Clinical Indicators: Tracheostomy

1. History (One or more required)

a. Upper airway obstruction with any of the following:

• stridor,
• air hunger,
• retractions,
• obstructive sleep apnea
• bilateral vocal fold paralysis or immobility,
• Laryngeal stenosis
• Tracheal stenosis
• Pharyngeal stenosis
• Previous neck surgery or throat trauma, or previous irradiation to the neck obstructing mass and/or inflammation in larynx, pharynx, or subglottis
• Adjunct to manage significant head & neck trauma.

b. Prolonged or expected prolonged oral- or nasal- tracheal intubation

c. Inability of patient to manage secretions

• Chronic aspiration
• Excessive broncho-pulmonary secretions

d. Facilitation of ventilation support
e. Inability to orally or nasally intubate
f. Adjunct to manage head and neck operation
g. Adjunct to manage head and neck traumatic injury
h. Subglottic and tracheal stenosis and possible reasons to need it.

2. Physical Examination (required)

a) Respiration–describe
b) Voice–describe
c) Endotracheal tube–document if present and for how long?
d) Larynx–describe, if possible.
e) Neck examination (always required).

Postoperative Observations

1. Breathing–satisfactory. Both sides of lung ventilating.
2. Bleeding from wound?
3. Subcutaneous emphysema?
4. Wound packing & sutures–document removal.
5. Tracheostomy tube, tighten if loose, check cuff for proper inflation.
6. Chest X-Ray–optional

Outcome Review

a) Document complications for departmental review
Associated ICD-10 Diagnostic Codes (Representative, but not all-inclusive codes)

• C01 Malignant neoplasm of base of tongue
• C06.9 Malignant neoplasm of mouth, unspecified
• C09.9 Malignant neoplasm of tonsil, unspecified
• C098 Malignant neoplasm of overlapping sites of tonsil
• C10.9 Malignant neoplasm of oropharynx, unspecified
• C32.0 Malignant neoplasm of glottis
• C32.1 Malignant neoplasm of supraglottis
• C32.8 Malignant neoplasm of overlapping sites of larynx
• D14.1 Benign neoplasm of larynx
• D37.01 Neoplasm of uncertain behavior of lip
• D37.02 Neoplasm of uncertain behavior of tongue
• D37.04 Neoplasm of uncertain behavior of the minor salivary glands
• D37.05 Neoplasm of uncertain behavior of pharynx
• D3709 Neoplasm of uncertain behavior of other specified sites of the oral cavity
• D49.1 Neoplasm of unspecified behavior of respiratory system
• J38.3 Other diseases of vocal cords
• J38.2 Nodules of vocal cords
• J38.4 Edema of larynx
• J38.6 Stenosis of larynx
• J38.7 Other diseases of larynx
• J95.821 Acute postprocedural respiratory failure
• J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
• J95.1 Acute pulmonary insufficiency following thoracic surgery
• J95.2 Acute pulmonary insufficiency following nonthoracic surgery
• J95.3 Chronic pulmonary insufficiency following surgery
• J95.5 Postprocedural subglottic stenosis
• J95.822 Acute and chronic postprocedural respiratory failure
• J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
• J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
• J96.01 Acute respiratory failure with hypoxia
• J96.02 Acute respiratory failure with hypercapnia
• J96.91 Respiratory failure, unspecified with hypoxia
• J96.92 Respiratory failure, unspecified with hypercapnia
• J96.10 Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
• J96.11 Chronic respiratory failure with hypoxia
• J96.12 Chronic respiratory failure with hypercapnia
• J96.21 Acute and chronic respiratory failure with hypoxia
• J96.22 Acute and chronic respiratory failure with hypercapnia
• J98.4 Other disorders of lung
• J98.01 Acute bronchospasm
• J39.8 Other specified diseases of upper respiratory tract
• J98.09 Other diseases of bronchus, not elsewhere classified
• J98.8 Other specified respiratory disorders
• J22 Unspecified acute lower respiratory infection
• R06.00 Dyspnea, unspecified
• R06.09 Other forms of dyspnea
• R06.3 Periodic breathing
• R06.83 Snoring
• R06.89 Other abnormalities of breathing
• R09.2 Respiratory arrest
• S02.609A Fracture of mandible, unspecified, initial encounter for closed fracture
• S02.609B Fracture of mandible, unspecified, initial encounter for OPEN fracture
• S02.609D Fracture of mandible, unspecified, subsequent encounter with routine healing
• S02.609G Fracture of mandible, unspecified, subsequent encounter with delayed healing
• S02.609K Fracture of mandible, unspecified, subsequent encounter with nonunion
• S02.609S Fracture of mandible, unspecified, sequela
• S02.69XA Fracture of mandible of other specified site, initial encounter for closed fracture
• S02.69XB Fracture of mandible of other specified site, initial encounter for open fracture
• S02.69XD Fracture of mandible of other specified site, subsequent encounter with routine healing
• S02.69XG Fracture of mandible of other specified site, subsequent encounter with delayed healing
• S02.69XK Fracture of mandible of other specified site, subsequent encounter with nonunion
• S02.69XS Fracture of mandible of other specified site, sequela
• S02.400A Malar fracture unspecified, initial encounter for closed fracture
• S02.400B Malar fracture unspecified, initial encounter for open fracture
• S02.400D Malar fracture unspecified, subsequent encounter with routine healing
• S02.400G Malar fracture unspecified, subsequent encounter with delayed healing
• S02.400K Malar fracture unspecified, subsequent encounter with nonunion
• S02.400S Malar fracture unspecified, sequela
• S02.401A Maxillary fracture, unspecified, initial encounter for closed fracture
• S02.401B Maxillary fracture, unspecified, initial encounter for open fracture
• S02.401D Maxillary fracture, unspecified, subsequent encounter with routine healing
• S02.401G Maxillary fracture, unspecified, subsequent encounter with delayed healing
• S02.401K Maxillary fracture, unspecified, subsequent encounter with nonunion
• S02.401S Maxillary fracture, unspecified, sequela
• S02.402A Zygomatic fracture, unspecified, initial encounter for closed fracture
• S02.402B Zygomatic fracture, unspecified, initial encounter for open fracture
• S02.402D Zygomatic fracture, unspecified, subsequent encounter with routine healing
• S02.402G Zygomatic fracture, unspecified, subsequent encounter with delayed healing
• S02.402K Zygomatic fracture, unspecified, subsequent encounter with nonunion
• S02.402S Zygomatic fracture, unspecified, sequela
• S02.411A LeFort I fracture, initial encounter for closed fracture
• S02.411B LeFort I fracture, initial encounter for open fracture
• S02.411D LeFort I fracture, subsequent encounter with routine healing
• S02.411G LeFort I fracture, subsequent encounter with delayed healing
• S02.411K LeFort I fracture, subsequent encounter with nonunion
• S02.411S LeFort I fracture, sequela\
• S02.412A LeFort II fracture, initial encounter for closed fracture
• S02.412B LeFort II fracture, initial encounter for open fracture
• S02.412D LeFort II fracture, subsequent encounter with routine healing
• S02.412G LeFort II fracture, subsequent encounter with delayed healing
• S02.412K LeFort II fracture, subsequent encounter with nonunion
• S02.412S LeFort II fracture, sequela
• S02.413A LeFort III fracture, initial encounter for closed fracture
• S02.413B LeFort III fracture, initial encounter for open fracture
• S02.413D LeFort III fracture, subsequent encounter with routine healing
• S02.413G LeFort III fracture, subsequent encounter with delayed healing
• S02.413K LeFort III fracture, subsequent encounter with nonunion
• S02.413S LeFort III fracture, sequela

Additional Information

Assistant Surgeon — Sometimes

Patient Information

Although often performed as an emergency procedure in life-threatening situations, tracheostomy may also be required for urgent and elective reasons. A tracheostomy is an opening made in the trachea (windpipe) to allow breathing when the larynx is obstructed or to permit long-term ventilation of the lungs through a tube inserted into the neck opening. The main complication is bleeding, and this is often related to the speed required to perform this operation in emergency situations. Other complications include escape of air into the tissues of the neck (subcutaneous emphysema), which is treatable, and postoperative narrowing in the trachea at the site of the tracheotomy, or scar formation in the lower neck skin. Tracheotomy is usually performed in the operating room, but may be done at the bedside using open or percutaneous (small incisional) approach by trained surgeons in properly selected patients.

Important Disclaimer Notice (Updated 8/7/14)

Clinical indicators for otolaryngology serve as a checklist for practitioners and a quality care review tool for clinical departments. The American Academy of Otolaryngology—Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Clinical Indicators are intended as suggestions, not rules, and should be modified by users when deemed medically necessary. In no sense do they represent a standard of care. The applicability of an indicator for a procedure must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical indicators will not ensure successful treatment in every situation.

The AAO-HNS/F emphasizes that these clinical indicators should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. The AAO-HNS/F is not responsible for treatment decisions or care provided by individual physicians. Clinical indicators are not intended to and should not be treated as legal, medical, or business advice.

CPT five-digit codes, nomenclature and other data are copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Updated November 2016