Anesthesia for tracheostomy

INTRODUCTION — A tracheostomy is a surgical opening into the trachea performed to bypass pathology that compromises upper airway patency or to provide access for ventilation support by creating a tracheal stoma with insertion of a tracheostomy tube (cuffed or uncuffed) below the larynx.

This topic will discuss anesthetic management for adult patients undergoing elective or emergency tracheostomy.

Other topics address anesthetic management of more complex tracheal surgical procedures:

●(See "Anesthesia for endotracheal stenting or repair of tracheoesophageal fistula".)

●(See "Anesthesia for tracheal resection and reconstruction".)

OPEN TRACHEOSTOMY

Preoperative assessment — The reasons for requiring open tracheostomy are assessed. This is typically an elective procedure performed for one of the following indications (see "Tracheostomy: Rationale, indications, and contraindications", section on 'Indications'):

●Need for prolonged intubation. Tracheostomy facilitates airway management in a currently intubated patient who requires prolonged ventilator support due to respiratory failure or for other conditions requiring airway protection [1].

However, this elective procedure is postponed in patients who are hemodynamically unstable and cannot be safely transported from the intensive care unit (ICU) to the operating room (OR) due to hemodynamic instability. Considerations for transport of intubated patients are discussed in a separate topic. (See "Transport of surgical patients", section on 'Considerations for critically ill patients'.)

●Anticipated airway compromise. Elective tracheostomy may be performed if airway compromise at or above the vocal cords is likely to develop due to existing tracheal pathology, as an expected result of planned surgery, or for expected progress of disease, particularly if worsening difficulty with endotracheal intubation is anticipated.

The patient's history and current disease status, airway anatomy, and patency of the trachea and esophagus are also assessed.

If the patient is not intubated, the risk of airway loss or aspiration of gastric contents after induction of general anesthesia are assessed, as discussed in a separate topic. (See "Anesthesia for tracheal resection and reconstruction", section on 'Preanesthetic assessment'.)

If the patient has an endotracheal tube (ETT) or another airway device in place, adequate function of that device is assessed (eg, cuff integrity of the ETT).

Preoperative preparation — Before beginning the procedure, the anesthesia clinician must understand the plan for airway management and confirm availability of various airway devices that may be needed. An array of ETTs of various sizes and a supraglottic airway (SGA) of appropriate size should be available to manage temporary loss of the airway that may occur during the procedure. Appropriate devices should be available to accommodate the surgical plan for insertion of a new or replacement tracheostomy device. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tube types'.)

Also, a flexible intubating scope (FIS) of appropriate size that will fit through the smallest size ETT or tracheostomy tube that might be selected should be available and set up, with functionality checked. This is critically important in the following situations (see 'Prevention and management of intraoperative complications' below):

●If correct positioning of the tracheostomy tube is uncertain after insertion, flexible bronchoscopy is used to verify its position within the trachea before initiating controlled ventilation to avoid exacerbating complications of malpositioning.

●If the airway is lost during the procedure due to accidental extubation, bronchoscopic guidance may be used to reinsert an ETT into the trachea over the bronchoscope.

Anesthetic techniques

Selection of anesthetic technique — If a tracheostomy is necessary due to existing or impending upper airway compromise above the vocal cords, then the choice between local versus general anesthesia is based on the likelihood that the airway would be lost as the patient becomes sedated or anesthetized:

●For patients who are already intubated or if upper airway anatomy allows for reliable visualization of the vocal cords and unhindered insertion of an appropriately sized ETT, then general anesthesia is often preferred.

●If oral access to the airway is worrisome or unreliable, then local anesthesia is usually selected rather than general anesthesia.

Management of general anesthesia — When general anesthesia is selected, the ETT can be inserted after anesthetic induction in most cases; then the surgeon may proceed with the tracheostomy.

Maintenance of general anesthesia involves continuing or adjusting baseline intravenous (IV) sedative-analgesic agents and/or adding additional anesthetic agents as necessary during noxious airway stimuli. The surgeon may use local anesthesia in the surgical field to supplement the effects of anesthetic agents.

We avoid use of the potent volatile inhalation agents during much of the procedure for the following reasons:

●During periods when the trachea is surgically opened, inhalation anesthetics escape, with consequent pollution of the OR.

●Anesthetic delivery of an inhalation agent will be compromised during each tracheal suctioning.

●Increased doses of vasopressor or inotropic infusions may be necessary to counteract the effects of a potent volatile inhalation agent used to increase anesthetic depth during noxious airway stimulation in a critically ill patient with hemodynamic instability. (See "Inhalation anesthetic agents: Clinical effects and uses", section on 'Cardiovascular effects'.)

A neuromuscular blocking agent (NMBA) is typically administered, particularly if the surgeon requests complete paralysis to minimize risk of accidental extubation in a patient with a difficult airway, or to minimize coughing in a patient with novel coronavirus disease 2019 (COVID-19) infection. (See 'Prevention and management of intraoperative complications' below and 'Tracheostomy in COVID-19 patients' below.)

In selected patients with anatomic or surgical challenges, NMBAs are withheld after discussion with the surgeon so that spontaneous ventilation can be maintained.

Management of local anesthesia — Preprocedure doses of local anesthetic may be administered by either the anesthesia or the surgical team. Local anesthetic techniques include use of aerosolized and ointment preparations of topical anesthetic (see "Awake tracheal intubation", section on 'Topical anesthesia'), transtracheal injection (see "Awake tracheal intubation", section on 'Trachea (transtracheal injection)'), and specific nerve blocks (glossopharyngeal and superior laryngeal nerve blocks) (see "Awake tracheal intubation", section on 'Nerve blocks').

Additional local anesthetic should be available on the field so that the surgeon may augment the blocks, if this becomes necessary during the procedure.

Administration of additional sedative or anesthetic agent (eg, dexmedetomidine) to supplement the local anesthesia techniques is guided by patient-related considerations and preferences of the anesthesia provider. The goal is a comfortable patient who is cooperative and possibly sedated but breathing spontaneously and not moving. (See "Monitored anesthesia care in adults", section on 'Drugs used for sedation and analgesia for monitored anesthesia care'.)

Procedural considerations — The surgical approach is midline at the neck approximately midway between the cricoid cartilage and the sternal notch, usually through the second and third tracheal rings. The patient is placed in the supine position with the upper back slightly elevated and the head extended to stabilize the trachea and improve surgical exposure. Subsequent surgical techniques are described in a separate topic. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tracheostomy techniques'.)

Clear communication with the surgeon is necessary, particularly while pulling back the ETT to allow insertion of a tracheostomy tube. The integrity of the patient's in situ ETT cuff is maintained throughout this process in case it becomes necessary to readvance this ETT to ventilate the patient. Clear communication is also necessary during connection of the new tracheostomy tube to the anesthesia breathing circuit to verify adequacy of ventilation via the new airway device.

Accidental premature extubation can occur before placement of the tracheostomy tube, or if initial attempts to position the tracheostomy tube are unsuccessful. This complication can be minimized by adequate neuromuscular blockade to prevent patient movement and coughing (see 'Management of general anesthesia' above). If the airway is lost, ventilation can be resumed via the original ETT, via the new tracheostomy tube, or by inserting a new ETT using bronchoscopic guidance if necessary. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Loss of the airway'.)

After the surgeon has inserted the tracheostomy tube, if correct positioning is uncertain, flexible bronchoscopy is used to verify its position within the trachea before initiating controlled ventilation. Ventilating the wrong space can distort anatomy and impede surgical correction of tube placement. Furthermore, if the tracheostomy tube is malpositioned into a false passage situated anterior to the trachea rather than into the lumen of the trachea itself, initiating ventilation may create a pneumothorax or pneumomediastinum. Management of this complication is presented separately. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Pneumothorax/pneumomediastinum from a false tract'.)

Prevention and management of intraoperative complications — Bleeding is the most common intraoperative surgical complication. Other possible complications include loss of the airway, creation of pneumothorax or pneumomediastinum due to malpositioning of the tracheostomy tube, tracheal ring fracture, and esophageal perforation. Prevention and management of these complications are discussed separately. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Intraoperative complications'.)

Also, risk for airway fire is high, particularly if supplemental oxygen is delivered via an open system such as a facemask or nasal cannula in an unintubated patient while an electrosurgery unit (ESU) is in use. Prevention of airway fire is discussed separately. (See "Fire safety in the operating room", section on 'Special precautions during airway surgery'.)

Postprocedure considerations — Considerations for transport of critically ill patients from the OR back to an ICU are discussed separately. (See "Transport of surgical patients", section on 'Considerations for critically ill patients'.)

Postoperative pain after a small transverse cervical incision is typically minimal. Management is discussed separately. (See "Anesthesia for tracheal resection and reconstruction", section on 'Postoperative pain management'.)

PERCUTANEOUS TRACHEOSTOMY — Percutaneous tracheostomy is performed between the second and fourth tracheal rings, with sequential dilations over a guide wire to allow for transcutaneous placement of a small diameter tracheostomy tube [2,3]. A modified technique employing a tube exchanger has been employed [4]. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Percutaneous'.)

Typically, this procedure is performed under local anesthesia in a patient who is already receiving sedative and/or analgesic agents (see 'Management of local anesthesia' above), supplemented with administration of additional anesthetic agents as necessary. Also, a short-acting neuromuscular blocking agent (NMBA) is given to prevent movement and coughing. Notably, airway loss is more likely during percutaneous compared with open tracheostomy, particularly if coughing occurs during the procedure in a patient who is not adequately paralyzed. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Loss of the airway'.)

The procedure is often performed at the bedside in the intensive care unit (ICU) to avoid risks of transporting a critically ill patient to the operating room (OR) for open tracheostomy. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Selecting percutaneous versus operative'.)

Other considerations regarding perioperative management are similar to those for open tracheostomy. (See 'Open tracheostomy' above.)

EMERGENCY TRACHEOSTOMY FOR CRITICAL AIRWAY OCCLUSION — Rarely, emergency surgical entry directly into the subglottic larynx (ie, cricothyrotomy) may be necessary if critical airway occlusion at or above the vocal cords develops with rapid onset. Indications and details regarding technical aspects for this procedure are discussed separately. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

TRACHEOSTOMY IN COVID-19 PATIENTS — Tracheostomy may facilitate the management of selected patients with COVID-19 who develop severe respiratory failure requiring prolonged mechanical ventilation [5]. Indications and timing for performance of the procedure are discussed separately. (See "COVID-19: Management of the intubated adult", section on 'Tracheostomy'.)

Tracheostomy (open or percutaneous) is an aerosol-generating procedure with potentially increased risk for viral transmission due to aerosolization of oropharyngeal and tracheal secretions, particularly if the patient coughs [6-9]. Adequate levels of a neuromuscular blocking agent (NMBA) are typically administered to avoid coughing. Other key principles for perioperative management of patients with COVID-19 during tracheostomy are addressed in sections of a separate topic [5-11]:

●Prevention of infection transmission to anesthesia and other personnel – (See "Overview of infection control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg, COVID-19)'.)

●Prevention of contamination of anesthesia equipment – (See "Overview of infection control during anesthetic care", section on 'Prevention of contamination of anesthesia machines and equipment'.)

●Precautions during patient transport back to an intensive care unit (ICU) – (See "Overview of infection control during anesthetic care", section on 'Precautions during patient transport'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Weaning from mechanical ventilation" and "Society guideline links: Airway management in adults".)

SUMMARY AND RECOMMENDATIONS

●Open tracheostomy

•Preoperative assessment – Open tracheostomy is usually an elective procedure. Preoperative assessment includes reasons for the procedure (eg, facilitation of airway management in an intubated patient requiring prolonged ventilator support, impending development of airway compromise at or above the vocal cords), patient history and current disease status, airway anatomy, patency of the trachea and esophagus, and risk of airway loss or aspiration of gastric contents after induction of general anesthesia. (See 'Preoperative assessment' above.)

•Preoperative preparation – Plans for airway management and availability of various airway devices that may be needed are confirmed including endotracheal tubes (ETTs) of various sizes and a supraglottic airway (SGA) of appropriate size. Also, a flexible intubating scope (FIS) of appropriate size that will fit through the smallest size ETT or tracheostomy tube that might be selected should be available. (See 'Preoperative preparation' above.)

•Anesthetic techniques

-Selection of anesthetic technique – We suggest general anesthesia if the patient's airway anatomy allows for reliable visualization of the vocal cords, with unhindered insertion of an appropriately sized ETT and subsequent ventilation (Grade 2C). Local anesthesia is usually selected if oral access to the airway is worrisome or unreliable. (See 'Selection of anesthetic technique' above.)

-General anesthesia – The ETT can be inserted after anesthetic induction in most cases.

Baseline intravenous (IV) sedative-analgesic agents are continued, and additional anesthetic agents are administered as necessary during noxious airway stimuli.

We avoid use of the potent volatile inhalation agents when the airway is open since delivery will be compromised and the operating room (OR) will be polluted during these periods.

We suggest administration of a neuromuscular blocking agent (NMBA) (Grade 2C). An NMBA may be useful to minimize cough and risk of accidental extubation but is not always necessary. (See 'Management of general anesthesia' above.)

-Local anesthesia – Local anesthetic techniques include aerosol, ointment, transtracheal injection, and specific nerve blocks.

Additional sedative or anesthetic agents are administered to supplement local anesthesia techniques as necessary to ensure that the patient is comfortable and cooperative, but breathing spontaneously and not moving. (See 'Management of local anesthesia' above.)

•Procedural considerations – Clear communication is necessary while pulling back the ETT to allow insertion of a tracheostomy tube, and after connection to the anesthesia breathing circuit to verify adequacy of ventilation.

If correct positioning of the tracheostomy tube is uncertain, flexible bronchoscopy is used to verify the position within the trachea before initiating controlled ventilation. (See 'Procedural considerations' above.)

•Intraoperative complications – Bleeding is the most common surgical complication. Other possible intraoperative complications include loss of the airway, pneumothorax or pneumomediastinum due to malpositioning of the tracheostomy tube, tracheal ring fracture, esophageal perforation, or airway fire. Prevention and management of these complications are discussed separately. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Intraoperative complications'.)

•Postprocedure considerations – Postoperative pain after a transverse cervical incision is typically minimal. Considerations for transport of critically ill patients from the OR back to an intensive care unit (ICU) are discussed separately. (See 'Postprocedure considerations' above and "Transport of surgical patients", section on 'Considerations for critically ill patients'.)

●Percutaneous tracheostomy – Percutaneous tracheostomy is typically performed in the ICU under local anesthesia in a patient who is already receiving sedative and/or analgesic agents. This avoids the risk of transporting a critically ill patient to the OR. Notably, airway loss is more likely during percutaneous compared with open tracheostomy, particularly if coughing occurs in a patient who is not paralyzed. (See 'Percutaneous tracheostomy' above and "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Percutaneous'.)

●Emergency tracheostomy for critical airway occlusion – Rarely, emergency cricothyrotomy may be necessary for critical airway occlusion at or above the vocal cords. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults".)

●Tracheostomy in COVID-19 patients – Tracheostomy facilitates management of selected patients with COVID-19. Open or percutaneous tracheostomies are aerosol-generating procedures with increased risk for viral transmission. Key principles are addressed separately:

•Prevention of infection transmission to anesthesia and other personnel – (See "Overview of infection control during anesthetic care", section on 'Infectious agents transmitted by aerosol (eg, COVID-19)'.)

•Prevention of contamination of anesthesia equipment – (See "Overview of infection control during anesthetic care", section on 'Prevention of contamination of anesthesia machines and equipment'.)

•Precautions during patient transport to and from the ICU – (See "Overview of infection control during anesthetic care", section on 'Precautions during patient transport'.)