Objectives

1. To recognize the indications for an elective tracheostomy procedure in patients with chronic respiratory failure.
2. To become familiar with the various factors involved in tracheostomy tube selection.
3. To understand the principles of tracheostomy management, in regards to cuff inflation, cleaning, secretions, and humidification.
4. To identify methods to improve speech and nutrition in the patient with a tracheostomy.
5. To recognize the complications involved in a tracheostomy.

Abbreviations

ALS = amyotrophic lateral sclerosis; HME = heat and moisture exchanger; PDT = percutaneous dilatational tracheostomy

Tracheostomy ventilation refers to mechanical ventilation delivered via a cannula placed into the trachea, and it is used mainly in patients who are unable to protect their upper airway or who require invasive mechanical ventilation for more than 21 days. Most patients receiving tracheostomy ventilation are institutionalized, although accurate statistics on numbers and locations of patients using tracheostomy ventilation are lacking.

For most patients, the ideal location for delivery of long-term mechanical ventilation is at home. Compared to skilled nursing homes, home mechanical ventilation is associated with improved patient quality of life and decreased cost of care.¹ However, many patients receiving tracheostomy ventilation are unable to go home because of insufficient resources. Regardless of the location, certain management principles pertain to tracheostomy ventilation care. Focusing on the principles of airway management, the following information reviews the trends in long-term mechanical ventilation, considers selection of patients for home mechanical ventilation, and discusses the choice of a tracheostomy tube, cuff management, humidification, secretion removal, preservation of speech, nutrition, and avoidance of complications. The focus is on adult patients, although many of the principles discussed are applicable to children as well.

Trends in Long-term Mechanical Ventilation

Chevalier Jackson standardized a tracheostomy as a surgical procedure in 1906.² With the improvements in patient survival following critical illness, more patients are potential candidates for receiving tracheostomy ventilation. The number of patients receiving long-term mechanical ventilation at home is estimated to be 10,000 to 20,000.¹ However, several trends have probably decreased the number of patients receiving tracheostomy ventilation at home. One trend is that caregivers are encouraged to discuss mechanical ventilation options for at-risk patients well in advance of respiratory deterioration. Thus, more patients with terminal respiratory conditions may be opting against receiving tracheostomy ventilation and other means of aggressive support.

A second trend has been the increasing use of noninvasive ventilation, thereby reducing the demand for tracheostomy ventilation. Noninvasive ventilation has numerous advantages over invasive mechanical ventilation, including the following: ease of management, greater portability, no need for suctioning, avoidance of tracheostomy complications, and lower cost.^3,4 It is considered to be the ventilatory modality of first choice for chronic respiratory failure, with tracheostomy ventilation reserved for patients who have failed a trial of, or have contraindications to, noninvasive ventilation.¹

Timing of Tracheostomy Placement

Tracheostomy procedures are performed because of two main settings: (1) patients are intubated because of acute respiratory failure with little prospect for weaning, or have failed multiple weaning attempts; and (2) patients with chronic respiratory failure who are poor candidates for, or cannot tolerate, noninvasive ventilation. Tracheostomy ventilation has a number of advantages over translaryngeal intubation, including improved stability, greater comfort, and liberation of the larynx for speech and eating. It also avoids trauma to the teeth, oropharynx, vocal cords, and larynx.⁵ Airway stabilization also allows for the patient to be discharged to non-ICU locations, such as long-term acute care facilities and home. Thus, prompt tracheostomy placement in the critical care setting has the potential to shorten ICU and hospital lengths of stay, thereby reducing health-care costs.

Elective tracheostomies are performed in patients with chronic respiratory failure for several reasons (Table 1). Patients with chronic respiratory or neuromuscular conditions, who are at risk for eventual respiratory failure, should be counseled well in advance of the development of respiratory complications. This allows patients with conditions, such as amyotrophic lateral sclerosis (ALS), <5% of whom eventually receive tracheostomy ventilation, to weigh the options and plan ahead. One survey showed that only 38% of patients with ALS, who had tracheostomy tubes placed without prior consent, would do it again, as opposed to 88% who gave prior consent.⁶

Families should be included in discussions about the patient's options, because much of the burden of caring for a patient receiving tracheostomy ventilation falls on them. Caregivers often suffer from emotional and psychological disorders as a consequence of the enormous time demands and sacrifice of personal life.⁴ In one survey, caregivers rated their life satisfaction as lower than the patients rated their own life satisfaction.⁴ This underlines the importance of counseling, not only for the patients, but also for primary caregivers. Ideally, tracheostomies for chronic respiratory failure should be placed when medically indicated, after patients and families are fully informed, and before the onset of an acute respiratory crisis. Situations where patients are intubated in emergency departments, without ever having been informed of their options, are inexcusable by today's standards.

Selection of Patients To Receive Home Tracheostomy Ventilation

Successful management of patients receiving home mechanical ventilation via a tracheostomy requires careful selection and planning. A caregiver with high motivation and a clear understanding of the demands of supporting a patient receiving tracheostomy ventilation at home is vital. Family members must be willing to subjugate their own desires to those of the patient, often giving up jobs and outside interests. Financial resources and insurance coverage should be adequate to provide adequate caregiver support for the patient and family. The home environment must be wheelchair accessible, with bed and bathroom on the same floor. Ideally, any needed renovations should be completed prior to the patient's discharge. Also, all caregivers should be thoroughly trained in relevant aspects of tracheostomy and ventilator management, as well as the handling of emergencies that may arise. The home site should be inspected prior to patient discharge to ensure that the environment is safe and that all requisite equipment is functioning properly. Home health-care personnel should also be identified and in place.

Patients prepared for home mechanical ventilation often lead productive lives with a good quality of life.⁷ They report satisfactory levels of psychosocial functioning, good quality of sleep, and mental well-being that compares favorably with that of the general population.⁸ Unfortunately, not all patients are candidates for home treatment because of a variety of reasons (Table 2). Often, the lack of adequate resources keeps people institutionalized, because some third-party payers, particularly Medicare and Medicaid, limit reimbursement for home-care services.

Techniques of Tracheostomy Placement

Until recently, surgical tracheostomy was the standard technique for placement. In recent years, percutaneous dilatational tracheostomy (PDT), first described by Ciaglia⁹ in 1985, has gained in popularity due to a number of advantages over the surgical tracheostomy procedure. In prospective randomized trials, PDT resulted in lower rates of stomal infection and tracheal stenosis, as compared to surgical tracheostomy.¹⁰ One meta-analysis observed that, although percutaneous tracheostomies were associated with more perioperative complications, including episodes of hypoxemia, aspiration, and local bleeding, postoperative complications, including peristomal bleeding and infections, were reduced.¹¹ A second meta-analysis found that both perioperative and postoperative complications were reduced, with an odds ratio of 0.15 for all complications.¹²

Patients with significant aspiration difficulties continue to have some aspiration even after placement of a tracheostomy tube, despite cuff inflation. If the patient is aphasic, conservative laryngectomy or laryngeal diversion techniques may be preferred.¹³ These procedures may leave a small pouch after the removal of the larynx or divert the larynx into the esophagus for better drainage. The former approach requires less surgery and may be preferred in ALS patients with advanced disease, but it may be more prone to pouch infection and fistula formation.

Selection of a Tracheostomy Tube

A myriad of tracheostomy tubes are available in different shapes and sizes, most often made of hard or soft plastic. Metal tracheostomy tubes were used for long-term applications in the past, but they are used less commonly now, largely because of the expense and difficulty of manufacturing them with durable cuffs. Although rigid plastic tubes are often chosen for hospital applications, more flexible shafts may be preferable, because they are less apt to traumatize the tracheal walls.

Size

When determining the size of a tracheostomy tube, a number of factors must be considered (Table 3). Body habitus is important, with taller patients and men receiving larger diameter tubes, allowing for individual variation. Typical initial internal tube diameters range from 6 to 8 mm, with transitions to smaller sizes (around 4 mm) as weaning progresses and speech and swallowing improve. The incidence of tracheal stenosis is reduced with smaller outer cannula diameter. An understanding of basic, physical, airway properties is important in the selection of tube diameter. Greater resistance to airflow through the tube will occur with a smaller diameter. However, when patients are weaning or speaking, a smaller caliber tube will permit increased airflow around the tube. For prolonged mechanical ventilation, patients may start with a larger tube to permit easier ventilation and suctioning. Larger tubes also restrict movement of the larynx against the epiglottis, thus protecting the lungs from potential aspiration when swallowing. As weaning of the patient progresses, or the patient becomes stable for transfer to a long-term facility or home, transition to a smaller tube may be more beneficial.

Tube length is also important, although most patients adapt well to standard-length tubes. Patients who are morbidly obese and have thick necks often need extra-long tubes or even a standard endotracheal tube inserted into the stoma until a custom tube can be obtained. Extra-long tubes may also be useful to bypass areas of tracheal wall injury related to prior intubation. Airways that have been distorted or shifted due to tumors, kyphoscoliosis, or lung surgeries pose particular challenges. A "hyperflex," a specialized wire-reinforced artificial airway that is available in a various lengths and cuff sizes, should be considered in these situations because of its ability to gently follow any curve.

Cuffs

Tracheostomy tube cuffs seal against the tracheal wall and prevent leakage of air around the tube, assuring that the tidal volume is delivered to the lungs. In the past, high-pressure cuffs were used, but these contributed to tracheal injury and have been replaced by high-volume, low-pressure cuffs. For long-term applications, some newer tubes have low-profile (tight to shaft) cuffs that facilitate the tracheostomy tube changes by eliminating the lip that forms when standard cuffs are deflated. Foam rubber-filled cuffs (Fome-cuff; Smiths Group-Bivona Medical Technologies; Keene, NH) may achieve an air seal at a lower pressure and may be preferred in patients who have already suffered a tracheal injury from an overinflated cuff. For unusual situations, customized tracheostomy tubes can be designed with cuffs made of different materials, in various locations, or even multiple cuffs.

Inner Cannulas

Some tracheostomy tubes consist of an inner and outer cannula. The inner cannula can be easily removed for cleaning and to clear obstructions. However, inner cannulas reduce the inner diameter of the tube for any given outer diameter, increasing airway resistance and may necessitate a tube with a larger outer diameter than would otherwise be needed.¹⁴ Inner cannulas may complicate tube management, because with some tubes (ie, Shiley Tracheostomy Tube; Mallinckrodt [UK] Ltd), the inner cannula must be in place in order for the tube to be connected to the ventilator. Caregivers must be trained to always have a backup inner cannula readily available in case of emergency.

Fenestrations

Fenestrated tubes have single or multiple openings located on the outer curve of the tube. When the tube is intentionally capped with a plastic cap that occludes the proximal opening and any nonfenestrated inner cannula has been removed, the fenestrations permit air to flow through the lumen of the tube and into the larynx, theoretically, reducing resistance to airflow (Fig 1).¹⁵ This can facilitate speech and reduce dyspnea related to the work of breathing. Thus, fenestrated tubes are often placed when patients are being weaned or when the tube is capped for extended periods of time. However, few systematic data are available to show that fenestrations actually achieve these advantages, and these tubes also have disadvantages. They are often improperly positioned so that the fenestration is occluded against the posterior wall of the trachea or in the stoma, preventing air from flowing through the fenestration. Furthermore, granulation tissue can grow into the fenestration, causing blockage, irritation, bleeding, or tracheal stenosis.¹⁶ When patients are progressing with weaning, transition to a smaller diameter tube may be preferable to a fenestrated tube.

Tracheostomy Management

Tracheostomy Tube and Stoma Care

The stoma site should be examined daily for secretions, signs of infection, and encrustation of the external surface of the tracheostomy tube and should be cleaned using a 50% hydrogen peroxide solution and saline solution or similar cleansing solution.¹⁷ Inner cannulas, if used, should be cleaned in hydrogen peroxide solution daily.¹⁸ Metal tubes may require brushing to remove encrusted debris. A drain sponge is inserted under the tracheostomy flange and replaced daily, or more often if secretions are heavy. The tracheostomy collar should also be inspected daily for excessive wear and to assure that it is not traumatizing the skin; it should be changed, as needed, to ensure cleanliness.

Tube Changes

The recommended frequency of tube changes is unclear based on current evidence. Commonly, tubes are changed if there is a malfunction, if a different type of tube is needed, or if the tube is grossly dirty. An observational study showed a significant decrease in the need for surgical intervention for granulation tissue at the stoma or in the trachea if tubes were changed every 2 weeks.¹⁹

Replacing tracheostomy tubes entails risks, including bleeding, inability to reinsert the tube, and insertion into a false passage, such as the mediastinum.²⁰ These complications are much more common during the initial tube changes and occur less often as the stomal tract matures.²⁰ Tubes with cuffs should be replaced more frequently (every 4 to 12 weeks) than cuffless tubes (every 3 to 6 months). Noncustom fenestrated tubes should also be changed more frequently to avoid granulation tissue growth in the area of the fenestration. Tube changes in patients requiring continuous mechanical ventilation must be done cautiously to avoid potential catastrophes. Advance preparation with appropriate staff and equipment is advisable. A tracheal tube changer can be passed through the tube lumen and allow for oxygenation while a new tube is exchanged over it. A suction catheter, an artificial resuscitator (Ambu type Bag; Narang Enterprises, New Delhi, India), and a smaller size tube should be readily available.

Cuff Management

Monitoring Cuff Pressure and Volume

Tracheostomy tube cuff volumes and pressures require constant monitoring to avoid tracheal injury. Past literature recommended routine inflation and deflation of cuffs every few hours, but this has not been shown to reduce the risk of tracheal injury and, actually, increases the risk for aspiration.^21,22 Because cuff pressures > 30 cm H₂O compress mucosal capillaries and impair blood flow, with total occlusion occurring at 50 cm H₂O,^23,24 it is generally recommended that cuff pressures do not exceed 20 cm H₂O. However, monitoring cuff pressure alone is insufficient, because tracheal damage and increases in cuff volume can occur even when cuff pressures are maintained within the desired range. Cuff volumes should not exceed 6 to 8 mL, ideally, and the need to inflate the cuff to > 10 mL should raise concerns about tracheal injury.¹

The measurement of cuff pressures in an institutionalized setting is best achieved using a sphygmomanometer or a specially designed pressure meter connected to the cuff tubing.^21,25 However, constant monitoring and pressure measurements at home may be difficult to achieve. The use of finger palpation of the external pilot balloon to estimate cuff pressure is inaccurate and should be discouraged.²⁶ Patients at home receiving mechanical ventilation may require cuff monitoring if problems relate to aspiration during mechanical ventilation or if concerns arise regarding excessive cuff volume or a cuff leak. Cuff volume is easily monitored by withdrawing air from the cuff into a syringe every few days. Inflation and deflation of the cuff should done be slowly, as sudden changes will often generate a coughing spasm.

Cuff Inflation Techniques

A number of techniques have been developed to assure proper cuff inflation. The minimal occlusive volume technique inflates the tracheostomy cuff to the minimal volume required to eliminate leaks at the end of inspiration. This assures that the set tidal volume is delivered in ventilator-dependent patients and helping to minimize tube movement; this may also reduce the incidence of aspiration.²⁷ However, it may be difficult to ascertain that the occlusive volume is truly minimal using this technique, and the risk of tracheal injury may be higher than with other techniques.

For this reason, authors favor the minimal-leak technique that inflates the cuff until there is a residual, minimal leak at end-inspiration that does not significantly reduce the delivered tidal volume. Potential advantages of this technique include reduced risk of cuff overinflation and less tracheal injury. Consistent with these advantages, cuff pressures are higher using the minimal occlusive volume strategy compared to the minimal-leak technique.²⁸ However, the minimal-leak technique may increase the risk of aspiration from upper airway secretions. Thus, there is no consensus regarding which strategy is superior, and both have been recommended.^1,22,25 Because of the reduced risk of tracheal trauma and infection, cuffless tracheostomy tubes are preferred to inflated cuffs for patients who can be adequately ventilated with them.

Secretion Management

Effective clearance of secretions is very important in order for tracheostomy ventilation to minimize airway resistance, maintain gas exchange, reduce the risk of infection, and prevent morbidity. Endotracheal trauma, related to the tube and cuff, impairs mucociliary clearance, and most patients who have tracheostomy procedures have some degree of cough dysfunction.²⁹ Tracheostomy tubes facilitate secretion removal by providing direct access to the lower respiratory tract, but routine and frequent suctioning is not recommended.²⁹ Suction catheters traumatize airway mucosa, contributing to airway inflammation and hemorrhage and potentially increasing secretion production, as well as the risk of infection. When suctioning is necessary, it should be performed as gently as possible, with the suction catheter remaining within the tracheostomy tube, if possible. If deep suctioning beyond the tube tip is necessary, the catheter should be advanced gently, and suction should be applied only during withdrawal of the catheter. Red rubber catheters are softer than polyethylene catheters and may reduce airway trauma.

Natural coughing avoids the introduction of a foreign body into the airway and may be the most desirable way to clear secretions, even with a tracheostomy tube in place. However, few patients can cough effectively with an unplugged tracheostomy tube in place because of the inability to compress air using the glottis and direct interference by the tube protruding into the trachea. Some techniques, such as manually assisted coughing or mechanical insufflation-exsufflation, can enhance cough effectiveness and potentially reduce the need for suctioning. Whether performed in the presence of a tracheostomy or not, both techniques increase peak cough flow rates over those achieved during unassisted coughing in patients with weakened cough muscles. The combination of the two techniques achieves almost a fourfold increase over rates achieved during unassisted coughing.³⁰ The in-exsufflator (CoughAssist, JH Emerson Co; Cambridge, MA) insufflates the lungs with positive pressures set to 30 to 40 cm H₂O for approximately 2 s. The pressure is then abruptly switched to an equal, negative pressure, simulating airflows during a normal cough.¹ Applied via a tracheostomy tube, cough in-exsufflation reduces the need for suctioning and is preferred by many patients.³¹ A small prospective study showed more improvement in oxygen saturation, peak inspiratory pressures, and mean airway pressures in ALS patients treated with in-exsufflation vs suctioning alone.³²

Humidification

Because tracheostomies bypass the air conditioning functions of the upper airway, humidification and warming of inspired air are important during tracheostomy ventilation to prevent mucosal desiccation and crusting of secretions. Heated pass-over and pass-through humidifiers force inspired gas over or through a heated water bath, humidifying by means of evaporation. Heat and moisture exchangers (HMEs), or artificial noses, are passive humidifiers that trap a portion of the heat and humidity as air passes through them during expiration and return that portion to the inspired air during the next breathing cycle. Heated active humidifiers provide higher temperatures and humidity levels than HMEs and are preferred for patients who require long-term tracheostomy ventilation.¹ Newer HMEs provide better moisture levels than earlier versions, but studies and recommendations regarding long-term ventilation are lacking. HMEs facilitate patient mobility and are a good choice for short periods of time when traveling (less than 12 h) or for active patients with minimal secretions.¹

Preservation of Speech

The ability to speak is associated with an improved quality of life during long-term mechanical ventilation. 33 With the exception of patients unable to vocalize because of severe bulbar dysfunction or other reasons, every effort should be made to enable chronically ventilated patients to speak. The expertise of speech and respiratory therapists should be sought in the evaluation and treatment of such patients. Several different methods can be used to enable speech in chronically ventilated patients, including equipment modifications and ventilator adjustments.

Patients who require continuous ventilation can speak if the cuff can be deflated sufficiently to allow a large air leak through the larynx and ventilator tidal volume is increased to compensate for the leak. Some patients are sufficiently tolerant of leaks to use cuffless tracheostomy tubes. Speech during mechanical ventilation is timed to the inspiratory cycle and is related to the tracheal pressure generated during the inspiratory phase. Upon expiration, the tracheal pressure rapidly drops and speech ceases. Speaking is characterized by short phrases, poor voice quality, and volume and long pauses during expiratory cycles.³⁴ Increases in the inspiratory time and the addition of positive end-expiratory pressure may improve speech quality, timing, and articulation, while shortening the gaps between speech segments.³⁴ In a small study of neuromuscular patients receiving tracheostomy ventilation that compared the effects of different ventilator modes on speech quality, bilevel positive-pressure ventilation increased speech duration by extending it into expiration as compared to the assist/control mode.³⁵

Patients who can tolerate periods of unassisted breathing can speak when the cuff is deflated or with the use of a fenestrated tracheostomy tube.³⁶ Upon discontinuation of ventilatory assistance, the inner cannula (if present) is removed, the cuff is deflated, and the tube is capped. Depending on the patient's spontaneous breathing capacity, this allows virtually normal speech. Unfortunately, most patients who are unable to wean long-term tracheostomy ventilation tolerate, at most, brief periods with the tube capped.

When patients cannot tolerate capping of the tracheostomy tube, a variety of speaking valves (Passy-Muir Valve; Passy-Muir Inc; Irvine, CA) can be used to facilitate speech. These consist of one-way flap valves that allow inspiratory airflow through the tracheostomy tube but prevent flow through the tube during exhalation. Expired air flows around the deflated cuff (which is mandatory) and through the vocal cords.³⁷ Speaking valves improve speech quality and increase tidal volume by an average of 50%, compared to breathing through the tracheostomy tube prior to cuff deflation.³⁸ When inserted into the ventilator circuit during mechanical ventilation with the cuff deflated, speaking valves restore speech and improve the emotional and motivational status of ventilator-dependent patients.³⁸

Speaking tracheostomy tubes can be used to restore speech in patients who are incapable of ventilator-free breathing and cannot tolerate in-line speaking valves.³⁹ These dual channel tubes have one standard channel to deliver ventilation beyond the cuff and a second that terminates just above the cuff with several openings on the outside wall of the tube. This channel directs compressed gas through the larynx (Fig 2).^39-41 The patient manipulates a thumb-operated valve to modulate airflow through the compressed gas channel. With practice, relatively normal patterns of speech can be achieved. In the authors' experience, mastery of these valves requires an alert and motivated patient with good manual dexterity and a minimum of oral secretions. In patients with intact upper airway function, a solution can almost always be found to enable speech, but it may be necessary to try a number of different methods.

Preservation of Swallowing

As with speech, the ability to eat orally is an important facet of quality of life for chronically ventilated patients. Furthermore, good nutrition is critically important in the long-term success of tracheostomy ventilation, serving an important role in sustaining respiratory drive, muscle mass and strength, gut mucosal integrity, and immunity. Unfortunately, tracheostomy tubes complicate the swallowing process and predispose to aspiration. Improper cuff inflation and sizing can also predispose to aspiration. Nearly 50% of patients who have tracheostomies aspirate when studied by video fluoroscopy, with the incidence even higher in older patients.⁴² Most of the episodes (77% in one study)⁴² are silent, and even repeated episodes may escape the notice of caregivers. Aspiration and the incidence of ventilator-associated pneumonia can be greatly reduced by maintenance of the semirecumbent position at 45 ° of head elevation.^43,44 Also, speaking valves have been shown to reduce the occurrence of aspiration.⁴⁵

Swallowing should be carefully evaluated prior to the initiation of any oral feeds. The tracheostomy tube interferes with glottic closure by preventing normal upward laryngeal motion during swallowing. It also blunts upper airway sensation and impairs cough efficacy, enhancing the potential complications of aspiration.^45,46 Cuffed tracheostomy tubes do not prevent aspiration and may intensify swallowing difficulties by compressing the esophagus. Also, by permitting secretions to pool above the inflated cuff that are then released as a bolus upon deflation, cuffs may even contribute to the development of pneumonia.

The Evan's colored dye test is a specific, but relatively insensitive (only 38%), screening tool for aspiration.⁴⁷ Videofluoroscopic and endoscopic examinations during both cuff inflation and deflation are much more sensitive for detecting swallowing abnormalities.^47,48 Instructions on positioning the head properly, training on swallowing technique, and using a soft mechanical diet may reduce the occurrence of aspiration. Some degree of aspiration may be inevitable but is not an absolute contraindication to oral feeding.

When patients are cleared for swallowing trials, oral feedings are often begun using custards with the cuff inflated. If no excessive aspiration is noted, feedings are advanced to clear liquids and solid foods, as tolerated, and, eventually, with the cuff deflated. If no significant problems are encountered, patients are encouraged to advance to a full diet, consuming all of their nutritional needs orally. If aspiration or repeated swallowing-associated oxygen desaturations or pneumonias are encountered, nutrition via a gastric tube may be necessary.

Long-term Complications of Tracheostomy

Complications of translaryngeal airways are related to trauma during insertion, prolonged translaryngeal intubation, or abnormal healing of injured airway mucosa.² Tracheostomies eliminate the laryngeal injury, but reported complication rates associated with tracheostomy run as high as 65%.^2,49 The most common complications are airway injuries, but the stoma is also commonly affected. Infection, bleeding, and poor wound healing can occur at the stoma site, and granulation tissue may partially occlude the orifice, contributing to pain, inflammation, and bleeding. Airway complications include tracheal stenosis, fistulas, tracheal dilatation, and tracheomalacia. A study followed 259 patients with COPD, receiving long-term tracheostomy ventilation at home, some for more than 10 years, with observed pneumothorax in 6%, home ventilator failure in 4%, tracheal stenosis in 4%, and tracheal granulomas in 4%.⁵⁰ Patients with cuffed tubes had higher complication rates than those with uncuffed tubes (18% vs 9%).⁵⁰

Tracheal stenosis occurs in response to tube-related trauma at various levels of the trachea, including the suprastomal area, the stoma itself, the tube cuff, and the distal tip of the tube tip. The cuff site was, at one time, a common location for stenosis, but after the advent of low-pressure, high-volume cuffs for both endotracheal and tracheostomy tubes, the stoma site is now more frequently affected.^2,51 In the critical care setting, tracheal stenosis occurs in 0 to 16% of patients who have tracheostomies, with higher rates occurring after surgical tracheostomies are performed, as compared to PDT. The incidence in patients who require long-term ventilation is unknown because of a lack of studies performed. Patients are usually asymptomatic until the tracheal diameter is reduced to less than 5 mm, at which time they may present with dyspnea, cough, stridor, and inability to clear secretions. These symptoms may not be apparent until trials with speaking valves and full capping are undertaken.

Patients who present with stridor should be evaluated for vocal cord dysfunction, tracheal stenosis and malacia, and a tube that excessively blocks the trachea despite cuff deflation. Measures to prevent tracheal stenosis include the inflation of cuffs, when necessary; maintenance of intracuff pressures <20 cm H₂O, using properly sized tracheostomy tubes; and avoidance of excessive pressure of the tube tip on either the anterior or posterior tracheal wall.⁵² Tracheal stenosis can be treated with dilatation, laser therapy, extra-long tracheostomy tubes to bypass the stenotic area, or endotracheal stents.

Tracheoesophageal fistula is a catastrophic, but rare, complication that occurs in less than 1% of patients who have tracheostomies.^2,50 It occurs if excessive pressure from the tube cuff causes necrosis of the tracheal and esophageal walls. Excessive suctioning through an improperly sized tube can also contribute to fistula formation. Clinical signs include coughing after eating and drinking, gastric distention, rushing abdominal sounds in synchrony with the ventilator, pneumonia, and increased tracheal secretions. Surgical repair is the treatment of choice, but stents have also been successful.^52,53 Inserting a longer tracheostomy tube with the cuff positioned beyond the fistula can temporarily stabilize the patient. Unfortunately, many patients who have tracheoesophageal fistulas succumb to sepsis deriving from mediastinal infection.

The most feared complication of tracheostomy is tracheoinnominate fistula, which is very rare and also occurs in less than 1% of patients.^2,49 This most commonly occurs at the stomal site but can also occur from high-pressure cuffs that erode into the innominate artery.⁴⁹ Tracheoinnominate fistula most often presents as bleeding around the tracheostomy site but can include massive hemoptysis. Another sign is a visibly pulsating tracheostomy tube in sequence with the pulse rate. This indicates that some portion of the tube rests against an artery. Risk factors include low placement of tracheostomy, high-pressure cuffs, excessive tube movement, and excessive head movement.⁵² Immediate treatment requires compression of the innominate artery, either digitally or with an overinflated cuff, but airway obstruction and exsanguinations are common sequelae. If bleeding can be controlled, surgical intervention may be successful.

Patients who have long-term tracheostomies are at increased risk of developing respiratory infections, with patients requiring long-term mechanical ventilation at the highest risk. Patients who have tracheostomies are frequently infected with enteric Gram-negative organisms, pseudomonas, staphylococcal species, and acinetobacter and are at risk for tracheobronchitis and pneumonia. However, the rates of pneumonia in noninstitutionalized patients receiving long-term tracheostomy ventilation at home appear to be lower than those of institutionalized patients.⁵⁴ Rates of lower airway infection are probably lowered by avoidance of deep suctioning and switching from tracheostomy to noninvasive ventilation, if feasible.³¹

Conclusions

References

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