Secure airway Expedite weaning or transfer from ICU Facilitate nursing care Communication Patient comfort and eating Mobility/physical therapy
Pneumothorax Tracheo‐innominate artery fistula
Early versus late tracheostomy
Early tracheostomy is variably defined, and generally performed within 4 days of intubation.
Earlier tracheostomy is considered if the likelihood of intubation is recognized to be prolonged beyond 2 weeks.
Patient discomfort secondary to translaryngeal intubation and multiple failed extubation attempts may also support earlier tracheostomy.
The benefits for earlier intervention are not clear. In some studies, such as in patients with traumatic brain injury or subarachnoid hemorrhage, reductions in length of stay (LOS) and pulmonary infections have been seen. However, in these neurosurgical populations, patients are often considered for earlier tracheostomy due to mental status issues and fear of weaning. A review and meta‐analysis also indicated early tracheostomy placement reduced the duration of mechanical ventilation and hospital stay.
There is no definitive mortality benefit for early tracheostomy.
In general, the decision for tracheostomy should begin with an evaluation of the patient within a week of intubation as to the likelihood of extubation in the upcoming week. The first week’s course is often predictive of ventilator dependency.
Open surgical tracheostomy versus bedside PDT
Bedside approaches are performed either as open, cut‐down procedures or via PDT using the Seldinger method. The Seldinger method is essentially a blind procedure done at the bedside.
The primary advantages to the bedside approach are the more efficient use of OR time and the consequent cost savings, which include those of patient transportation and general anesthesia.
Further advantages of PDT include smaller incisions, decreasing the likelihood for poor wound healing, scarring, and peristomal bleeding, and reduced local site infections. The procedure can also be more timely.
LOS in the ICU as well as time to placement of the tracheostomy is significantly shortened with PDT, suggesting further cost savings when using bedside procedures.
Most importantly, major complications and mortality are similar between PDT and open surgical tracheostomy. This is regardless of whether the bedside procedure is PDT or open.
Consent for procedure includes the risks of: pneumothorax (PTX), tracheo‐innominate artery fistula, airway damage and stenosis, bleeding, infection, and death.
Mortality of this procedure is less than 1%, while major morbidity is 5–10%.
Bleeding with PDT is minimal. Prior ultrasonography of the trachea assesses for any smaller crossover veins, which are uncommon but may cause bleeding.
PTX is a serious complication that can be fatal if not immediately recognized and treated. It presents with difficulty in ventilation, hypotension, and/or oxygen desaturation due to tension PTX, and often within minutes of the tracheotomy. Chest tube kits should be readily available during these procedures.
Innominate artery fistula can either be a relatively early or late event, and is a surgical emergency. A surgeon should immediately assess any bleeding from the tracheostomy site since any manipulation of the tube may undo the (possibly life‐saving) tamponade effect on the fistula.
Tracheal stenosis and tracheomalacia can be late complications at the tracheostomy site.
Selection of candidates for bedside PDT
Patient’s history and clinical status
Indication for tracheostomy: failed weaning/extubation, relief of airway obstruction or secretions.
Review surgical history for prior neck surgery, tracheostomy, or radiotherapy to the anterior trachea/neck.
Hemodynamic stability, stable cardiac condition.
Lack of bleeding, intact coagulation profile (preferably INR <1.5 and platelet count >50 000).
Absent severe sepsis.
In making the decision for PDT, it is important to keep in mind that this is an otherwise elective procedure so care must be taken to avoid potential complications.
Examination of candidates
The ideal patient for PDT has a well‐defined anatomy – a long thin neck, with palpable tracheal spaces that can be hyperextended safely. The first criterion safeguards the anatomy for this essentially blind procedure: namely that the tracheotomy is done between the third and fourth tracheal cartilage. The splaying of the cartilage rings is key in the proper positioning of the patient for PDT. In general, patients with recent neck injuries, morbidly obese necks, and previous tracheostomy or neck irradiation are contraindicated for bedside PDT. Anterior infection or burns of the neck, as well as goiter or masses, are also contraindications. Such patients are better relegated to an open surgical procedure.
If cervical spinal injury is present, PDT is contraindicated, and if in question, neurosurgical or neurological clearance for hyperextension would be necessary. Patients whose neck cannot be hyperextended such as patients with cervical osteoarthritis are also better treated in the OR. Note: PDT is not meant for acute emergency tracheotomies where the more cephalad cricothyroid membrane is the anatomy of choice for the tracheotomy.
The physical exam concentrates on identifying adenopathy, burns, infection, masses, scars (previous surgery or old tracheostomy scar), trauma, and thyromegaly (goiter). Review the skin surface for small veins to avoid lacerating during the procedure. If available, US examination can assist in identifying any aberrant vasculature or other anomalies that may defer PDT to an operative procedure.
Assess the extent of neck hyperextension. Is the neck short and thick? Is extension not possible due to cervical arthritic changes? Inability to palpate the tracheal anatomy due to obesity or short neck length, and/or inability to hyperextend allowing at least two finger breaths above the sternal notch would contraindicate the procedure.
Patients with obese necks may have successful PDT although they may require bronchoscopic assistance, cut down, and longer tracheostomy tubes. The patient must be hemodynamically stable as significant sedation and/or paralysis may be needed for the procedure. The most common reason to prolong the PDT procedure is sedation‐related hypotension necessitating intravenous fluids or vasopressors. Assessing the degree of hyperextension earlier will require full sedation, indicating the need for fluid resuscitation prior to the procedure. Also be aware that bradycardia due to vagal effects may worse.
The patient should have satisfactory gas exchange, not requiring high PEEP.
Previous tracheostomy, surgery.
Skin infection or burns.
Short obese neck, goiter, adenopathy, mass.
Spinal injury, lack of hyperextension.
High O2 requirements (high PEEP).
Poor nutrition status.
The procedure (Video 6.1) can be performed in a critical care unit with continuous monitoring.
Patient must be NPO for at least 6 hours and subcutaneous heparin is withheld prior to the procedure.
All appropriate sterile precautions must be employed, using sterile gowns, masks, gloves, and drapes along with the PDT kits.
Procedure without bronchoscopic guidance
Start by providing appropriate sedation. Fentanyl and propofol are given to the patient, ideally as an infusion, and titrated so the patient is motionless, without cough or gag, when palpating the trachea. If hypotension develops, the decision to provide fluids, vasopressors, and to continue the procedure are made jointly between the surgeon and anesthesiologist. Paralysis is not a requirement for this procedure and is reserved for those patients with movement despite adequate sedation.
After sedation is achieved, a roll is placed midline under the scapula to facilitate hyperextension of the neck (Figure 6.1). The head is ideally hanging in air unless you place a pillow underneath. This positioning may arouse the patient if they are not adequately sedated.
Prepare the PDT kit (Figure 6.2): test the tracheostomy tube (TT) cuff for patency, and remove all air after testing; adequately lubricate the TT and trochanter; prepare the guidewire; fill the subcutaneous and catheter syringes with 1% lidocaine/epinephrine; and hydrate the dilator with saline flush.
Increase the oxygen to 100% FiO2; suction the endotrachea (ET) and mouth for secretions; clean the anterior neck and inject lidocaine/epinephrine subcutaneously two fingers above the sternal notch and midline. The respiratory therapist then deflates the ETT cuff while increasing the tidal volume to compensate for creating a leak (add 100 mL to the tidal volume).
Palpate your needle puncture point at two fingers above the sternal notch and two cartilage rings below the cricoid cartilage. The needle is advanced in a perpendicular position midline on the trachea.
At the midline position of the trachea there is no muscle or vasculature. The sternocleidomastoid, sternohyoid, and sternothyroid are lateral. A puncture too high will result in difficulties with the cartilage; too low may result in erosion of the tracheostomy tube into the innominate artery creating a fistula.
Advance the needle while pulling on the syringe filled with 1% lidocaine and epinephrine. When air is drawn into the syringe you have entered the trachea.
Aspiration of air confirms intraluminal tracheal placement. Entering the ET is a possibility; however it would require an extraordinary effort in piercing during the needle insertion. More likely you are in the trachea where the needle tip may be scratching the ET surface. The cuff may be ruptured at this point, but you should simply proceed. Adding to the tidal volume earlier should maintain ventilation.
Immediately ‘anchor’ the needle by placing your fingers at the junction of the needle and the skin of the neck to avoid dislodgment. Inject 5 mL of the 1% lidocaine/epinephrine solution.
Repeatedly reaffirm placement by demonstrating air bubbles during the procedure, especially if there is dislodgment from movement or otherwise. At any time if the location of needle is of concern start the procedure again, including palpating the trachea as above.
Once the needle is touching the ET, the respiratory therapist pulls the ET back and forth which leads to tugging the needle in your fingers and affirming your position on the ET (Figure 6.3A).
The ET is then gradually pulled to the 20 cm mark or when you no longer feel the ET any more (Figure 6.3B), usually between 18 and 19 cm.
Angle the needle caudally and pass the catheter. It should pass easily into the trachea.
If there is immediate resistance to advancing the catheter, you may not be in front of the ET, or possibly in a blind pouch. Return the needle to the perpendicular position; reaffirm position with air bubbles and have the respiratory therapist pull the ET slightly further cephalad. Retry passing the catheter as above.
The guidewire is now advanced into the trachea and should pass freely, inducing a cough when at the bifurcation. At this point, bronchoscopic or US confirmation can be performed (Figure 6.4).
Using the scalpel, make a perpendicular cut longitudinally, next to the guidewire, above and below it. The single straight dilator follows, opening the tracheotomy, after which blood‐tinged secretions may be seen bubbling through the incision. The plastic guidewire is placed over the metallic guidewire followed by the tapered dilator. The tapered dilators are marked to identify the level of dilation fitting the sized tracheostomy tube to be placed; proceed slowly with continued effort as you are dilating.
Ultrasonography prior to the procedure reviews the anatomy and assesses for anomalous vasculature that risks bleeding. It may also be of benefit in confirming the guidewire presence in the tracheal lumen. This is especially helpful if any questions arise during the procedure, so ultrasound should be available at the time of the procedure. This can also be done by bronchoscopy.
Once fully dilated, the TT is inserted over the guidewire left in place once the dilator was removed. Again, maintaining the patient in the fully extended position is key to performing this step smoothly.
Remove the trochanter from the TT, replace it with the inner cannula and connect to the ventilator. Do not extubate unless the patient is receiving full tidal volumes on the ventilator (remember air escaping from the ET may falsely diminish tidal volumes); listening to breath sounds and assessing O2 saturation and end‐tidal CO2 will help verify TT placement.
Remove the ETT, suture the TT in place and order a CXR to rule out PTX.
The use of bronchoscopic guidance during tracheostomy is not routinely required and in at least one study did not result in better outcomes.
It allows for positioning of the ETT and the placement of the needle under direct visualization.
Bronchoscopy may be of more use in complicated cervical collar patients or the obese; or acutely if uncertainties arise during the procedure.
The advantages of bronchoscopy include: real‐time needle‐tip localization during the procedure with less needle punctures; confirmation of endoluminal placement and supracarinal measurement; and if there is dislodgment of the ETT or TT during the procedure it can guide replacement.
The disadvantages include: additional equipment and personnel (bronchoscopist) and greater cost. Bronchoscopy can obstruct the airway with possible impaired ventilation.
Management of complications
Pneumothorax: in the event of deterioration from a diagnosed or suspected PTX, immediately place a needle anteriorly between the first and second ribs, and bilaterally unless unilateral PTX is obvious.
PTX can also present later, which is why a CXR always follows the procedure. If pneumothorax is present, a chest tube is required to prevent the development of tension pneumothorax.
Standard tracheostomy care and gradual weaning from the ventilator is followed.
De‐cannulation is considered when the patient is breathing spontaneously without mechanical ventilation for a specified period of days, demonstrates reduced secretions, is able to cough secretions through the mouth, and has a patent airway.
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