Laryngectomy and Tracheostomy

Information you need to know now

• Has the patient had a laryngectomy or tracheostomy?
• Is the upper airway difficult or impossible to manage?
• How old is the tracheostomy?
• Surgical or percutaneous tracheostomy?

4 main types of incisions to create tracheostomy

• Horizontal slit
  • Typically between 2/3 or 3/4^th tracheal rings
  • Silk stay suture can be placed through tracheal wall on each side and tapes to neck skin to facilitate tube replacement by pulling trachea forwards and widening the opening should the tube become dislodged
  • Sutures removed after first tube change at day 5-7 post-op
• Window
  • More permanent option
• Vertical slit
  • Semi-permanent option
  • Absorbable sutures often placed in tracheal flaps and tacked to skin edges to facilitate replacement of dislodged tube
• Bjork flap
  • Ramp of trachea is sutured to the skin allowing easier replacement of tubes
  • The sutures act to hold the flap in place NOT to elevate the trachea for tracheostomy change
  • If these sutures are pulled, may tear the ramp and occlude the stoma

Surgical vs. Percutaneous

• Surgical tracheostomies
  • Established tracts wthin 2-3 days
• Percutaneous tracheostomies
  • Skin and tissues will spring back if tube removed
  • Should ideally not be changed for 7-10 days

Immediate complications

• Haemorrhage
• Misplacement of tube
• Pneumothorax
• Tube occlusion
• Surgical emphysema
• Loss of upper airway
• 10% complication rate of percutaneous vs. 8.7% for surgical tracheostomies

Delayed complications (<7 days)

• Tube blockage (sudden or gradual; blood or secretions)
• Partial or complete tube displacement
• Infection of stoma site
• Infection of bronchial tree (pneumonia)
• Ulceration and/or necrosis of trachea by tube migration
• Risk of occlusion of tracheostomy tube if fatigued/obese and difficulty extending the neck
• Tracheo-oesophageal fistula formation
• Haemorrhage (erosion through blood vessels)

Tracheostomy site infection

• Surgical site infection more common post-surgical tracheostomy (7%) than percutaneous (3.4%)
• May be polymicrobial with most common organisms being S. aureus, Pseudomonas and Candida
• Stable patients can be treated with Augmentin BD
• Unstable patients should receive PipTaz + Vancomycin
• Use a fluoroquinolone for Pseudomonas
• Dressing changes with gauze soaked in 0.25% acetic acid are effective for local wound infections

Tracheostomy site bleeding

• Slow bleeding can be controlled with packing of site with gauze
• Local bleeding may be controlled with silver nitrate
• If bleeding is brisk, replace the tracheostomy tube with a cuffed ET with cuff BELOW bleeding site
• Tracheo-innominate arterial fistula is a rare but life-threatening complication
  • Cuff pressure >25mmHg, tube below 3^rd tracheal ring and deformed neck/chest are all risk factors
  • Usually present within 3 weeks (peaks between week 1 and 2)
  • Some patients may have sentinel arterial bleed or haemoptysis
  • Bleeding may be mild or severe but needs to be thoroughly investigated as subsequent haemorrhage can be fatal
  • Immediate ENT and cardiothoracic surgical consultation is required

Tracheostomy site bleeding

• If massive bleeding
  • Hyperinflate the cuff to control brisk bleeding while planning operative intervention
  • IF bleeding persists, slowly withdraw tube while exerting pressure on anterior trachea
  • If this fails, place a cuffed ET from above past the site of bleeding to prevent pulmonary aspiration of blood and remove tracheostomy as ET passes using fibreoptic bronchoscopy
    • Stomal haemorrhage is then controlled by digital pressure through stoma of the innominate artery against the manubrium (Utley maneuver)
    • Maintain tamponade until operating theatre

Tracheal stenosis

• Treat with oxygen, nebulised adrenaline and steroids

Late complications (>7 days)

• Granulomata of the trachea may cause respiratory difficulty when tube removed
• Tracheal dilation, stenosis, persistent sinus or collapse
  • Risk factors for tracheal stenosis are >1 week duration and tube >7.5mm
• Scar formation
• Blocked tubes can occur at any time
  • Especially if not suctioned/humidified regularly
• Haemorrhage

Physiological changes

• Upper airway anatomical deadspace reduced by 50%
  • Can help facilitate weaning off ventilator
• Loss of natural warming, humidification of air by upper airway
  • Risk of thick and dried secretions – blockage
• Loss of ability to speak
  • Distress, anxiety and complications of speaking valves
• Ability to swallow is adversely effected
  • Cuff limits laryngeal function and laryngeal musculature can become wasted with prolonged disuse
• Sense of taste and smell can be lost
• Altered body image

Equipment

Uncuffed tubes

• With patent upper airway, can breath around tracheostomy tube
• No airway protection
• Cannot provide PPV via tube

Minitrach

• 4mm internal diameter without cuff
• Primarily for airway suction but can facilitate O2 delivery
• Too small to provide ventilation
• Sometimes used prior to decannulation to facilitate suctioning and keep tract open in case tracheostomy tube needs re-insertion

Cuffed tube

• Seals off upper airway preventing breathing around the tube if inflated
• Airway protected
• PPV can be applied
• If tube becomes blocked, patient has no other way to ventilate

Fenestrated tubes

• Have opening on outer cannula to allow air to pass from oropharynx as well as via the tracheostomy
• Air movement allows speech and more effective cough
• Different inner cannulae allow outer hole to be kept patent or blocked
• Increases risk of aspiration
• Suctioning with a fenestrated tube should ONLY be performed with non-fenestrated inner cannula to prevent suction tube rising up into larynx
• Can help train the larynx after prolonged tracheostomy use

Airway red flags

• If cuffed tube
  • Talking, audible air leaks, bubbles of saliva at mouth/nose means cuff is not effective (damaged) or tube tip not correctly sited
  • Grunting
  • Snoring
  • Stridor

Breathing red flags

• Apnoea
• Accessory muscle use
• Tachypnoea
• Higher airway pressures on ventilator
• Lower tidal volumes on ventilator
• Hypoxia
• Whistling noises or noisy breathing

Tracheostomy-specific red flags

• Visibly dislodged tracheostomy tube
  • If adjustable flange, check to see where it was last positioned in notes
• Blood or blood-stained secretions around tube
• Increasing discomfort or pain
• Repeated cuff inflations
  • Damaged or malpositioned requiring hyperinflation to seal off

General red flags

• Anxiety
• Sweating
• Tachycardia
• Hypotension
• Loss of consciousness
• Agitation
• Restless
• Confusion

Tracheostomy management protocol

• Call for help
• Look, listen and feel at mouth and tracheostomy
• Waveform capnography
• High-flow O2 to mouth and tracheostomy
• Remove speaking valve/cap/inner cannula
• Attempt to pass suction catheter
• Deflate the cuff
• Remove the tracheostomy tube (stitch cutters may be required)
• Standard oral airway manoeuvres
  • Cover stoma
  • BVM, oral or nasal airway adjuncts, LMA
  • Tracheostomy STOMA ventilation via paediatric face mask or LMA
• Advanced airway manoevres
  • Attempt oral intubation preparing for difficult airway
  • Attempt intubation of stoma (6.0) with consideration of Aintree/Bougie/fibreoptic scope

Laryngectomy algorithm

• Call for help
• High-flow O2 to laryngectomy stoma
• Most stomas will not have a tube in situ
  • Remove stoma cover/inner tube if present
• Attempt to pass suction catheter
• Deflate the cuff if present
• Remove tube from stoma if present
• Laryngectomy stoma ventilation via paeds face mask or LMA
• Attempt intubation of laryngectomy stoma 6.0 tube with consideration of fibreoptic scope/Aintree/bougie

Changing a tracheostomy tube

• If <7 days old:
  • Tract will not be mature and may easily create false passage
  • Tract may easily collapse if obese or swollen neck
  • Should only be performed by surgeon familiar with procedure
• If >7 days old
  • Patient can breathe through stoma so don’t rush
  • Check cuff if using cuffed tube
  • Cricoid hook can be used to lift and stabilise trachea
  • Use obturator within new tube to prevent hollow tube damaging structures
  • If encounter resistance, can try smaller tube or ET 6.0 but smaller diameter tubes will also be shorter (could be too short for patients neck)

Laryngeal stents

• Solid stents block the airway at the level of the larynx
• Entirely dependent on tracheostomy
• Dislodgement can occur
• T-tubes may require suctioning of both upper and lower limbs
• If fails to resolve obstruction, may have to remove T-tube and replace with traditional tracheostomy or ET tube

Speech valves

• Passy-Muir valves
  • One-way valves that close during forced exhalation to allow air to pass around uncuffed tube and through vocal cords
  • Should NEVER be used with a cuffed tube as patient will NOT be able to exhale
• Tracheo-oesophageal prosthesis
  • Used for laryngectomy patients to allow air to pass 
  • Do NOT remove these in the case of airway obstruction in laryngectomy patients
  • One-way valve surgically placed between posterior tracheal wall and anterior wall of cervical oesophagus
  • Placement of finger over stoma while exhaling forces exhaled air into oesophagus, which vibrates to create sound
  • Complications
    • Leakage due to enlargement of tracheo-oesophageal fistula
      • Increases risk of aspiration pneumonia
      • Temporary solution to this is replacement with Foley catheter
    • Valve aspiration
    • Valve extrusion

Last Updated on August 29, 2024 by Andrew Crofton