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

This is the LITFL CCC master page for tracheostomy — follow the links for further discussion of the following:

• Percutaneous Tracheostomy
• Advantages and disadvantages of tracheostomy
• Percutaneous versus surgical tracheostomy
• Tracheostomy insertion techniques
• Tracheostomy literature summaries
• Swedish nose, Tracheostomy Heat and Moisture Exchanger (in process)
• Timing of Tracheostomy
• Tracheostomy ready for decannulation hot case
• Fenestrated Tracheostomy Tube
• Assessment of Swallow in a Tracheostomy Patient
• Anatomy for tracheostomy
• Tracheostomy complications
• Bleeding tracheostomy
• Respiratory distress in a tracheostomy patient

INDICATIONS

• bypass glottic or supraglottic stenosis/obstruction
• access for tracheal toilet
• provision of a more comfortable airway for prolonged ventilation
• protection from aspiration

COMPLICATIONS

• Tracheostomy complications
• Bleeding tracheostomy
• Respiratory distress in a tracheostomy patient

INSERTION

• Percutaneous Tracheostomy
• Tracheostomy insertion techniques
• Anatomy for tracheostomy
• Percutaneous versus surgical tracheostomy
• Timing of tracheostomy

“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

See Fenestrated Tracheostomy Tube

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

Afterward the stoma site is covered by an occlusive dressing.

• Tracheostomy ready for decannulation hot case

EVIDENCE SUMMARY

• Tracheostomy literature summaries

References and links

LITFL

• Paul Young’s ICU Mind Maps

Journal Articles and Textbooks

• Bittner EA, Schmidt UH. The ventilator liberation process: update on technique, timing, and termination of tracheostomy. Respir Care. 2012 Oct;57(10):1626-34. PMID: 23013900. [Free Fulltext]
• 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. 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. PMID: 10470774.
• Engels PT, Bagshaw SM, Meier M, Brindley PG. Tracheostomy: from insertion to decannulation. Can J Surg. 2009 Oct;52(5):427-33..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. PMID: 11083694. [fulltext]
• Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005 Apr;50(4):497-510. PMID: 15807912. [Free Fulltext]
• Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007 Mar;117(3):447-54. PMID: 17334304.

Social media and web resources

• ATOTW —Tracheostomy (pdf)
• UK National Tracheostomy Safety Project at www.tracheostomy.org.uk
• NSW Tracheostomy CPG — Care of Adult Patients in Acute Care Facilities with Tracheostomy (pdf)
• RCH — Tracheostomy Management Guidelines
• Resus.ME — Bleeding Tracheostomy
• Resus.ME — LMA to stoma ventilation
• Resus Room — Airway Management in the Trached Patient: Not an Oxymoron!