critical care medicine
Surgical Airway
Tracheostomy
Tracheostomy is a more complex procedure because the trachea rings are very close together and part of at least one ring usually must be removed to allow tube placement. Tracheostomy is preferably done in an operating room by a surgeon. In emergencies, the procedure has a higher rate of complications than cricothyrotomy and offers no advantage. However, it is the preferred procedure for patients requiring long-term ventilation. Percutaneous tracheostomy is an attractive alternative for mechanically ventilated, critically ill patients. This bedside technique uses skin puncture and dilators to insert a tracheostomy tube. Fiberoptic assistance (within the trachea) is usually used to prevent puncture of the membranous (posterior) trachea and esophagus. Rarely, tracheostomy insertion causes hemorrhage, thyroid damage, pneumothorax, recurrent Vocal Cord Paralysis , injury to major vessels, or late tracheal stenosis at the insertion site. Erosion of the trachea is uncommon. It results more commonly from excessively high cuff pressure. Rarely, hemorrhage from major vessels (eg, innominate artery), fistulas (especially tracheoesophageal), and tracheal stenosis occur. Using high-volume, low-pressure cuffs with tubes of appropriate size and measuring cuff pressure frequently (every 8 hours) to maintain it at<30 cm water decrease the risk of ischemic pressure necrosis, but patients in shock, with low cardiac output, or with sepsis remain especially vulnerable. 