Percutaneous Tracheostomy

OVERVIEW

  • Tracheostomy is an airway that is inserted subglottically through neck tissues directly into the trachea.
  • Surgical Tracheostomy involves dissection and incision of trachea under direct vision.
  • Percutaneous Tracheostomy involves Seldinger technique and dilatation of trachea between rings.
  • PDT is percutaneous dilational tracheostomy

INDICATIONS

  • airway obstruction
  • inability to protect the airway (e.g. from aspiration)
  • access for pulmonary toilet
  • facilitate weaning from prolonged mechanical ventilation

CONTRAINDICATIONS

Absolute

  • patient or family refusal
  • emergency
  • paediatric patient (< 16 years)
  • midline neck mass
  • uncorrected coagulopathy or platelet dysfunction
  • infection at site

Relative

  • suspected or known difficult intubation
  • poor respiratory function: FiO2 > 0.6, PEEP > 10
  • difficult anatomy – obese/short neck/neck distortion
  • tracheomalacia
  • unstable c-spine or c-spine immobilisation (cervical fusion/instability, rheumatoid arthritis)

INSERTION TECHNIQUE

  • assess for appropriateness of PDT
  • consent
  • fast
  • IV access
  • preoxygenate
  • emergency re-intubation gear
  • standard monitoring (including ETCO2)
  • personnel: surgeon, anaesthesia + bronchoscopist (all with adequate experience or supervision)
  • GA + LA
  • pull ETT back to cords (?LMA use)
  • sterile technique
  • insert percutaneous tracheostomy

Different techniques of PDT are discussed in more detail here.

POST-INSERTION

  • secure
  • CXR
  • if accidental decannulation takes place in first 72 hours -> oral intubation

ADVANTAGES OF PDT

  • reduced sedation requirement (greater comfort than oro-tracheal intubation)
  • airway protection while unconscious
  • allows gradual weaning of ventilatory support (reduced work of breathing)
  • enhanced communication (written or phonation)
  • decreased ICU mortality
  • enhanced nursing care (mouth care and mobility)
  • ease of replacement of tracheal tube
  • can facilitate transfer to the ward

DISADVANTAGES/COMPLICATIONS OF PDT

TIMING

“DOWN SIZING”

  • hang over from when all tracheostomies were surgically inserted (window cut into trachea) -> downsizing would allow gradual closure of tract and was less likely to result in fistula.
  • no real place in percutaneous tracheostomies
  • advantages: improved swallow
  • disadvantages: increased work of breathing, repeat trauma to airway, not really needed

FENESTRATED TRACHEOSTOMY TUBES

  • for awake alert patients who want to phonate
  • must have no risk of aspiration
  • need to deflate cuff and insert a fenestrated inner
  • prevents disuse atrophy of the vocal cords
  • must warn patients that they will have sensation of air coming up through vocal cords
  • may allow cough into mouth

WARD CARE

  • often suboptimal on non-surgical wards
  • patient are by definition high risk patients
  • if managed by outreach teams can improve outcomes (doctor, nurses, SLT, physio) – TRAM team
  • emergency and replacement equipment should be at the bedside at all times

WEANING AND REMOVAL

Weaning

  • Some consider it once the patient has had the tracheostomy tube plugged for 48 hours or more, whereas others consider it once a speaking valve is tolerated
  • Weaning may be achieved with a number of different pathways including direct removal of the TT, routine downsizing, changing to a cuffless TT, use of fenestrated TT, spigotting/capping/corking or use of a speaking valve.
  • no evidence for any specific pathway
  • approach tends to be clinician / institution specific

Removal

  • absence of airway obstruction (tracheal stenosis or granulation tissue) according to nasoendoscopy and/or clinically by tube occlusion with cuff down
  • sputum burden decreasing (2-4 hourly)
  • patient co-operative
  • good cough
  • patient able to protect upper airway from aspiration
  • no longer requires mechanical ventilation

References and links

litfl.com

Journal Articles and Textbooks

  • Cheng E, Fee WE Jr. Dilatational versus standard tracheostomy: a meta-analysis. Ann Otol Rhinol Laryngol. 2000 Sep;109(9):803-7. PubMed PMID:11007080.
  • Clec’h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, Azoulay E, Adrie C, Jamali S, Zaccaria I, Cohen Y, Timsit JF. Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med. 2007 Jan;35(1):132-8. PubMed PMID: 17133180.
  • Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55. Review. PubMed PMID: 16606435; PubMed Central PMCID: PMC1550905.
  • De Leyn P, Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y, Van Meerhaeghe A, Van Schil P; Belgian Association of Pneumology and Belgian Association of Cardiothoracic Surgery. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg. 2007 Sep;32(3):412-21. Epub 2007 Jun 27. Review. PubMed PMID: 17588767. [Free Fulltext]
  • Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med. 1999 Aug;27(8):1617-25. PubMed PMID: 10470774.
  • Engels PT, Bagshaw SM, Meier M, Brindley PG. Tracheostomy: from insertion to decannulation. Can J Surg. 2009 Oct;52(5):427-33. Review. PubMed PMID: 19865580; PubMed Central PMCID: PMC2769112.
  • Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000 Nov;118(5):1412-8. PubMed PMID: 11083694. [fulltext]
  • Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005 May 28;330(7502):1243. Epub 2005 May 18. Review. PubMed PMID: 15901643; PubMed Central PMCID: PMC558092.
  • Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005 Apr;50(4):497-510. Review. PubMed PMID: 15807912. [Free Fulltext]
  • Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007 Mar;117(3):447-54. Review. PubMed PMID: 17334304.
  • Wang F, Wu Y, Bo L, Lou J, Zhu J, Chen F, Li J, Deng X. The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Chest. 2011 Dec;140(6):1456-65. Epub 2011 Sep 22. Review. PubMed PMID: 21940770.

Social media and web resources


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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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