Risk factors in a morbidly obese patient:
(1) reduced expiratory reserve volume, with increased risk of hypoxemia
(2) short, thick neck with excessive amounts of soft tissue between the skin and trachea
Major complications:
(1) obstruction of the tracheostomy tube lumen by blood clot, mucous plug or impingement on the posterior tracheal wall
(2) malposition during reinsertion following dislodgement/decannulation, especially misplacement into paratrachaeal soft tissue with
(2a) subcutaneous emphysema
(2b) tracheal compression
(2c) loss of tube patency
Ways that the authors reduced the risk of complications:
(1) monitoring in the ICU during mechanical ventilation and for 72 hours after mechanical ventilation discontinued
(2) use of a metal tracheostomy tube rather than a cuffed Shiley tube
(3) special care during initial insertion to reduce the problems during tube reinsertion
(3a) cervical lipectomy
(3b) creation of Bjork flap of anterior tracheal rings (Price, 1983)
(4) use of an uncuffed pediatric endotracheal tube to re-establish the airway if the tracheostomy tube becomes dislodged. The tracheostomy tube can then be passed over this tube, after which the endotracheal tube is removed.
