Surgical Critical Care: Tracheostomy

Tracheostomy

Benefits (Compared to Endotracheal Intubation)

  • More Comfortable & Better Tolerated by the Patient
  • Decreased Dead Space & Airway Resistance
  • Decreased Work of Breathing
  • Improved Pulmonary Toilet, Oral Care & Secretion Clearance
  • Facilitates Liberation from Ventilator
  • Decreased Ventilatory Dependent Days
  • Shorter Hospital Stay
  • Shorter ICU Stay

Indications

  • Indications:
    • Will Require Prolonged Mechanical Ventilation > 7 Days
    • Unable to Protect the Airway (Unable to Clear Secretions, Severe TBI, Severe Maxillofacial Injury or Severe Neck/Vocal Cord Injury)
    • Complex Tracheal Repair
    • Cervical Spinal Cord Injuries
    • Ventilator Dependent Due to Frequent Trips to the OR
  • Relative Contraindications to Percutaneous Approach:
    • FiO2 > 60%
    • PEEP > 12
    • Peds (Collapsible/Mobile Trachea)
    • Moderate-Severe Coagulopathy
    • Midline Neck Mass
    • BMI > 30

Timing

  • Definitions Vary
    • Early: Approximately 2-14 Days
    • Late: Approximately 14-21 Days
  • Benefits:
    • Early Tracheostomy
      • Higher Likelihood of Ventilator Liberation
      • Earlier Return to Walking, Talking & Eating
    • No Change In:
      • Ventilator Associated Pneumonia (VAP)
      • ICU Length of Stay
      • Hospital Length of Stay
      • Mortality
  • Specific Indications for Early Tracheostomy:
    • Severe TBI
    • Cervical Spinal Cord Injuries

Surgical Approach (Open vs Percutaneous)

  • Percutaneous Tracheostomy
    • Lower Risk of Surgical Site Infection
    • Improved Scar Cosmesis
    • Faster Procedure
    • Lower Cost
  • Similar Bleeding, Decannulation Risk & Mortality

Other Considerations

  • Inner Cannula – Allows Easy Replacement of the Cannula if it Becomes Obstructed or Filled with Secretions

Tracheostomy 1

Tracheostomy – Material

Material

  • Shiley (Coviden) – Polyvinyl Chloride Plastic (Most Common)
  • Bivona (Portex) – Silicone (Softer & More Flexible)
  • Jackson – Metal (Rarely Used)

Size

  • In General Use the Largest Size Possible
  • Most Common Sizes:
    • Adult Males: 8.0-8.5 mm
    • Adult Females: 7.5-8.0 mm

Cuff

  • Cuffed: Allow Secretion Clearance, Protect from Aspiration & Allow More Effective PEEP
    • Generally Preferred
    • Cuff Pressure Should Be Maintained at 15-22 mmHg to Avoid Injury (Tracheal Capillary Perfusion Pressure is Normally 25-35 mmHg)
  • Uncuffed: Allow Airway Clearance but No Protection from Aspiration

Fenestration

  • Has an Additional Opening in Posterior Tube, Above the Cuff
  • Also Requires a Fenestrated Inner Cannula
  • Allows Airflow Around the Tube but Does Not Prevent Aspiration
  • Used During the Weaning Process, Generally Not Used for the Initial Placement

Length

  • Standard
  • XLT (Extended-Length Tube)
    • XLTP – Extra Length Proximally (In-Neck Before the Radial Turn)
      • For Swollen/Thick Neck Anatomy
    • XLTD – Extra Length Distally (After the Radial Turn into the Trachea)
      • For Long Tracheal Anatomy or Tracheal Stenosis

Tracheostomy; Cuffed (Left) and Uncuffed (Right)

Fenestrated Tube (Top), Non-Fenestrated (Bottom) 2

Tracheostomy – Procedure

Goal Location

  • Location: Below the Second or Third Tracheal Rings
  • Risks of Improper Position
    • Higher: Stenosis
    • Lower: Tracheo-Innominate Fistula

Open Tracheostomy

  • 2 cm Incision (Horizontal or Vertical) About 2 Finger-Breadths Above the Sternal Notch
  • Divide Platysma & Retract Laterally
  • Retract Thyroid Isthmus Superiorly
  • Expose the Trachea
  • May Place Stay-Sutures
  • Preform Tracheostomy with #11 Blade Scalpel Under the Second or Third Tracheal Ring
  • Pull Endotracheal Tube Back to Just Above the Tracheostomy Site
  • Insert Tracheostomy Tube, Place Inner Cannula & Inflate the Balloon
  • Fully Remove the Endotracheal Tube

Percutaneous Dilational Tracheostomy (PDT/Modified Ciaglia Technique)

  • May Use Bronchoscope Through the Endotracheal Tube to Directly Visualize the Procedure
    • Generally Recommended but Not Mandatory
  • 2 cm Incision (Horizontal or Vertical) About 2 Finger-Breadths Above the Sternal Notch
  • Retract the Endotracheal Tube Proximal to the Second/Third Tracheal Ring
  • Access the Trachea:
    • With Bronchoscope: Needle Placed with Direct Visualization
    • Without Bronchoscope: Advance a Needle with a 10 cc Saline Syringe to Enter the Trachea Confirming Position Once Air Bubbles Return in the Syringe Under Negative Pressure
  • Pass Guidewire Through the Needle & Then Remove the Needle
  • Dilate the Tract Over the Guidewire
    • First Using the Short-Dilator
    • Next Either with Multiple Serial Dilation (12-36 French) or a Single Tapered Dilator (Blue-Rhino)
  • Insert the Tracheostomy Tube on an Appropriate Dilator Over the Guidewire
    • Appropriate Dilator: 20 + The Size Tube (No. 8 Tube Over a 28 F Dilator)
  • Remove the Dilator & Guidewire
  • Insert the Inner Cannula & Inflate the Balloon
  • Possibly Secure the Trachea to the Skin with 2-4 Sutures (Debated – No Evidence They Actually Prevent Accidental Decannulation)

Additional Content

Care & Weaning

Complications

References

  1. Kramp B, Dommerich S. Tracheostomy cannulas and voice prosthesis. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2009;8:Doc05. (License: CC BY-NC-ND-3.0)
  2. Cancer Research UK. Wikimedia Commons. (License: CC BY-SA-4.0)