Epidemiology
Common ICU procedure
Used in 8-24% of patients on prolonged vent
Increasing frequency
Lack of evidence-based guidelines, variances in Trach utilization - anywhere from 4 to >20 days on vent
Tracheostomy Indications
Upper airway obstruction (like tumors)
Prolonged need for vent. support (common, less clear cut)
Airway protection
Airway access for secretion removal
Tracheostomy Contraindications
Neck Soft Tissue Infection
Anatomic aberrations of upper airway
+/- Hypocoagulability
+/- High level of Vent support / Instability - need to tolerate switch from one airway to another
Local prosthetic devices
- Vascular patch - like in carotid
- HD cath - do HD cath first and tunnel it away
- spinal fixation hardware - infection risk is lower than risk of PNA, go ahead and trach them
Potential Benefits of Tracheostomy
More secure airway
Less trauma to vocal cords / larynx
Increased patient comfort - can eventually talk through trach
Decreased analgesic need
Reduced airway resistence
Easier, safer vent weaning
Timing of Tracheostomy
> 21 days of vent - Trach indicated
< 10 days of vent. - Trach not indicated
10 – 21 days of vent - Selective Trach use
Potential benefits of “early” tracheostomy (early varies from <2 to <21 days)
Decreased laryngeal injury
Decreased duration of ventilation
Improved pulmonary toilet
Decreased VAP rate
Decreased time to extubation/discharge
Decreased mortality
Early Tracheostomy affect on duration. of mechanical ventilation
Most studies find decreased duration of ventilation with early tracheostomy
Early Tracheostomy affect on duration. of ICU Stay
Most studies find decreased duration of ICU stay with early tracheostomy
Early Tracheostomy affect on duration. of Hospital Stay
Not as many studies compare hospital stay with early tracheostomy, data is mixed
Early Tracheostomy affect on the risk of Vent-Associated Pneumonia
Most studies find trend towards decreased incidence of ventilator associated pneumonia with early tracheostomy, not necessary statistically significant
Early Tracheostomy affect on Mortality
Some data shows decreased mortality with early tracheostomy, not-uniform results in studies
Recent Prospective Studies - (Look at Frieman Review paper)
Terragni et al study:
- Benefits of early trach: decreased duration on vent, decreased ICU LOS
- Mortalities/serious complications: 0
- Equivalent outcomes: VAP, Mortality, hospital LOS, need for LTACH
Troullet et al study:
- Benefits: decreased unplanned extubations, decreased sedatives/analgesics, earlier mobilization
- Mortalities/serious complications: 0
- Equivalent outcomes: Duration on vent, mortality, VAP, hospital LOS, ICU LOS
TracMan Study
- benefits: decreased duration of sedation
- Mortalities/serious complications: 0
- Equivalent outcomes: mortality, hospital LOS, ICU LOS
Summary:
- Tracheostomy can be performed safely (majority were dilatational technique, 0 mortality/comp)
- Most patients probably don’t benefit from Trachs prior to 14 days
Circumstances not accounted for in these trials which might benefit from earlier trachs
- multiple failed extubations
- difficult to manage agitation or delirium
- significant neuro deficits (CVA, Trauma, etc...)
- significant comorbidities / ongoing issues / needs for multiple OR returns
Open Tracheostomy
Small collar incision
Disect strap muscles to side
move or dissect thyroid if needed
Look for 2-3rd tracheal rings
- Higher = tracheal stenosis
- Lower = tracheoinominate fistulas
Make incision in-between cartilage
Deflate ET balloon and pull back slightly
Place tracheostomy tube
When removing tracheostomy, just ET intubate the patient, especially when very early
“Percutaneous” Tracheostomy
1985 – Ciaglia described
“Dilatational” Tracheostomy is more accurate
More readily performed at bedside
Originally done under bronchoscopic guidance which has subsequently been shown not to be needed routinely
Position patient with arms at side, role under shoulders with head extended
Prep, palpate, small transverse collar incision 2 finger breadths above the sternal notch
Separate the strap and maybe thyroid tissue
Palpate cricoid cartilage then down to 2nd and 3rd tracheal rings
Push hard and feel ET tube, deflate ET balloon, pull ET back above entry
Using seeker needle aspirate air bubbles
Place J wire through
Pull sheath out, DOUBLE CHECK MIDLINE APPROPRIATE PLACEMENT, once dilated you're done
Pass sequential dilatation catheters or blue rhino, make sure ET tube is out of the way
Percutaneous VS Open Tracheostomy
Percutaneous pros
- wound infection
- unfavorable scarring
- cost effectiveness
- case length
- overall complications
- major hemorrhage
- subglottic stenosis
- death
Open pros
- decannulation/obstruction
- false passage - tracheostomy to nowhere or through trach to esophagus
- minor hemorrhage
Tracheal Stenosis
Common long term complication of prolonged vent.
Can see anywhere from glottic area to mid trach
See c both ET & Trach use
- With ET-tube is usually related to cuff decreasing local mucosal blood flow and causing scarring near distal aspect of ET-tube
- With trach most commonly occurs as result of excess scarring at insertion site
Laryngotracheal Injuries after Intubation
Prospective, Spanish trial with 650 ICU pts (1992 – 1999) published in 2005
650 intubated pts --> 302 Tracheotomies
Protocol = Trach at day 8 (Neuro cases) or 14 (non-neuro)
- Interim analysis after 125 patients --> change to day 8 in non-neuro
Fibroendoscopy 72-96 hr after extubation or trach
Repeated at 15 days, 30 days, & 6-12 monthss
Acute & Chronic (minor or severe) Injuries tracked
Acute Complications: airway loss, acute tube obstruction, hemorrhage, acute airway trauma, infected
trach site
- Intubation --> 94/650 (14%) with 0 deaths
- Tracheotomy --> 84/302 (28%) with 2 deaths (0.3%)
Early endoscopy performed in 473/650 cases, 417 had some injury (88%)
- 197/417 mild injuries, 220/417 severe injuries
- Early Minor Injuries: edema, glottic/subglottic inflammation, vocal cord granuloma, tracheal mucosal irritation, arytenoid injury without impaired mobility
- Early Severe Injuries: altered laryngeal motility, laryngeal or tracheal stenosis, subglottic or tracheal necrosis or ulceration
Late Endoscopy performed in 280 (43%)
- Chronic Injuries found in 30 cases (11%)
Multivariate Analysis of risk factors for late complications: duration of intubation prior to tracheotomy, duration in ICU
Other factors on Univariate Analysis: male sex, presence early injury
Conclusion: “… it is mandatory to avoid the association of prolonged intubation followed by (late) tracheotomy.” “Perform the tracheotomy in time” ie: at 8 days if extubation is not imminent
Decannulation
Little guiding data
Chamber's approach: wait at least 7 to 10 days, down stage to #6, passe muire valve, capped off x 24-48 hours --> remove
Tracheostomy
Place at 2-3rd Ring
Higher assoc. c Stricture
Lower assoc. c Tracheoinominate Fistulization
Tracheoinnominate Artery Fistula
Rare
90% Fatal
Herald Bleed around trach is common
Management: overdistention of balloon, endotracheal intubation and anterior compression via trach tract, sternotomy with arterial resection +/- reconstruction
Airway Emergencies
eg: oral maxillofacial trauma
Sit Patient Up - keeps tongue from falling back and obstructing airway
Beware of Paralytics
Quickly Inspect Wound
Focus: Secure Airway, Stop Bleeding, call a plastic/omf surgeon
Airway - Cricothyroidotomy
Cricothyroid membrane connects thyroid cartilage (superior) to cricoid cartilage (inferior)
Palp adams apple = thyroid cartilage
Cricoid cartillage below
Cricothyroid membrane lies between
Skin incision - longitudinal vs. transverse
Dissect through subcutaneous tissues (can be bloody)
Stabilize thyroid
Cricoid hook (can bend a 22 gauge needle on a hemostat to make cric-hook)
Incise membrane
Have suction available
Dilate (with pinky)
Place tracheostomy tube (can use endotracheal tube but don't bury it)
Secure tube
Convert cricothyroidotomy to tracheostomy within 24-48 hours since it is still going through cords
Must have cuffed tube
Don't forget to secure it
Additional Points
- Extended length trachs - should use them more, especially with obese population
- Avoidance of saline lavage: 5cc saline --> dislodgement of 300,000 bacterial colonies
- Trach Mask tips
- Passe’ Muier Valve
- Downsizing
- Post – extubation swallowing eval.
- Management of Trach-Inominate Fistula
General Principles of Airway Management
Mask ventilation is better than esophageal intubation.
Development of the need for ventilator support signals the loss of a battle…. but better to accept losing the battle than to lose the war.
Tracheostomy is better than re-intubation.
A cut neck heals better than an anoxic brain.
There is no such thing as an easy emergent cric.
Airway management is best learned in the OR, not the ICU.
Summary
Trach at 1-2 weeks if extubation not close
Perc Trach approach
Crics for emergency