Chapter 55 Tracheostomy for sleep apnea
Tracheostomy historically is the first treatment offered for obstructive sleep apnea. It remains the only surgical option directed at obstructive sleep apnea that uniformly eliminates sleep apnea permanently. Since it was first introduced in 19681 and subsequently reported in several large studies,2,3 newer choices of medical and surgical intervention have reduced the number of people needing a tracheostomy to relieve severe and life-threatening obstructive sleep apnea (OSA).
There remain some patients for whom other treatments have been ineffective, intolerant or refused. Current reports4,5 have agreed with the long-term success at maintaining an open upper airway by creating a tracheostomy to reduce morbidity and mortality.
Patient selection and counseling are paramount in long-term, uncomplicated success of tracheostomy for OSA. Education of the patient and family, in anticipation of surgery, as well as post-surgical support of the caregivers is needed. The patient and family frequently attend training in stoma and device care. The confidence and the ability to manage a tracheostomy at home achieved by support and good teaching justifies the time and effort of these sessions. The patient must be discharged with a full complement of equipment available, and with the knowledge of how to use this in the home environment. Nurse visits are helpful, but the surgeon and his or her staff are the best source to create a confident patient and family in the management of the tracheostomy. Many patients do very well with infrequent office visits and manage self-care with telephone contact and equipment supplies as the only support needed. We recommend an office visit twice to four times a year in all circumstances once the stoma care is stable.
For the patient with normal body habitus who has failed mechanical devices and stepwise surgery of the palate and tongue, a routine tracheostomy through a horizontal skin incision created midway between the cricoid cartilage and the sternal notch will result in satisfactory stoma maintenance. Blunt and sharp dissection through the platysmal layer is performed and a vertical dissection at the midline of the strap muscles results in an approach to the cricoid with the thyroid gland immediately below. This endocrine gland is divided and ligated to expose the midline of the trachea and a window below the second tracheal ring can be removed as is standard for open tracheostomy. A cuffed double lumen tube (Shiley #8 in males; Shiley #6 in females) is placed through this fenestra and the faceplate is sutured to the skin. Sutures are left in place 3–5 days. Gauze ties of inch (6.35 mm) to secure the tube in place are placed around the neck and secured with one or two fingers laxity between tape and neck skin. Patients with sleep apnea are anticipated to have an active and productive life once sleep apnea has been treated surgically and even with significant co-morbidities, we anticipate an active lifestyle. However, the tracheostomy technique described above does not allow temporary extubation, and under only extraordinary circumstances would allow a tube-free tracheostomy, even for short times during the day or overnight. Therefore, most patients, including many of normal body habitus, who have severe obstructive sleep apnea and have been untreatable with mechanical positive pressure or upper airway surgery are recommended to have a tracheostomy as described below. Most of these patients are severely obese with a Body Mass Index greater than 36 and with sizable adipose tissue between skin and trachea. These people need a more thorough approach to the airway and a better solution to stoma hygiene in what is anticipated as life-long airway and apnea management.
Complications from routine tracheostomies in this population have included granulation, tracheal stenosis, loss of lumen with accidental extubation and low-grade chronic wound infection with pain, malodor, bleeding and a weeping wound.
While tracheostomy for obstructive sleep apnea was reported by Kuhlo in 1968,1 Fee and Ward6 described a technique of skin-lined flap tracheostomy to overcome the above complications in the obese patient with obstructive sleep apnea. The goal had been to create a stoma of permanence with a diameter of 8–10 mm.
Their plan was to create a series of vertical and horizontal skin incisions which allow easy access to the fibrofatty pad of tissue overlying the muscles from the level of the hyoid bone above to the sternal notch below (Fig. 55.1). This flap elevation includes defatting the skin flaps safely and creating two vertical and two horizontal skin flaps that will be sutured to the trachea mucosa. Defatting and elevating the skin flaps safely with respect to vitalizingthe skin is most important. When elevation is complete, the surgical field is ready for a lipectomy, which is achieved from the level of the hyoid bone often down to the levelof the fifth tracheal ring (Fig. 55.2). The skin flap elevation allows access to perform a hyoidopexy to the mandibleor thyroid cartilage, if indicated, and allows removal of submental fat which will permit the healed patient to maintain an open tracheal lumen without a submental flap occluding the stoma when the head falls to the chest during sleep.
Fig. 55.1 A horizontally designed ‘H’ with extension of the flaps superiorly and inferiorly, which allows defatting of the skin flaps and access to the inferior neck from the level of the hyoid bone to the fifth tracheal ring.
Fig. 55.2 Lipectomy to remove a panniculus panus in the central compartment of the neck and allowing access to the trachea, as well as permitting the skin flaps to oppose the fascia of the neck with better healing.
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