Background
Tracheostomy remains a common intervention in critically ill patients requiring prolonged mechanical ventilation, offering advantages such as improved airway clearance and patient comfort. However, the long-term impacts on laryngotracheal anatomy and the sequelae affecting decannulation remain insufficiently characterized. Laryngotracheal structural alterations can lead to airway obstruction, complicating removal of the tracheostomy tube (decannulation) and resulting in significant clinical challenges. Previous clinical observations have suggested the presence of tracheal stenosis and fibrotic changes, but systematic radiological quantification and comparative assessment of surgical versus percutaneous tracheostomy techniques are lacking. This study addresses this gap using computed tomography (CT) to precisely quantify morphological changes and identify imaging predictors of decannulation success, informing clinical decision-making.\n\n
Study Design
This retrospective cohort study analyzed 82 chronically ventilated patients who underwent either surgical open tracheostomy (SOT) or percutaneous dilatational tracheostomy (PDT) with CT performed at least four weeks after the procedure. Using a standardized methodology, lumen areas were measured in triplicate at the cricoid, suprastomal, and distal tracheal levels. Additional assessments included identification of cartilage fractures, stoma position relative to the cricoid cartilage, and tracheal wall thickness. The study aimed to compare morphologic outcomes between SOT and PDT groups and to explore CT-based predictors of successful decannulation.
Key Findings
CT imaging revealed substantial morphological alterations in the laryngotracheal complex following tracheostomy. Specifically, the cricoid lumen area was reduced by an average of 37%, corresponding to a mean difference of -88.9 mm2 (95% CI: -113.2 to -64.6; p < 0.001). The suprastomal lumen area exhibited an even more pronounced constriction, decreasing by 53% (mean difference: -135.1 mm2, 95% CI: -160.2 to -110.0; p < 0.001). Notably, the distal tracheal lumen did not demonstrate significant change (p = NS). Additionally, tracheal wall thickness increased significantly from 1.93 mm to 2.89 mm (+0.96 mm; 95% CI: 0.80 to 1.12; p < 0.001), reflecting probable fibrotic remodeling.\n\nCartilage fractures were identified in 63.4% of patients, highlighting a high prevalence of structural injury post-tracheostomy. Regarding stoma positioning, 22% of stomas were located at or above the cricoid cartilage level. This positional variable was strongly associated with decannulation outcomes; none of the 14 patients with cricoid-level stomas achieved successful decannulation, compared to 29.4% decannulation success in other positions (Fisher exact p = 0.016).\n\nSuprastomal fibrotic or cartilaginous block, whether partial or complete, was significantly more common in patients who failed decannulation (63.3%) versus those successfully decannulated (35.0%; Fisher exact p = 0.038; odds ratio 0.32, 95% CI: 0.11-0.92), indicating its importance as a predictor. No statistically significant differences in all measured outcomes, including lumen area reductions, cartilage injury, or wall thickness, were noted between the surgical and percutaneous tracheostomy groups.
Expert Commentary
The findings underscore that long-term tracheostomy induces significant morphologic alterations predominantly in the suprastomal and cricoid regions, areas critical for airway patency. The strong correlation between stoma positioning at the cricoid and decannulation failure highlights the need for careful anatomic consideration during tracheostomy placement to minimize upper airway compromise. Moreover, the identification of suprastomal fibrotic or cartilaginous obstruction as an independent predictor of decannulation failure provides a targetable lesion for airway interventions.\n\nImportantly, the lack of significant differences between SOT and PDT techniques suggests that both carry similar risks of inducing these structural changes, emphasizing that the procedural approach per se may be less critical than stoma location and postoperative remodeling. The high incidence of cartilage fractures raises concerns about mechanical trauma during tracheostomy and its role in subsequent airway stenosis, warranting careful technique and potentially postoperative surveillance.\n\nThe use of CT as a non-invasive modality for quantitative assessment thus offers a valuable tool in the management of chronic tracheostomy patients. Clinicians should consider imaging-based evaluation before attempting decannulation, particularly in patients with prolonged cannulation durations or prior failed attempts, to identify candidates for surgical or endoscopic airway interventions that may optimize outcomes.
Conclusion
This study demonstrates that chronic tracheostomy leads to substantial reductions in laryngotracheal lumen dimensions, increased airway wall thickness, and frequent cartilage injury, resulting in clinically relevant airway remodeling. No significant structural differences were observed between surgical and percutaneous techniques. Crucially, stoma placement at or above the cricoid cartilage and suprastomal fibrotic or cartilaginous block are significant predictors of decannulation failure. These insights support routine CT assessment in chronically tracheostomized patients, especially prior to or after unsuccessful decannulation, to guide individualized airway management and intervention strategies. Future prospective studies are needed to evaluate preventive approaches, refine procedural techniques, and validate CT-based predictive models to improve patient outcomes in this challenging population.
Reference:
Pinhas S, Bartov N, Adi M, Shapira-Galitz Y, Kiderman D, Allon R. CT Assessment of Laryngotracheal Changes After Surgical and Percutaneous Tracheostomy. Laryngoscope. 2026 Jul 20. doi: 10.1002/lary.70756. Epub ahead of print. PMID: 42476951.
