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
- requirement for a surgical procedure
- See Tracheostomy complications
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
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
LITFL
- Paul Young’s ICU Mind Maps
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
- UK National Tracheostomy Safety Project at www.tracheostomy.org.uk
- Resus.ME — Bleeding Tracheostomy
- Resus.ME — LMA to stoma ventilation
- Resus Room — Airway Management in the Trached Patient: Not an Oxymoron!
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC