Brian Locke

Tracheostomy

Terms

Technically:

  • Tracheotomy: actual procedure of opening the trachea.
  • Tracheostomy: suturing an opening to create a permanent stoma.

But, everyone just calls it tracheostomy

alt

Terms:

  • DCT, DCCT = disposable cannula cuffed trach
  • DIC = disposable inner cannula
  • XLT = extra long trach
  • CFN = cuff less fenestrated cuff
  • LPC = low pressure cuff
  • Speaking valve = 1 way
  • Cap = covers hole

Overview

3 Types of Surgical Airway Access:

  • standard open tracheostomy (costly, larger cuts to heal, in OR)
  • percutaneous dilatational tracheostomy with bronchoscopic guidance (can lose airway, vasc / tracheolaryngeal injury possible. However, fewer infections and smaller procedure)
  • cricothyroidotomy (emergent)

Indications:

  • prolonged ventilation. Consider after 10, rec after 21 of ETT. Why? patient comfort to allow weanin (decreased sedation)g, facilitates mobility / nursing care, more secure, speech/oral feeding, potentially aid in weaning by reducing airway resistance. Allow transfer to LTACH as they require the more secure airway
  • upper airway obstruction / maxillofacial trauma
  • refractory OSA
  • secretions / purulent sinusitis (how so?)

For PCT:

  • need hemodynamic stability, fio2 <0.6, PEEP < 10, palpable cricothyroid cartilage 3cm w neck extended. (Have to be able to tolerate temporary loss of recruitment with apnea)
  • Cannot have coagulopathy, tracheomalacia, tumor/thyromegaly, inability to extend neck
  • high riding innominate (higher risk of fistula, also with low riding track)

Benefits:

  • Enhanced nursing care
  • decrease sedation
  • patient communication
  • eventual return of PO intake
  • ability for physical therapy
  • step-wise ventilator liberation

Grey Areas:

  • mortality?
  • LOS?
  • subglottic, tracheal complications?

Timing

TracMan JAMA 2013: UK 2004-11, Early (w/n 4 days) vs Late (10 days if still indicated - 50+% ended up not). No difference in morality, infections, LOS, duration of mech vent. Less sedation in tracheostomy group.

Large meta-analyses: Shorter ICU is only consistent effect. (Not mortality). Late tracheostomy = many patients don't get trashed. => we don't do well at predicting.

Complications

  • Upper airway injury: glottic and subglottic ulcerations (want to keep balloon inflated 30 cmH2O or less), chronic glottic incompetence, laryngeal stenosis, vocal cord paralysis, dislocation of arytenoid cartilages, ~10%
  • tracheal stenosis, in 90% but rarely clinically important
  • laryngeal injury
  • bacterial airway colonization (though no clear diff to prolonged ETT in nosocomial pneumonia)
  • surgical scar

Note: subglottic and tracheal stenosis - duration of ETT (or tracheostomy) is not correlated. Cuff pressure is more correlated (maybe also infection, rubbing, fit.. unclear if cuff pressure is the cause or a correlate)

Equipment:

  • forceps
  • catheter / wire
  • dilator
  • lidocaine
  • tracheostomy tube

Technique

  • aim for 1-2nd or 2-3rd tracheal rings
  • cut and make rent with hemostat / fingers
  • insert catheter
  • insert wire
  • dilator over the catheter
  • insert cuff

In COVID, instead of bronchoscope being inserted through ETT then tube pulled back to subglottic space - the bronchoscope is inserted outside the ETT, the ETT is pushed down to the carina, and the wire is inserted into the trachea next to the ETT. Finally, ETT removed and trach inserted simultaneously with ventilator switch.

Management

Cannot change the tube (or re-insert if dislodged) in the first 7 days (need wire / seldinger technique for this time to avoid dissecting into potential space). If it comes out emergently, take it out and ventilate from above.

Always insert the obturator before inserting or exchanging the tracheostomy.

Sizing

There is a size (diameter) that is slightly smaller if there is an internal lumen. What is the purpose of the inner cannula? It's to be able to take it out and clean without exchanging the trach itself.

alt

Standard Trach: Shiley. Comes in 8, 6, 4 diameters.

There is also a size (length) that should be matched with the patient's anatomy. XLT are longer, and then length can be "proximal XLT" (thick neck), "distal XLT" (long trachea) - difference being where the turn in the trach is.

  • larger = more ventilator support, easier to suction
  • smaller = can use with speaking valve or button (because air can move around the outside), closer to eventually closing.

Progression for weaning

Cuffed (seals off) vs Uncuffed. Generally (but not absolutely), cuffed is used if a patient is requiring ventilation such that pressure is transmitted into the airways. Uncuffed (or deflated) is required for speaking.

Speaking valves (Passy-Muir valve): 1 wave valve where inspiration occurs through the tracheostomy, then exhalation goes around the trach and through the vocal cords. Requires more work (as there is more resistance to inspiration, and more work to exhale). CUFF MUST BE DOWN or they can't exhale.

Similarly, cuff has to be down (or cuff less trach) prior to eating to avoid compression of the esophagus.

Fenestrated tracheostomies theoretically also allow thus, but are out of favor due to "cheese-grater" effect in airway.

Decannulation

Capping trials = see if patient can breath out of the mouth

Button: a plug that closes the trach off, but makes it so that a new one can be reinserted easily.

DOI: 10.1056/NEJMoa2010834