A 58-year-old male who completed radiation therapy for a large supraglottic tumor 4 months ago now presents to the Emergency Department in significant respiratory distress with biphasic stridor. He is somewhat agitated and prefers to remain in a semi-sitting position. He is cachectic, a heavy smoker but nondrinker. He is not taking any medications and has no allergies. His oxygen saturation is 88% on room air and improves to 94% with supplemental oxygen. He is cooperative enough to allow the otolaryngologist to perform a flexible nasopharyngoscopy at the bedside, which reveals extensive supraglottic edema, completely obscuring identification of normal laryngeal landmarks, and any visualization of the upper airway (see Figure 15–1). The otolaryngologist suspects there is recurrent tumor below this edema.

What Is the Historical Evolution of the Development and Acceptance of Surgical Tracheotomy?

Tracheotomy is one of the oldest surgical procedures in recorded history and often viewed historically as intimidating and inherently dangerous to perform. The Italian anatomist and surgeon Fabricius ab Aquapendente (1537–1619) stated, “The terrified surgeons of our times have not dared to exercise this surgery and I also have never performed it. Even the mention of this operation terrifies the surgeons; hence it is called the “scandal of surgery.”¹ Tracheotomy was performed during the diphtheria epidemic in the early 19th century for cases of severe upper airway obstruction. In 1833, Armand Trousseau, a French internist, recounted his experiences with the procedure: “I have now performed the operation in more than 200 cases and I have the satisfaction of knowing that one fourth of these operations were successful.”² Faint praise indeed!

Throughout the 19th and into the early 20th centuries, tracheotomy was employed only in extreme circumstances, in order to avoid total upper airway obstruction from infectious processes involving the larynx and upper trachea. The “modern” technique of tracheotomy was formally presented and described in detail by Chevalier Jackson³ in 1909. Among other pearls, Dr. Jackson emphasized precise surgical technique with adequate exposure, careful hemostasis, and the prevention of damage to the cricoid cartilage. He is generally credited with vastly decreasing the morbidity and mortality of the procedure as well as the long-term complication of subglottic stenosis.

With the introduction of endotracheal intubation, positive pressure ventilation and ongoing advancements in intensive care leading to requirements for long-term ventilation, we have seen a significant shift in the indications for tracheotomy. Some two-thirds of all tracheotomies performed today are now done semi-electively for critically ill patients in an intensive care setting.

While a common procedure, tracheotomy can be one of the most straightforward or one of the most challenging operations to perform. Many factors, both anatomic and disease related, add considerable variability and unique challenges to the same procedure in different patients.

What Are the Clinical Indications and Contraindications to Performing a Tracheotomy?

Indications for a tracheotomy can broadly be divided into four main categories: (1) to relieve upper airway obstruction from either acute or chronic causes; (2) to promote improved pulmonary toilet; (3) to provide an airway access for long-term ventilation; and (4) to promote weaning from the ventilator. Current indications have been summarized by the American Academy of Otolaryngology, Head & Neck Surgery⁴ in the 2000 Clinical Indications Compendium (see Table 15–1). There are very few absolute contraindications provided the practitioner has sufficient and appropriate training in tracheotomy (see Table 15–1).

In This Clinical Situation, Why Would a Tracheotomy be Favored Over a Cricothyrotomy or a Percutaneous Dilational Tracheotomy?

Due to the obstructive nature of this patient’s edema and likely underlying tumor, there is uncertainty regarding its inferior extent, which makes a cricothyrotomy potentially dangerous as there is an increased risk of transecting tumor in this location. With its more inferior entry into the airway, a traditional tracheotomy is hence a safer option to ensure that the airway will be secured below the level of obstruction. With regards to percutaneous tracheotomy techniques, these are always contraindicated in cases where the airway is not already secured (see Chapter 33).

What Are the Options to Secure This Challenging Airway and Provide Oxygenation for This Patient?

Endoscopic visualization of the larynx reveals almost complete airway obstruction due to edema and potential tumor. Given the patient’s current obstructive pathology, the attempted use of bag-mask-ventilation, extraglottic device, or intubation would likely lead to a disastrous outcome for this patient. Any manipulation of such a precarious airway puts the patient at greater risk of complete obstruction. Tracheotomy is the only realistically viable option for this patient. Although the airway is tenuous, he is currently not in extremis, and hence the safest location for the procedure is in the operating theatre.

Should the Tracheotomy be Performed Awake or Under General Anesthesia?

This patient is teetering on the edge of obstructing his airway. A general anesthetic is not the best initial option as there are no viable options to access the airway other than a controlled tracheotomy. An awake look could be performed, but again increases the risk of triggering total upper airway obstruction. In the authors’ opinion, topicalization of the airway in these tenuous circumstances may precipitate immediate complete airway obstruction as the subjective perception of airflow by the patient is essential in maintaining airway patency (see section “Can Topical Lidocaine Anesthesia of the Upper Airway Cause Airway Obstruction?” in Chapter 3).

An awake tracheotomy under local anesthesia in the operating room is the only realistically viable option for this patient.

You Make Arrangements to Take the Patient Urgently to the Operating Room But Are Told There Will be a 20-Minute Delay. What Supplementary Supportive Care Can You Offer This Patient in the Meantime?

There are a variety of supportive steps that can be taken to reduce the risk of total upper airway obstruction without manipulating the airway or upsetting the patient. The importance of this latter point is often underestimated. The increasingly anxious patient is likely to generate higher inspiratory airflow velocity resulting in increased resistance across the obstruction potentially leading to total airway obstruction. This “dynamic airway obstruction” can be seen in a crying newborn due to the pliability of the underlying cartilaginous structures of the larynx, and in inflamed laryngeal tissues as is seen in croup and epiglottitis.

Keeping the patient calm in a sitting position is critical in these situations as upper airway obstruction is a most distressing condition. Hence, the simplest measures, such as constant calm reassuring dialogue with the patient cannot be overemphasized. Likewise, very careful use of low-dose anxiolytics could be entertained though it should be recognized that they may attenuate reflexive active airway opening maneuvers and precipitate total airway obstruction.

Supplemental oxygen is obviously important although it is often better delivered via nasal prongs as a mask can sometimes feel smothering to patients in this situation. The use of heliox, which has a density six times lighter than air by replacing atmospheric nitrogen with helium, will promote a significant reduction in airflow resistance through a narrowed airway (improved “orifice flow”). The decrease in turbulent flow leads to increased airflow by as much as 50% in a narrowed airway.⁵ Aerosolized epinephrine, by way of its mucosal vasoconstrictive effects, may be of some benefit although care must be taken not to aggravate the patient’s anxiety. The use of intravenous corticosteroids, while helpful in the medium term, does not work quickly enough in impending upper airway obstruction.

The Operating Room Is Now Ready and the Patient Has Been Brought Into the OR. How Should You Position and Prepare the Patient for the Tracheotomy?

During a normal routine tracheotomy, the patient should be positioned supine with the neck extended and a shoulder roll placed to elevate the larynx and bring more of the trachea up into the neck out of the chest. This standard position cannot be safely utilized in this case; however, as lying fully recumbent will worsen the airway patency, increase the patient’s anxiety, and will not be tolerated by the patient. Thus, positioning the patient with the upper body reclined from a totally erect position to the extent permitted by the patient’s symptoms will lessen the risk to the airway obstruction while still allowing for reasonable surgical exposure.

When Planning for a Tracheotomy, How Do You Accurately Identify the Critical Landmarks and Prepare the Surgical Site?