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Laboratory Animals
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DOI: 10.1258/002367778781088495
1978 12: 203 Lab Anim
J. N. Leverment and S. Rae
Cuffed tube tracheostomy in the dog

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Laboratory Animals (I978) 12,203-206
Cuffed tube tracheostomy in the dog
J.N. LEVERMENT* & S. RAE
Thoracic Surgical Department. Medical Sciences Building, University of Toronto. Toronto, Canada
203
Summary
A surgical technique of performing tracheostomy in
dogs requiring prolonged intubation with either cutTed
or uncutTed tubes is described. Cannulae used in
humans are anatomically unsuitable for the dog. The
cannula and cutT described in this paper did not
predispose to severe mechanical trauma to the trachea
and we attempted to minimize factors that may
predispose to tracheal damage during the period of
intubation and the subsequent development of late
tracheal injuring after extubation.
A simple method of humidification in these healthy
dogs proved adequate; neither tenacious tracheobron-
chial secretion nor the retention of secretions were
seen.
Nelson (1957), in reviewing the history of tracheo-
stomy, mentions that it was once considered a'scandal
of surgery', a description which still may apply today
because it is too often considered to be an easy
operation. However, if it is done without due care it
can lead to serious complications.
During a recent series of experimental studies
involving tracheostomized dogs for prolonged in-
tubation with uncuffed and cuffed tubes, a surgical
technique was evolved to circumvent some of the diffi-
culties commonly encountered. Modifications in
tracheostomy tube design were also made.
Materials and methods
Tracheostomy tubes
Tracheostomy tubes designed for man are
anatomically curved for man's trachea, but not for the
dog's. A horizontal incision in the trachea (hereafter
referred to as the 'stoma') often allows this curved
cannula to tilt further anteriorly at its tip, or the curved
part of the tube may inwardly buckle the superior
margin of the stoma or damage the posterior tracheal
wall. Soft low-pressure cuffs attached to these tubes
expand asymmetrically on inflation, or are inefficient
in centering the tube in the tracheal lumen.
An anatomically suitable tube can be moulded from
a semi-rigid siliconized vinyl tube 10 cm long with
* Present address: Cardiothoracic Surgery, Bristol Royal
Infirmary, Bristol, England.
Received 10 December 1976.Accepted 13April 1978.
internal and external diameters of 7 and 9 mm
respectively. The section which lies outside the trachea
is 3 cm long and the endotracheal section is 7 cm, the
first 3 cm of which curves through an angle of 140
0
.
The end of the tube is bevelled so that the tip is dorsal
in the trachea. The endotracheal section is long
enough to guard against displacement of the tube out
of the trachea. The 3 cm length of the external section
is sufficient to allow for the swelling and induration of
the peri stomal tissues, and further guards against
dislodgement of the tube.
Fig. I. Modified tracheostomy cannula fittedwithlow-pressure culT.
A short adaptor can be fitted, but the length of tube
projecting above the skin must be limited so that
repeated contact is not made with the dog's lower jaw.
Fig. I shows the tube fitted with a low-pressure high-
residual-volume cuff.
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204
Leverment &Rae
Incision
When the dog is supine with its head extended, as
during the tracheostomy procedure, thelax skinof the
neck is drawn upwards in relation to the trachea. 2
surface markings weretherefore used (Fig. 2), point A
suture was used to check the movement cranially of
the tube and prevent thedestruction of intact tracheal
rings proximal to the incised rings. The snare was
constructed witha silk suture (0) and a3cmlengthof
vinyl tubing (Portex 800/010/250; Portex Ltd, Hythe,
Kent) as depicted in Fig. 4. The suture was subse-
quently completed by looping it over theadaptor piece
Fig. 3. Incision with retractors showing incised tracheal rings
posteriorly and 'traction' sutures anteriorly.
--A
--B
Surgical technique
Anaesthesia was obtained using a single intravenous
dose (20mg/kg) of a 2% solution of sodium thio-
pentone. Endotracheal intubation was not used. The
hair around the neck was cut short with an electric
clipper, but only the skin overlying the trachea where
theincision was to bemade was cleanly shaved with a
scalpel. Strict asepsis with proper preparation and
surgical techniquewas used.
flig. 2. Surface markings ondog for tracheostomy skin incision.
being the midline between the cricoid cartilage and
suprasternal notch withtheneck inthenormal 'awake'
semiflexed position, and point B being the midline
between the cricoid and the suprasternal notch with
the dog anaesthetized and the neck extended. These
points were marked witll a pencil line and a vertical
incision made between them. The cervical strap
muscles were split on the midline and retracted
laterally to exposethetrachea.
The stoma was fashioned by avertical slit involving
the 3 tracheal cartilages exposed at the lower end of
the wound (Fig. 3). Two long 'traction' silk or nylon
sutures (000) wereplaced at theupper end of the skin
incision; each suture first passing through the skinand
subcutaneous tissue, then through the proximal and
distal incised tracheal rings, and finally back again
through thesubcutaneous tissueand skin.
It is difficult to prevent excessivemovement of the
tracheostomy tube in a playful and restless animal
such as the dog. In addition, rapid up and down
excursions of the trachea and oesophagus occur
during deglutition and attempts at barking. A 'snare'
"
.
I '. )~
II!
Fig.4. Tracheostomy with'traction' and 'snare' sutures.
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Tracheostomy in the dog
when the animal had fully recovered from the
anaesthetic. By sliding the vinyl tubing up or down,
tension in the suture could be adjusted.
The tracheostomy tube was kept in place with
cotton tapes tied around the neck. The pilot tube and
mechanical valve of the tracheostomy tube were
sutured onto the cotton tapes out of reach of the
inquisitive tongue of the dog. Broad cotton tapes were
found to cause less chafing to the animal's neck than
broad rubber strips. Suturing of the neck plate of the
tracheostomy tube directly to the skin proved an
unreliable method of preventing displacement of the
tube. In addition, unnecessary skin sepsis can result
from these sutures being as they are, so near the
tracheostomy wound.
A thin short elastic band with metal paper clips at
each end can be used to approximate the 'traction'
sutures behind the animal's neck, keeping these sutures
out of reach of the ever-exploring tongue of the dog.
After only a short period of intubation, healing of the
tracheostomy wound by primary intention can be
enhanced by crossing these sutures and similarly
approximating them behind.
With the dog in the normal standing position, the
stoma and tracheostomy tube come to lieopposite the
'traction' sutures, which facilitated introduction of the
tube and subsequently simplified the process of
cleaning and changing the tubes. In addition, no
unsightly redundant cervical skin folds appeared
above the tracheostomy with the tubes in situ (Pig. 5).
\
Fig. 5. Traeheoslomy assembly insitu.
The lower end of the tracheostomy incision must
not be sutured, but should be left open to allow free
drainage of secretions, otherwise severe peristomal
infection or abscess formation is likely to occur. After
205
4-5 days this part of the tracheostomy heals by
primary intention, leaving a neat stoma just slightly
bigger than the cannula of the tracheostomy tube. At
this stage the process of changing the tubes becomes
simple and the 'traction' sutures can be removed. Inner
cannulae prevent unnecessary trauma which may
result from repeated reinsertions of cuffed tracheo-
stomy tubes.
Antibiotic cover should be given for the first 5 days
postoperatively, and analgesics as required.
Humidification
There are practical difficulties in obtaining prolonged
optimal humidification in such an active animal as the
dog. Modelle, Giammona & Davis (1967) exposed
puppies to ultrasonic aerosols of normal saline
solution or distilled water for 72 h and found patho-
logical changes in the lungs. However, Noguchi
(1972) claimed that lung function in tracheostomiz~
dogs can be conditioned best with air of 100% relative
humidity saturation at 25-30C for 24 h. We used a
simple method of providing humidification for tracheo-
stomized dogs continuously intubated with cuffed
tracheostomy tubes for 14 days. The dogs were caged
separately under a transparent canopy in a large air-
conditioned room. Humidity was provided as tap
water vapour mist to each cage by a commercial
humidifier (Sovereign model 707S/M; Water Refining
Co. Ltd, 475 Edward Street, Richmond Hill, Ontario,
Canada). The humidified environment was maintained
at 100% relative humidity at 22-24C, with the
oxygen concentration 20% and carbon dioxide con-
centration negligible.
The animals were set free from their cages twice
daily for 30 min while the tracheostomies were
inspected and the cages cleaned. Drinking water and
food were supplied ad libitum.
Tracheobronchial secretions were serosanguinous in
nature over the first 4-5 days after tracheostomy and
intubation, but became markedly decreased and less
viscous afterwards. At no stage was endobronchial
suction used.
All the dogs remained clinically healthy and
apparently happy during the 2 weeks of intubation.
Their body weights remained steady. Chest radio-
graphs showed no evidence of bronchopneumonic
changes.
3 bronchoscopic examinations were done during
intubation. Throughout this period, only superficial
patchy areas of damage to the trachea were seen at the
cuff site. No residual damage was noticed en-
doscopically 2 weeks after removal of the cuffed tubes.
The stomas healed by primary intention within the 1st
week after removal of the tube. Permanent puckering
of the skin around the tracheostomy site was not
evident. No post-intubation tracheal stenoses
developed.
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206
Discussion
Richards &Glenn (1932) and Watts (1963) presented
experimental evidence that cartilage does not regener-
ate, and that healing occurs by fibrous tissue. Large
cartilage defects at the stomal site after tracheostomy
can result from surgical removal of too large a piece of
cartilage, pressure necrosis of the cartilage by using
tubes with large external diameters, or excessive
movement of these tubes. Infection which invariably
follows tracheostomy and intubation also impairs the
viability of the cartilage at the margin of the stoma.
Such large defects may subsequently result in the
formation of functionally significant tracheal stenoses
at stomal level (Andrews, 1971).
Damage to the tracheal wall at cuff level was
reportedly due to pressure necrosis by the cuff; non-
yielding low-residual volume cuffs caused extensive
early and late damage to the trachea at cuff site
(Goldberg & Pearson, 1972). The superiority of
References
Andrews, H. J. (1971). The incidence and pathogenesis of
tracheal injury following tracheostomy with cuffed tube
and assisted ventilation. Analysis of a 3 year prospective
study. British Journal of Surgery 58, 749-755.
Goldberg, M. & Pearson, F. G. (1972). Pathogenesis of
tracheal stenosis following tracheostomy with a culTed
tube: an experimental study indogs. Thorax 27.678-691.
Grillo, H. C., Cooper, J. D., Geffin, B. & Pontoppidan, H.
(1971). A low-pressure culT for tracheostomy tubes to
minimize tracheal injury. Journal of Thoracic and
Cardiovascular Surgery 62, 898-907.
Leverment, J. N., Pearson, F. G. &Rae, S. (1975). Tracheal
size following tracheostomy and culTed-tube intubation:
anexperimental study indogs. Thorax 30, 271-277.
Leverment &Rae
recently-designed low-pressure cuffs over those pre-
viously used is now clinically and experimentally well
established (Grillo, Cooper, Geffin & Pontoppidan,
1971; Leverment, Pearson & Rae, 1975). The
majority of experimental studies to investigate factors
predisposing to tracheal injury have been carried out
in dogs. Investigators should bear in mind that faulty
technique in itself will cause severe tracheal damage,
and this can be minimized by suitably modifying the
surgical procedure and the tracheostomy devices.
Acknowledgements
We wish to thank Miss C. Allen, secretary to Thoracic
Surgical Department, Frenchay Hospital, Bristol for
secretarial assistance. Our sincere thanks are due to
Professor F. G. Pearson, Head of Thoracic Surgery,
University of Toronto, Canada, for his extremely
helpful suggestions and support.
Modelle, H. J., Giammona, S. T. & Davis, J. H. (1967).
Effect of chronic exposure of ultrasonic aerosols on the
lung.Anesthesiology 28,680-688.
Nelson, T. G. (1957). Tracheotomy: a clinical and ex-
perimental study. Part Ill. American Surgeon 22, 841-
881.
Noguchi, H. (1972). Studies on proper humidification in
tracheostomised dogs. Nagoya Medical Journal 17, 159-
178.
Richards, L. & Glenn, F. (1932). The histopathologic
reaction of the tracheotomic wound. Archives of
Otolaryngology 15,389-412.
Watts, J. McK. (1963). Tracheostomy in modern practice.
British Journal of Surgery so, 954-975.
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