94 | Byers

Section X - PROCEDURES IN EMERGENCY AND CRITICAL CARE MEDICINE

Temporary tracheostomy

Stéphanie M.P. Noël DVM, PhD, Dipl. ECVS

Indications

Temporary tracheostomy relieves life-threatening upper airway obstruction. The most common indications are laryngeal masses, trauma, upper airway swelling^1,2,3,4,5,6 and dynamic upper airway obstruction secondary to severe feline asthma.⁷ Perioperative temporary tracheostomy can be considered for tracheal,⁸ temporomandibular,⁹ or arytenoid surgery.¹⁰

Contraindications

Contraindications are the presence of a mass, obstruction, or collapse distal to the tracheostomy site or previous tracheal stent placement.^11,12

Devices

The diameter of the tube should not exceed 75% of the tracheal diameter to allow airflow around the tube when obstructed.¹¹ In cats, single lumen non-cuffed pediatric plastic tracheostomy tubes from 3- to 5-mm are typically used.^3,8,10 If commercial tubes are not available, an endotracheal tube serves as an alternative^.8,11,12

Technique

If possible, general anesthesia and intubation secures the airway and allows for oxygenation and ventilation. In emergency scenarios, slash tracheostomy,¹³ percutaneous tracheostomy^14,15 and needle cricothyroidotomy¹² have been described. An emergency tracheostomy pack readily in the emergency area should include tracheostomy tubes of different sizes, sterile surgical instruments, suture material, and umbilical tape. Different techniques, such as transverse tracheostomy, tracheal flap, or vertical incision, have been described.¹¹ We’ll present the transverse tracheostomy, the easiest technique, in which the incision width may not exceed half of the tracheal circumference (video 94.1).

1. Equipment

Device: commercially single lumen non-cuffed pediatric tracheostomy tube (from 3- to 5-mm) (fig. 94.1) or modified endotracheal tube.
Sterile surgical instruments: four to six towel clamps, #4 and #3 scalpel handles, #20 and #11 blades, DeBakey forceps, Mentzenbaum and Mayo scissors, two Gelpi retractors, needle holder.

Equipment: clippers, surgical scrub, sterile drape(s), suture material (nylon 4-0 and 2-0), tape, umbilical tape, sterile gloves.

2. Preparation

Induction of general anesthesia.
Cat positioned in dorsal recumbency with a sand bag under the neck and the head maintained in extension with a tape.
The ventral cervical area should be widely clipped (from the caudal border of the mandibles to the manubrium of sternum) and prepped in a sterile fashion.

3. Procedure outline

Sterile surgical drapes are placed on the borders of the clipped ventral cervical area.
A ventral cervical midline incision of the skin and the subcutaneous tissues is made (#4 scalpel handle, #20 blade).
To expose the ventral trachea, the sternohyoideus muscles are separated at their midline aponeurosis (DeBakey forceps, Mentzenbaum scissor). Gelpi retractors are placed at each extremity of the surgical field to maintain a good exposure.
A horizontal incision is ideally made between the fourth and fifth tracheal rings (#3 scalpel handle, #11 blade).
Long stay sutures (needle holder, nylon 2-0) are placed around the adjacent tracheal rings to the incision to facilitate manipulation of the site for further tube exchange. At the end of the procedure, the stay sutures have to be clearly labelled (“Up” and “Down”).
The endotracheal tube has to be moved back and the tracheostomy tube is inserted into the tracheal lumen. The anesthetic system is connected to the tracheostomy tube (fig. 94.2).
The skin is closed with simple interrupted or interrupted cruciate sutures (DeBackey forceps, needle holder, nylon 4-0)
The tracheostomy tube is secured around the neck with an umbilical tape (fig. 94.3).
After tube removal, the tracheostomy site will heal by second healing.

Management

As a tracheostomy bypasses the upper respiratory airways, cold dry air is delivered to the trachea, inducing increased mucus production. Permanent monitoring and intensive care are mandatory. Regular care is required at least every 4 to 6 hours. It consists of preoxygenation, humidification with sterile isotonic saline solution or nebulization, and sterile aspiration if required. Due to the small trachea of cats, tubes lack a removable inner cannula to facilitate cleaning. Therefore, the tracheostomy tube must be changed daily. After tube removal, the surgical site heals by second intention.¹¹

1. Indications

To decrease mucus production and keep the tracheostomy tube and area clean.

2. Equipment

Tracheostomy tube for exchange.
Cleaning of the tracheostomy site: 2% chlorhexidine, gauzes.

Humidification and cleaning of the tracheostomy tube: sterile 0.9% saline, sterile urinary catheter and suction apparatus or 60 mL syringe, 2% chlorhexidine, oxygen.

3. Procedure outline

Cats with a tracheostomy tube require constant monitoring to avoid life-threatening complications secondary to tube obstruction or dislodgement.
Secretions at the tracheostomy area are cleaned with 2% chlorhexidine, and the skin is dried with gauze.
Preoxygenation at the level of tracheostomy tube during 3 to 5 minutes.
Nebulization or instillation of 1-3 mL of sterile 0.9% saline within the tracheostomy tube.
Introduction of a sterile urinary catheter within the tube and suction with a suction apparatus or with a syringe during 5 to 15 seconds to remove mucus and blood clots. The cycle preoxygenation-instillation-suction should be repeated 3-4 times every 4 to 6 hours or more frequently if needed.
The tube has to be changed 1 or 2 times a day. To change a tube, apply a gentle traction on the stay sutures and introduce the new tracheostomy tube within the tracheal stoma. Ideally, a new tube should be used for each change; otherwise, tubes should be cleaned and soaked in 2% chlorhexidine and rinsed with sterile 0.9% saline before placement.

Complications

Major complications are reported in 44% of cats with temporary tracheostomies, including tube occlusion by excessive mucus production and tube dislodgement. Minor complications are reported in 74%, including partial obstruction, fever, pneumomediastinum, subcutaneous emphysema, edema, Horner’s syndrome, laryngeal paralysis, cough, vomiting, and dislodgement of stay sutures.¹

References

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2. Guzu M, Gaillot HA, Rosati M. Bilateral fibrodysplasia ossificans affecting the masticatory muscles and causing irreversible trismus in a domestic shorthair cat. J Fel Med Surg Open Reports doi 10.1177/20551 16919839857, 2019.

3. De Gennaro C, Vettorato E, Corletto F. Severe upper airway obstruction following bilateral ventral bulla osteotomy in a cat. Can Vet J 58:1313-1316, 2017.

4. Hardie RJ, Gunby J, Bjorling DE. Arytenoid lateralization for treatment of laryngeal paralysis in 10 cats. Vet Surg 38:445-451, 2009.

5. Tasker S, Foster DJ, Corcoran DM, Whitbread DJ, et al. Obstructive inflammatory laryngeal disease in three cats. J Fel Med Surg 1:53-59, 1999.

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7. Davis A, Khorzad R, Whelan M, et al. Dynamic upper airway obstruction secondary to severe feline asthma. J Am Anim Hospit Assoc 49: 142-147, 2013.

8. Asher A, Caldwell F, Brissot H, et al. One lung ventilation in a cat via tracheostomy for tracheal mass resection. Vet Anaesth Analg J 45: 236-238, 2018.

9. Aghashani A, Vestaete FJM, Arzi B. Temporomandibular joint gap arthroplasty in cats. Front Vet Sci 7 doi 10.3389/fvets.2020.00482, 2020.

10. De Lorenzi D, Mantovani C, Tripaldi F et al. Redundant arytenoid mucosa: clinical presentation, treatment, and outcome in three cats. J Small Anim Pract 57:40-43, 2016.

11. Haynes AM, Seibert R, Sura PA. Trachea and bronchii. In Johnston S, Tobias K, editors. Veterinary Surgery Small Animal, 2^nd edition, 2018, Saint Louis, Elsevier, pp 1963-1983.

12. Mazzafero E. Temporary tracheostomy. Top Compan Anim Med 28:74-78, 2013.

13. Sumner C, Rozansky E. Management of respiratory emergencies in small animals. Vet Clin North Am Small Anim Pract 43:793-815, 2013.

14. Silverman BS, Robello G, Fowell E. Percutaneous tracheostomy in the dog. Mod Vet Pract 63:62-63, 1982.

15. Colley P, Huber M, Henderson R. Tracheostomy techniques and management. Compend Contin Educ Pract Vet 21:44-52, 1999.