Trache ostomy in

Palliative C are
Teresa Chan, MDa, Anand K. Devaiah, MD, FACSa,b,*

KEYWORDS
Tracheostomy Palliation Respiratory failure Ventilator
ALS End of life Aspiration

Tracheostomy is a procedure with a long history. The earliest account of tracheostomy

is depicted in Egyptian tablets dating back around 3600 BC.1 Although other accounts
from Egypt and India describe what are believed to be tracheostomy procedures,
a formally recognized account of elective tracheostomy is credited to Aesclepiades
of Bithynia in the first century BC. The earliest accounts of tracheostomy largely
described the procedure as a life-saving maneuver associated with a high mortality
risk. Although early physicians such as Galen hailed the procedure as holding promise
for patients, millennia would pass before the inherent risks could be overcome to make
the procedure more acceptable.2,3
Pierre Bretonneau is credited as being one of the pioneers in making tracheostomy
an accepted procedure. In the 1820s, he described the use of tracheostomy for treat-
ment of obstructive diphtheria. The procedure had a 73% mortality rate, which was
still an improvement over the overall mortality of diphtheria at the time.2 Chevalier
Jackson’s pioneering work in laryngology and bronchoesophagology during the late
1800s helped to improve the tracheostomy procedure. His work in understanding
and manipulating the airway helped improve the surgical techniques of tracheostomy
to make it a safer procedure. Use of the procedure, particularly in the treatment of air-
way obstruction, became a more viable alternative with a lower mortality. The use of
tracheostomy decreased with the development of a diphtheria antiserum. When cases
of diphtheria dropped by the early 1900s, removing this disease as a significant health
threat, the rate of tracheostomy decreased concomitantly.4
One could credit the ravages of polio and post polio syndrome as leading to the
resurgence of tracheostomy and its consideration in palliative care. In 1928, the iron
lung was successfully used on a pediatric patient with polio-induced respiratory fail-
ure.5,6 As a noninvasive means of ventilation, this device was useful and saved

a
Department of Otolaryngology—Head and Neck Surgery, Boston University School of Medicine,
Boston Medical Center, D608 Collamore, 88 East Newton Street, Boston, MA 02118, USA
b
Department of Neurological Surgery, Boston Medical Center, 88 East Newton Street, Boston,
MA 02118, USA
* Corresponding author. Department of Otolaryngology—Head and Neck Surgery, Boston
University School of Medicine, Boston Medical Center, D608 Collamore, 88 East Newton Street,
Boston, MA 02118.
E-mail address: [email protected] (A.K. Devaiah).

Otolaryngol Clin N Am 42 (2009) 133–141

doi:10.1016/j.otc.2008.09.002 oto.theclinics.com
0030-6665/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
134 Chan & Devaiah

many lives; however, it was large and expensive, costing as much as the average
home at the time. Such limitations led James Wilson to propose the use of tracheos-
tomy in 1932 as a means of ventilation.7 This consideration by Wilson helped moved
tracheostomy from a treatment in obstruction to palliative ventilation.
ANATOMY AND SURGICAL TECHNIQUE

Knowledge of the relevant anatomy is important in tracheostomy. Although this anat-

omy is well known to those who perform the procedure, key elements are described
herein for those who are less familiar. The trachea is palpable in the midline neck
below the level of the thyroid cartilage and cricoid cartilage. Important landmarks to
identify include the sternal notch, thyroid notch, thyroid cartilage, and cricoid cartilage.
In patients with thick necks, intervening neck tumor, or life-threatening infection, the
landmarks may be less prominent. The position of the thyroid gland is identified and
is necessarily encountered in tracheostomy placement. One must be careful to identify
these structures, because the trachea may be diverted off midline in some patients
due to pathologic processes pushing the trachea to the side; in other patients the
trachea may dive deep and away from the neck skin.
Tracheostomy may be performed by several means. The main divisions of tracheos-
tomy methods are open and percutaneous. One version of the open method, preferred
by the authors, is described briefly herein. The skin is palpated and marked below the
level of the cricoid cartilage at the approximate level of the second tracheal ring. With
the patient’s neck extended using a shoulder roll and the skin prepared in a sterile fash-
ion, a horizontal incision is made long enough to facilitate access to the deeper tissues
and trachea. Once the strap muscles are encountered, they are pulled laterally after
division of the median raphe. The thyroid isthmus is encountered and divided. The tra-
chea is identified, and the interspace between the second and third tracheal rings is lo-
cated (Fig. 1A). In any airway surgery clear communication with the anesthesia team is
maintained because they need to assist in completing a successful tracheostomy
without losing the airway. This interspace is sharply incised, and the trachea is entered.
Once the airway is entered, the final steps to creating a tract are at hand. For a long-
term tracheostomy, it is recommended that a skin-trachea flap be developed. This flap
allows for rapid creation of a well-defined tract and permits easy tracheostomy tube
exchange in the short and long term. A common method is a Bjork flap. By making
an inferiorly based U-shaped flap in the trachea, the skin is sutured down to this
flap to create a tract (Fig. 1B). Another method is to remove a section of the trachea
and suture the skin to the edges of the trachea circumferentially (Fig. 1C). Both of
these methods can be particularly helpful in the palliative care setting in which a family
member, visiting nurse, or nursing home practitioner primarily cares for the tracheos-
tomy on a regular basis. After creating the opening and tract, an appropriately sized
tracheostomy tube is placed within the opening and secured to the patient (Fig. 2).
The authors prefer to suture the flanges to the skin and place a tracheostomy tie
around the neck at the time of surgery.
The percutaneous method respects the same anatomic boundaries as in the open
method. The airway is entered by first making a small skin incision. Concurrent trache-
obronchoscopy to visualize the percutaneous airway instrumentation may be
performed to reduce complications.8 A needle is used to enter the tracheal interspace.
Through the needle, a wire is passed in to the airway, which allows for percutaneous
dilators to pass into the trachea. In this manner, the airway tract is developed for
placing a tracheostomy tube.
There is an ongoing discussion over the merits of each method. Extensive review of
this discussion is beyond the scope of this text; the notes provided in the following
Tracheostomy in Palliative Care 135

A B C

Fig.1. (A) Drawing shows the thyroid cartilage, cricoid cartilage, and upper rings of the tra-
chea. (B) An inferior-based tracheal flap can be developed to sew to the skin and form a sta-
ble opening. This flap will open into the trachea and allow for passage of a tracheostomy
tube. (C) Alternatively, a segment of cartilage can be removed, allowing circumferential
sewing of skin to the edges of the tracheal opening.

sections are offered as general considerations. Each method has its advantages and
disadvantages. The open method allows for excellent visualization and creation of
a stable tract. Generally, it requires an operating room setting but can be performed
at the bedside with the proper set-up. The percutaneous method is facile at the
bedside and in the operating room. It should not be performed in patients who have
thick necks or distorted cervical anatomy, because there is increased risk of airway
and cervical complications. Both methods carry the risk of airway loss, bleeding,
trauma to the airway, and other complications. When compared with the earliest
efforts at the procedure, the surgery is generally safe and well tolerated by patients.

INDICATIONS AND DECISION MAKING IN PALLIATIVE CARE

The indications for tracheostomy as part of a palliative care plan do not differ greatly
from those in the acute or intensive care setting; however, the decision is often guided
by a different set of objectives, such as symptom relief, improvement in patient well-
being, facilitation of activities of daily living, and, if possible, optimization of long-term
function. Surgical intervention is not decided on the basis of curative outcomes which
are for the most part measurable and objective; instead, the decision must address
the foreseeable and imminent course of a patient’s disease and take into account
other more humanistic factors such as spiritual needs and psychosocial resources.
Whenever tracheostomy is considered in the setting of palliative care, it is necessary
to have a dialogue about the patient’s desire for his or her quality of life, their projected
prognosis, and the optimal timing in the natural progression of their disease.
136 Chan & Devaiah

Fig. 2. Tracheostomy tubes come in a variety of types, such as cuffed plastic (A) and low-pro-
file metal (B). (C) Shown is the appearance of a patient’s neck in which dwells a well-healed
tracheostomy site with a tracheostomy tube in place. At the end of this tube is a valve that
allows for vocalization.

Of utmost importance is preservation of the quality of life. What this means may
differ widely from patient to patient. In the setting of terminal illness, this discussion
naturally extends into the topic of the quality of dying as well. Patients and their
families are often concerned about the potential limitations that tracheostomy and
eventual ventilator dependence will place on the patient’s quality of life.9 Often, there
are concerns that tracheostomy serves to prolong life without contributing significantly
to quality of life.10 Additionally, for most patients, a tracheostomy implies an impend-
ing change in swallowing and speech function. It is necessary for the physician to
address these fears, to present possible options for voice and swallowing preserva-
tion, and to discuss realistic outcomes for the individual patient before proceeding.
In the setting of progressive motor neuron or neuromuscular disease, this conversa-
tion is often complicated by the anticipated decline in bulbar function which was
perhaps the impetus for discussion of tracheostomy in the first place. Early involve-
ment of a speech and language pathology team may be helpful in optimizing long-
term outcomes.
Tracheostomy in Palliative Care 137

Tracheostomy should be considered in the context of a patient’s desires and beliefs

and integrated as part of a larger long-term palliative care plan. If needed and timed
properly, it can contribute greatly to the quality of a patient’s life.
Common reasons for placement of a tracheostomy include airway obstruction,
chronic aspiration, or the need for pulmonary toilet or prolonged ventilation from
general deconditioning, an acute neural insult, or progressive neuromuscular decline.
Loss of control of any one of the closely coordinated functions of the upper aerodiges-
tive tract (respiration, deglutition, or speech) often may result in difficulties with the
others. Each of these indications is discussed herein with particular attention to
relevant issues in palliative care.

Airway Obstruction or Prolonged Ventilation

The need to secure an airway in the setting of impending airway compromise seems at
first glance to require little discussion. Examples of possible airway obstruction
encountered in the palliative care setting include unresectable malignancies of the
oral cavity, oropharynx, larynx, and thyroid; vocal cord fixation from invasive tracheal
tumors; and obstructive cervical metastases. In addition to obstructive processes,
decline in muscular control of the upper aerodigestive tract or generalized decondi-
tioning may necessitate long-term mechanical ventilation and intubation.
In the setting of palliative care when impending airway obstruction or compromise
may not be on the order of minutes but projected on the order of weeks to months,
anticipation is key. As Ross and Abrahm advocate in their article,11 discussion of
palliative surgery should ideally happen on a continuum of disease management
rather than when the patient reaches the point of distress or extremis. This dialogue
should be an ongoing and paced discussion that anticipates but does not unduly
burden the patient or family physically, psychologically, socially, or spiritually.
Symptom anticipation is an advanced approach to the principle of symptom
management in palliative care. Anticipatory management before catastrophic events
is desirable and supported by outcomes. There is a greater complication rate with
emergency airway management in the field and in the hospital.12,13 Cricothyroidotomy
carries with it the highest risk of complication, ranging from 13% to 40%.12 Elective
tracheostomy has about a 15% complication rate, and emergency tracheostomy is
estimated to be associated with two to five times the risk of elective tracheostomy.12
Moreover, within a hospital setting, cricothyroidotomy was successful in only 87% of
attempts to establish an airway, whereas tracheostomy was successful in securing the
airway in 100% of attempts.12 In the field, the adequacy of cricothyroidotomy
decreased to 64%, but this was not recognized until arrival at a trauma center. In
fact, advanced life support providers judged that they had adequately secured these
airways via cricothyroidotomy in 89% of patients.13
The primary physician responsible for coordinating the patient’s palliative care plan
should engage the patient, family members, and appropriate consultants in an inter-
disciplinary dialogue early in the onset of disease. This collaboration may include
disease specialists such as oncologists, surgeons, anesthesiologists, speech
language pathologists, nurses, social workers, and clergy. This discussion should ide-
ally occur when airway compromise is foreseen as the natural course of disease, be-
fore the point when the urgency of the decision obscures the ability to weigh the
patient’s values and desires adequately. The discussion of tracheostomy should be
integrated as a part of an ongoing discussion of the patient’s long-term plan rather
than a separate singular surgical intervention. The patient should be presented with
any reasonable alternatives for airway management, such as surgical debulking of a tu-
mor or palliative radiation and chemotherapy with the goal of relieving tumor burden.
138 Chan & Devaiah

Ultimately, the decision for or against tracheostomy should be left to the patient;
however, specialists and primary palliative care providers have the obligation to
ensure that a patient understands the ramifications of his or her decisions. For in-
stance, a patient with an unresectable cancer of the upper aerodigestive tract who re-
fuses tracheostomy as part of their care plan must understand what he or she is
choosing in terms of comfort and dignity in dying by progressive respiratory
compromise.

Chronic Aspiration and the Need for Pulmonary Toilet

Chronic aspiration and pulmonary toilet requirements are common, closely related
indications for tracheostomy in palliative care. Loss of specific muscle coordination
due to decline of bulbar function, loss of lower cranial nerves secondary to stroke,
the mass effect or fixation of any part of the swallowing apparatus from a sizable
head and neck tumor, excessive gastric secretions in gastrointestinal cancers or
carcinomatosis of the bowel, and general deconditioning are all situations that may
predispose a patient to chronic aspiration and the need for aggressive pulmonary
toilet.
Tracheostomy should not be thought of as a cure for aspiration. In fact, tracheos-
tomy can worsen aspiration by preventing elevation of the larynx with swallowing.
Schonhofer and colleagues14 reported a 30% aspiration rate in patients who were
tracheotomized.
First-line measures for the prevention of aspiration include pharmacologic control of
excessive secretions, limitation of food consistencies based on swallow evaluation,
reinforcement of swallowing techniques by a speech language pathologist, and the
use of nonoral feeding options (eg, parenteral nutrition and nasogastric tube feeds).
If all other medical alternatives have been attempted and deemed ineffective for
a long-term solution, consideration of surgical management options including trache-
ostomy is appropriate. In the palliative care setting, surgical intervention may be jus-
tified for intractable life-threatening aspiration and on the basis of improving patient
comfort.

CONTRAINDICATIONS

The most obvious contraindication to tracheostomy or any surgical intervention is

patient objection. Both a patient’s conscious objection and his or her inability to know-
ingly consent to the procedure should be reason to stop and seek alternatives.
Although preservation of patient autonomy is the most basic tenet taught from the first
years of medical school, it can be disconcerting to a physician when a patient’s deci-
sion contradicts what would be thought of as ‘‘the best option’’ medically speaking. In
palliative care as in all health care circumstances, the patient’s right to decide must be
respected and upheld.
Establishment of advanced directives and a proxy decision maker before cognitive
decline is desirable and the current standard of practice. Nevertheless, observations
from the SUPPORT study found that many patients would not want their prehospital-
ization resuscitation preferences strictly followed if they were to lose decision-making
capacity. They would prefer their family and physician to make resuscitation decisions
for them.15
Other relative contraindications to tracheostomy include anatomic or patient factors
that preclude safe effective tracheostomy with an acceptable blood loss. For example,
in the situation of a large thyroid malignancy that obscures safe surgical access to the
airway, it may be in the patient’s best interest to remain intubated rather than undergo
Tracheostomy in Palliative Care 139

tracheostomy. In the situation of an obstruction distal to the trachea for which the
patient remains chronically intubated (eg, obstructing lymphoma of a mainstem bron-
chus), tracheostomy would be of little help in ventilation. If a patient’s belief system
precludes the use of adjuncts that might be necessary for safe surgery, one must
proceed with caution to surgical intervention. Anesthetic factors such as pulmonary
reserve, cardiac health, and expected blood loss in the setting of bleeding diatheses
are all risks that must be weighed against the benefits of surgery.
Ultimately, when deciding whether to operate, three questions should be asked and
answered: (1) Does the patient understand and desire this intervention and its alterna-
tives? (2) Will this intervention facilitate palliation or supportive care? (3) Do the
benefits of the procedure outweigh the risks?

USE OF TRACHEOSTOMY IN PALLIATIVE CARE

Progressive neuromuscular or motor neuron disease can lead to any of the previously
listed indications for tracheostomy, and much of the current literature about end-of-life
use comes from studies of patients with amyotrophic lateral sclerosis (ALS).16–18
For this subset of palliative care patients, the use and optimal timing of tracheostomy
is possibly the most controversial. Without some form of respiratory support, the current
5-year survival rate for patients with ALS is approximately 7% to 20%, with a median sur-
vival of 19 to 30 months from diagnosis.19,20 Many of these patients are able to function
comfortably with noninvasive ventilation (non-assisted ventilation with nasal prongs for
oxygen supplementation) for a time, especially if bulbar involvement has been spared;
however, if bulbar impairment is more severe or if noninvasive ventilation is not tolerated,
a tracheostomy and positive pressure ventilation are sometimes sought.
Despite the survival statistics, the overall rate of use of tracheostomy and mechan-
ical ventilation in patients with ALS or other motor neuron diseases is low in the United
States, approximately 4% or less.18 This rate is consistent with the overall pattern of
resource use in this subset of patients. In a study by Albert and colleagues,18 a total of
121 ALS patients were followed up for a median of 12 months. Twenty-two percent
had percutaneous gastrostomy (PEG), 19.4% used Bi-PAP, and 4.3% had a tracheos-
tomy. Many patients did not take advantage of palliative care options before death.
For example, 36.6% used hospice, 48% had signed a power of attorney form, and
18% had ‘‘do not resuscitate’’ orders in their medical charts. The reasons are not
completely clear, although many explanations have been sought.
In a 1999 article by Albert which looked at preferences and actual treatment choices
in ALS patients, initial preferences toward tracheostomy and PEG tube placement
coincided with the eventual treatment choices. Patients who found the interventions
initially acceptable and who went on to use them were more likely to be recently
diagnosed, expressed a greater attachment to life, and showed great declines in
pulmonary function over follow-up.16 A separate article investigating the incidence
and predictors of PEG placement in patients with ALS and other motor neuron
diseases corroborates these data. The strongest predictor for PEG use was the
patient’s baseline preference, and patients who were inclined to PEG tubes were
also more likely to be proactive in their own care and to have established health
care proxies in advance. Patients who received PEG were also more likely to have
tracheostomies than patients not using PEG.17
In a study by Rabkin, 72 hospice-eligible ALS patients were followed up until trache-
ostomy or death. Fourteen patients, nearly 20%, chose long-term mechanical ventila-
tion and 58 died without it. The profile of the patients who chose tracheostomy was as
follows: younger patients with more young children, more education, and higher
140 Chan & Devaiah

household incomes on average. Although their physical conditions were similar, they
reported higher levels of optimism, including a belief in imminent cure and more pos-
itive appraisals of their ability to function in daily life, their physical health, and overall
life satisfaction. At study entry, none of the patients who later chose tracheostomy and
long-term ventilation were clinically depressed compared with 26% of those who
ultimately refused tracheostomy.10
ALS patients are a special subset of palliative care patients. They are typically young
and healthy before diagnosis and experience rapid functional decline over 1 to 5 years.
Although they are faced with similar dilemmas in end-of-life care as older patients or
those with chronic disease, any broad conclusions about palliative care patients with
respect to tracheostomy or other considerations from the perspective of this unique
subset of patients should be drawn with caution.
The timing of the discussion of tracheostomy and the circumstances of the decision
also influence the likelihood of a patient electing to undergo tracheostomy. Whether
this occurs in the acute care/intensive care setting, outpatient, or post intensive
care setting influences the gravity of the situation and the perceived prognosis. In
a study by Lloyd and colleagues21 looking at intensive care decision making in the
seriously ill and elderly, 50 patients were followed up prospectively. Seriously ill
patients were defined as adult inpatients with chronic illness and an estimated 50%
6-month mortality rate. Also included in the study were patients aged 80 years and
older with an acute illness. Patients were given two options: (1) mechanical ventilation
for 14 days or (2) mechanical ventilation for 1 month followed by placement of a trache-
ostomy and feeding tube. There was a wide variation in the preference for aggressive
care that did not appear to be influenced by the prehospitalization quality of life. The
predicted quality of life appeared to be as important as estimates of intensive care unit
survival in decision making. When confronted with extended mechanical ventilation
and associated care, a significant proportion of patients would accept this care only
for an improved prognosis.

FUTURE DIRECTIONS

Although the surgical method of tracheostomy is less likely to have marked enhance-
ments, gains may be realized in other areas such as the decision-making process. We
can further hone the tenets of medical ethics, further stratify risk (both short and long
term), and refine our understanding of overall patient benefits. The gain is in maximizing
judicious use of palliative tracheostomy. To arrive at this without compromising long-term
outcomes while improving the quality of remaining life would be highly desirable.
On the less esoteric side, further improvements in tracheostomy cannulas may bring
benefits. By refining the assortment of airway cannulas that allow for a stable airway,
proper ventilation, good pulmonary toilet, and low material complications, patient
benefit can be increased. Accidental decannulation due to excessive mobility or
poor placement/replacement of the cannula still occurs and can be devastating.
Further developments in cannula design to reduce interference in speech production
and swallowing are other areas for improvement. In palliative patients who have other
upper aerodigestive tract compromise, the airway cannula can be a lifesaver and
a detriment to their remaining quality of life.

SUMMARY

The use of tracheostomy in palliative care offers a viable option for airway control.
Through a dialogue with the patient, family, and a multidisciplinary set of providers,
this procedure can be a useful component to a patient’s overall palliative care plan.
Tracheostomy in Palliative Care 141

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