Indications

The indications for tracheostomy include (1) prolonged mechanical ventilation (>7 days); (2) an inability to protect airway such as in severe traumatic brain injury, severe maxillofacial trauma, extensive neck, or vocal cord edema/trauma/injury; (3) complex tracheal repair; (4) cervical spinal cord injuries; and (5) respiratory failure and the need for multiple and frequent trips to the OR.

Procedure Options, Contraindications, and Preparation

Bedside tracheostomy can be performed via an open or percutaneous technique based on the surgeon’s preference. Tracheostomy is not recommended at times when respiratory complications related to the procedure will be poorly tolerated by the patient. These include situations such as severe hypoxemia, severe hypercarbia, or respiratory acidosis. Redo tracheostomies in patients with difficult anatomy (short neck, goiter) should preferably be performed in the OR under more favorable conditions with optimal lighting. Specific relative contraindications to the percutaneous tracheostomy include a redo tracheostomy, moderate to severe coagulopathy, and unstable cervical spine injuries or an inability to extend the neck.

Adequate preparation for this procedure is critical, as errors can quickly lead to major complications. A complete surgical tracheostomy set and percutaneous tracheostomy kit are present at the bedside (Table 1). Lighting in the SICU should be optimized or surgeons may prefer using a headlight. Assisting personnel include a surgical team with an operating surgeon attending and one or two assistant surgeons, one respiratory therapist, one anesthesiologist, and a nurse. All personnel in the room have protective headwear, masks, and gloves, and the surgeons also wear sterile gowns and gloves.

Table 1 Equipment Required for Bedside Tracheostomy

Open Tracheostomy Technique

Once the patient is paralyzed and sedated, the neck is prepped and draped. Local anesthetic is injected at the surgical site, and then a 2-cm vertical midline incision is made below the cricoid. The platysma is divided and the strap muscles are retracted laterally. The second to fourth tracheal rings are exposed by retracting the isthmus of thyroid superiorly (using a vein retractor) or by dividing the isthmus of the thyroid. Stay sutures can be placed at the lateral aspect of trachea; note that the balloon of endotracheal tube should be deflated while placing stay sutures. Before the procedure begins, the surgeon should test the balloon of the tracheostomy, and ensure that the anesthesiologist suctions the endotracheal tube and mouth and that all equipment works and is within reach. A tracheotomy is performed using an 11-blade scalpel, the opening is dilated, and under direct vision the endotracheal tube is pulled back to just above the tracheotomy site. The tracheostomy is inserted, the inner cannula is placed, and the balloon is inflated. Then capnography is performed, adequate return of tidal volume is assessed, and chest wall movement is visualized. When placement is confirmed, the tracheostomy is sutured to the skin and secured with tracheal ties, and then the endotracheal tube is removed (Figure 1).

Figure 1 Tracheostomy tube insertion.

(From Velmahos GC: Bedside tracheostomy. In Shoemaker WC, Velmahos GC, Demetriades D, editors: Procedures and Monitoring in the Critically Ill. Philadelphia, WB Saunders, 2001, figure 5-4, p. 34.)

Percutaneous Dilatation Technique

There are several kits available today with various modifications for the percutaneous tracheostomy using the Ciaglia technique. The authors recommend the following percutaneous technique, which includes making a 2-cm vertical midline incision below the cricoid, and gentle dissection and retraction of the strap muscles with the ability to identify the thyroid and palpate the tracheal rings. With or without the use of a bronchoscope in the endotracheal tube, the endotracheal tube is pulled back superiorly so that a 10-ml saline-filled syringe is inserted into the trachea just below the endotracheal tube at about the second or third tracheal ring. Once air bubbles enter the syringe, the syringe is removed and a guidewire is advanced into the tracheal lumen. The needle is removed and the tract is dilated with the short dilator. With the use of a guiding catheter, either serial dilation (12–36 Fr) or a single tapered dilation is performed. The 28-Fr dilator within a #8 tracheostomy tube is placed over the guiding catheter and the entire unit is inserted into the trachea (Figure 2). Once in place, the guidewire, the guiding catheter, and the 28-Fr dilator are removed; the inner cannula is placed; and the balloon is inflated. Placement is confirmed and securing of the tracheostomy is performed as previously explained.

Figure 2 Percutaneous dilation technique (up to 36FR). FR, French.

(From Velmahos GC: Bedside tracheostomy. In Shoemaker WC, Velmahos GC, Demetriades D, editors: Procedures and Monitoring in the Critically Ill. Philadelphia, WB Saunders, 2001, figure 5-9, p. 37.)

Mortality, Morbidity, and Complications

Bedside tracheostomy is considered a safe procedure when performed meticulously and using the suggestions stated above. It has a low mortality rate (0.1%–1%) and minimal morbidity (up to 3%).³ Complications related to tracheostomy occur intraoperatively, early postoperatively, and late postoperatively. Intraoperative complications include bleeding, perforation of posterior wall of the trachea or anterior wall of esophagus, hypoxia, and loss of the airway. Early postoperative complications include bleeding, hematoma, pneumothorax, and tracheoesophageal fistula. Late postoperative complications include subglottic stenosis, laryngeal nerve injury, tracheal granulation, and tracheoinnominate fistula.

A meta-analysis comparing open surgical and percutaneous tracheostomies found that the rate of serious complication was similar in the two groups.⁴ The authors also noted that perioperative complications occurred more often with the percutaneous technique, but that postoperative complications were more frequent with the open surgical tracheotomy. However, most of the differences in complication rates were attributed to minor complications. Another meta-analysis by Freeman et al.⁵ found no difference in overall operative complication rates, but found lower postoperative complications and bleeding in the percutaneous technique. Currently, there are no prospective data to support the use of bronchoscopy to reduce complications related to percutaneous tracheostomy, but using it is advocated during the learning curve.

Indications

Many patients undergoing major surgery for trauma will have a jejunostomy tube or gastrostomy tube inserted at the time of surgery. In the SICU setting, patients needing access to the gastrointestinal tract are those who remain ill and are unable to eat. Any organ failure may cause inability to tolerate oral feedings, especially failure resulting from prolonged ventilatory dependency, traumatic brain injury, or prolonged sepsis. If the duration of injury is expected to be 1–2 weeks, feeding can be given by naso- or oro-gastric tube. Longer periods of naso- or oro-gastric intubation are associated with sinusitis, increased reflux, aspiration, and rarely esophageal stricture. Other indications for PEG include facial trauma and dysphagia.