partial cuff deflation.57 Pneumatic speaking tubes provide an additional opportunity for speech for patients who can master this technique.9*,lZ4A source of gas is attached to a special port on a speaking tracheostomy tube that exits at the curved portion of the tube above the cuff and within the patient’s trachea. Application of a flow of gas through this port allows airflow through the patient’s larynx and promotes articulated speech. Up to 75% of properly selected ventilator-dependent patients may accomplish articulated speech with this 78 APpropriate patients for this technique have

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good mental status, access to appropriately trained staff, a normal native upper airway, and adequate m o t i v a t i ~ n . ~ ~ Use of an electrolarynx has a high rate of success for producing intelligible speech in motivated patients?, 14*These devices produce a vibratory tone when applied against the submandibular triangle. More than 90% of properly selected patients with a tracheotomy achieve speech with them.3 Patients who can breathe spontaneously during intervals of weaning from mechanical ventilation may speak spontaneously with the use of a fenestrated tracheostomy tube.59 After removal from mechanical ventilation, the inner cannula of the fenestrated tube is removed, allowing expiratory airflow through the larynx when the external end of the tracheostomy tube is occluded transiently. Deflation of the tracheostomy tube cuff during periods of spontaneous breathing can enhance expiratory airflow further across the vocal cords. Application of a one-way valve (e.g., Passy-Muir valve, Passy and Passy, Irvme, CA; Phonate Speaking Valve, Mallinckrodt Medical, St Louis, MO) (Fig. 4) permits inspiratory airflow through the tracheostomy tube during inspiration but closes during expiration promoting airflow through the tube fenestrations and around a deflated cuff.”, 96, lo6, lo7 Patients managed with a Passy-Muir valve require careful evaluation to be certain that the airway resistance during exhalation with breathing through a fenestrated tube does not interfere with weaning.34 NUTRlTlON

The presence of a tracheostomy tube provides opportunities for oral nutrition but also complicates alimentation because of tube interference with normal swallowing and airway control. Between 20% and 70% of patients with a chronic tracheostomy experience at least one episode of aspiration every 48 hours.26 Placement of a nasogastric feeding tube in a ventilator-dependent patient interferes with gastroesophageal sphincter function and promotes reflux of bacteria-laden gastric contents, further increasing the risk for airway aspiration. To decrease risks for nosocomial pneumonia caused by aspiration, patients with tracheostomy are kept with their heads elevated to 45” during periods of tube feeding.134

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Figure 4. Phonate Speaking Valve allows vocalization for patients with a tracheostomy who breathe independently. (Courtesy of Mallinckrodt Medical, St. Louis, MO.)

Swallowing abilities should be evaluated carefully before initiating oral diets in ventilator-dependent patients with a tracheostomy because of the effects of tracheostomies on swallowing function.16,l o l A tracheostomy tube prevents normal upward movement of the larynx during swallowing and hinders glottic closure.l* An inflated tracheostomy cuff does not protect patients from aspirating into the lower airway oral contents that pass through an incompetent glottis. Mentally alert patients should be selected for an oral diet when they have adequate oxygenation with low inspired oxygen concentrations and sufficient ventilatory reserve to allow them to tolerate an episode of aspiration during introduction of oral feeding. Speech therapists should evaluate oral motor strength, swallowing, and the adequacy of volitional and reflex coughing and the gag reflex. The presence of a gag reflex, however, does not ensure that pharyngeal contents will not be aspirated during r e f e e d i ~ ~ g . ~ ~ The first feeding attempts should begin with ice chips to accustom patients to swallowing, followed by soft foods, such as gelatins, that would not have important consequences if aspirated into the airway.45Liquids present problems during the initial phase of refeeding because patients can not control liquid boluses within the mouth and position

them in the posterior pharynx before they regain swallowing reflexes. Caregivers should recognize that up to 45% of patients experience some degree of aspiration during the introduction of oral feedi11g.4~ When patients demonstrate tolerance of soft food, the diet can be advanced rapidly. It is unclear whether an inflated tracheostomy cuff assists training for an oral diet or increases the risk for aspiration.", 26, 133 In some patients, cuff deflation during oral feeding may promote an airleak around the tube cuff that assists the clearance of subglottic food particles into the mouth, where they can be swallowed.133Also, an inflated tracheostomy cuff can compress the esophagus and cause swallowing difficulties. Patients should be evaluated for the adequacy of swallowing with and without cuff inflation. WEANING FROM TRACHEOTOMY

Most patients who have been liberated successfully from long-term ventilatory support benefit from a systematic approach to weaning the tracheostomy tube to ensure that respiratory difficulties will not occur after airway d e c a n n ~ l a t i o nTracheostomy .~~ stomas can narrow markedly or close within 48 to 72 hours after tube removal. Difficulties may

TRACHEOSTOMY MANAGEMENT IN THE CHRONICALLY VENTILATED PATIENT

occur, therefore, with tube replacement if respiratory complications occur after decannulation. Moreover, many patients have anatomic abnormalities in their airways, such as vocal cord injuries, granulation tissue, or strictures, after long-term intubation that can be identified during a systematic weaning program. It should not be forgotten that these airway lesions initiated by endotracheal and tracheostomy tubes can contribute to failure of weaning from mechanical ~enti1ation.l~~ Patients can be evaluated for decannulation after they demonstrate stability for 24 to 48 hours after discontinuation of mechanical ventilation. The patient's ability to protect the airway should be assessed for 24 hours by deflating the tracheostomy cuff and observing for signs of a s p i r a t i ~ nEvidence .~~ of moderate to severe aspiration warrants laryngoscopic inspection of the glottis before further weaning efforts. Airway strictures and adequacy of the native airway can be assessed by deflating the tracheostomy cuff and capping the tube.l18 Adults who can breathe around a capped #8 tracheostomy tube have adequate ventilatory reserve and a sufficiently preserved native airway to tolerate decannulation. Patients who have difficulty breathing around a capped #8 tube can be reassessed with a capped #7 tube in place. Successful breathing with a #7 capped tube in place supports the likelihood that patients will tolerate decannulation.ll* Patients who fail breathing trials with capped tracheostomy tubes should be evaluated by flexible fiberoptic endoscopy from the level of the supraglottis to the mainstem bronchi for evidence of airway lesions and adequacy of airway f u n ~ t i 0 n . l ~ ~ Many patients recovering from long-term ventilatory support may have normal airways but fail breathing around a capped #7 or #8 tracheostomy tube because of limited ventilatory reserve. Patients with neuromuscular disease or underlying chronic obstructive pulmonary disease are examples of such patients. These patients benefit from stepwise weaning using downsizing and capping of tubes or stomal obturators ("stomal buttons"). Downsizing of tube caliber can occur until patients tolerate a small, uncapped tube without breathing discomfort. The tube provides a port for suctioning and ventilation in addition to the native airway. Once a small tube is tolerated, it can be capped and the patient

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observed for 24 to 48 hours. The ability to breath and clear airway secretions around a small, capped tube signifies readiness for decannulation.'13 Some patients with a moderate degree of airway secretions have difficulty with tube downsizing because the tracheostomy tube interferes with secretion clearance through the native airway. Stoma1 obturators can assist these patients because they clear the tracheal lumen of potentially obstructing indwelling devices, promote breathing through the nose and mouth, provide tracheal access for suctioning, and maintain the stoma until final decannulation can occur. The Olympic stomal button (Olympic Medical Corp., Seattle, WA) is an example of an obturator system that consists of a hollow tube with retention flanges that dilate with insertion of a solid plug into the tube.61,93, lZ1 Insertion of the hollow tube into the stoma maintains a patent stomal tract. Insertion of the solid plug dilates the retention flanges within the tracheal lumen adjacent to the anterior tracheal wall, which secures the system into place. When the patient tolerates 24 to 48 hours of spontaneous breathing through the native airway without needing suctioning through the obturator, the stomal button can be removed. COMPLICATIONS Management of Pre-existing Airway Injury From Translaryngeal lntubation

Because of the long duration of ventilatory dependency of some patients in chronic ventilator units, airway complications from a period of pre-existing translaryngeal intubation may require diagnosis and care. Airway injury from translaryngeal intubation can occur at any point along the path of an endotracheal tube:

Nasopharyngeal injury Sinusitis Ulcerative lesions of the nares and pharynx Otitis Nasal septa1 fractures Laryngeal injury Granulation tissue forming interarytenoid adhesion Posterior glottic stenosis

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Subglottic stenosis Mucosal ulceration Dislocation or subluxation of the arytenoid Vocal cord laceration Damage to intrinsic muscles Airway perforation Healed fibrous nodule Vocal cord paralysis Web formation Vocal cord fixation from fibrosis of the cricoarytenoid joint Cricoid cartilage abscess Tracheal injury Tracheal stenosis Injury can occur as a result of the initial intubation attempt or from maintenance of the endotracheal tube in place. Orotracheal tubes can produce ulcerative and erosive lesions of the lips, hard palate, and soft tissues of oral structure^.'^^^ lZ6UP to 0.1% of patients undergoing initial placement of an endotracheal tube during general anesthesia sustain dental injuries92that remain the number one cause of malpractice litigation against anesthesiologists. Nasotracheal tubes can damage nasopharyngeal structures. Transection of nasal turbi79 necrosis of the nasal nates and alae,lMand perforation of the nasal have been reported rarely. Few studies have examined long-term complications of nasotracheal intubation. One study with a 2-year follow-up demonstrated frequent airway difficulties in patients intubated through the nasotracheal route.69 Symptoms related to the ears occurred in 24% of patients, maxillary sinuses in 20%, voice changes in 29%, and throat difficulties in Other airway complications occur with a similar frequency in patients intubated through the nasal or oral routes. Persistent dysphonia detected during introduction of interventions to promote speech for patients with a tracheostomy may signify abnormalities of laryngeal structures. Vocal cord granulomas represent the most common of these abnormalities. Positioning of endotracheal tube cuffs high in the airway can produce unilateral or bilateral vocal cord paralysis by damaging the anterior branch of the recurrent laryngeal nerve, which lies in the submucosa 6 to 10 mm below the glottis.27,28 Unilateral vocal cord paralysis presents with hoarseness, and bilat-

eral vocal cord paralysis causes inspiratory stridor and varying degrees of hoarseness. Vocal cord paralysis caused by ischemic neuropraxis usually resolves within days to months after removal of the endotracheal tube. Endotracheal tubes also can damage the external laryngeal nerve and cause cricothyroid muscle paralysis. The most serious complication of translaryngeal intubation is glottic and subglottic stenosis. Endotracheal tubes must bend posteriorly as they pass through the glottis to conform to normal airway anatomy. The resulting tube flexion produces tension against posterior supraglottic, glottic, and subglottic structures in the region of the arytenoid cartilages, the endolarynx, and the cricoid carti1age.lll This tension against endolarygneal structures has been measured to exceed 200 to 400 mm Hg in animal models.127, 139 Resulting pressure necrosis can cause laryngeal structures to undergo involution that can present as postextubation subglottic stenosis, interarytenoid fibrous bands, and glottic incompetence during the time that tracheostomies are still in place.6o These abnormalities can be causes of failure to undergo successful decannulation of a tracheostomy tube. Tracheal stenosis after translaryngeal intubation rarely occurs since the advent of highvolume, low-pressure tube cuffs.lZ9Overinflation of cuffs within the region of the cricoid cartilage, however, remains a contributing cause of subglottic s t e n o ~ i s . ~ ~

Airway Complications Related to Trac heostomy

Many of the complications of tracheostomy may emerge before discharge from a longterm acute care facility:

Stoma Stoma site infection Stoma1 hemorrhage Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula Trachea Granuloma Tracheoesophageal fistula Tracheoinnominate fistula Tracheal stenosis Tracheal dilatation Tracheomalacia

TRACHEOSTOMY MANAGEMENT IN THE CHRONICALLY VENTILATED PATIENT

Tracheostomy can cause tracheal stenosis adjacent to the tube cuff or at the level of the tracheostomy stoma site?, 5, 51, 52 High-volume, low-pressure cuffs have decreased markedly the incidence of stenosis at the cuff site.24 Tracheal stenosis at the stoma site, however, continues to be an important clinical problem that can develop from 1 to 6 months after decannulation.60The incidence of tracheal stenosis after tracheotomy in patients who require long-term ventilation is unknown because of the absence of longitudinal studies with adequate follow-up. Published studies of patients in a critical care managed setting with a tracheostomy suggest that the risk for tracheal stenosis ranges between 0% and 16% (Table 1).=,29, 85, 135, 136 Most patients, however, lose only 10% to 40% of their tracheal caliber, which usually does not compromise ventilatory function. Tracheomalacia with dynamic airway narrowing during spontaneous expiration also occurs. Randomized studies comparing the long-term outcome of patients managed with standard surgical tracheotomy compared with percutaneous dilational tracheostomy have not been performed. Tracheoesophageal fistulae represent rare complications of tracheostomy and occur in fewer than 1%of patients as a result of pressure necrosis of the tracheal and esophageal mucosa from the tube Risk factors include high airway pressures, high cuff pressures, presence of a nasogastric tube, excessive tube movement, and underlying diabetes mellitus.lo8Clinical manifestations of tracheoesophageal fistulae include increased tracheal secretions, increased coughing, coughing after eating or drinking, gastric distention, frequent belching, and pneumonia.49 Chest radiographs may suggest the presence of a tracheoesophageal fistula by demonTable 1. LONG-TERM RISKS FOR TRACHEAL STENOSIS AFTER TRACHEOTOMY Reference

n

LawM 81 RosenboweP 55 ~ a n H e u r n ' ~ ~150 Callanan= 9 Lawa 41

Tracheotomy Techniaue

Tracheal Stenosis I%)

Open PDT/open PDT PDT PDT

'16 0 <1 0 t7

PDT = Percutaneous dilatational tracheotomy; open = standard surgical tracheotomy. *Denotes definition of tracheal stenosis was greater than 20% tracheal narrowing. tDenotes group lost <40% airway caliber.

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strating an air-filled esophagus or gastric distention. The fistula may be detected by tracheoscopy after removal or retraction of the tracheostomy tube. The sensitivity of tracheoscopy, however, is low, and negative studies should be followed by a barium-swallow imaging study. Tracheoesophageal fistulae are universally fatal unless surgically repaired.131 Insertion of a long tracheostomy tube with the cuff positioned below the fistula and placement of a jejunostomy for nutrition can stabilize the patient before surgical repair with a single-stage procedure.50,98 Tracheoinnominate fistula is the most feared complication of tracheostomy and occurs in fewer than 1%of patients.20Improper traction on the tracheostomy tube produces tracheal injury at the level of the innominate artery, which crosses the trachea near the tracheostomy cuff or tip. Risk factors for this complication include excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy.30,lo2 Major airway hemorrhage may be heralded by movement of the tracheostomy tube in synchrony with cardiac systole and episodes of minor airway bleeding. Major airway hemorrhage related to a tracheoinnominate fistula may occur first within several days or as long as 7 months after performance of a tracheotomy.lo5,117 Patients with an episode of airway hemorrhage suggestive of a tracheoinnominate fistula should undergo tracheoscopy in an operating room in preparation for an immediate surgical repair if manipulation of the airway initiates massive hemorrhage. Patients who present with major airway hemorrhage require emergency management to avoid asphyxiation. Hyperinflation of the tracheostomy tube cuff or insertion of an endotracheal tube through the stoma may tamponade the bleeding site. Translaryngeal intubation and insertion of a gloved finger into the tracheostomy stoma may allow compression of the innominate artery and control bleeding. Patients require an emergency sternotomy with ligation and resection of the innominate artery, which is invariably infected.143 Tracheocutaneous Fistula

Occasionally, the tracheostomy stoma may fail to close after airway decannulation because the stoma tract has become epithelial-

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ized. Surgical repair may require a muscle flap inserted into the stoma followed by skin clos~re.~, 87 SUMMARY Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.

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Address reprint requests to John E. Heffner, MD Department of Medicine Medical University of South Carolina 96 Jonathan Lucas Street, Suite 812CSB PO Box 250623 Charleston, SC 29425 e-mail: heffnerj8musc.edu