3. INTRODUCTION
• Tracheostomy is one of the earliest surgical procedures
recorded, with illustrations depicting it as early as 3600 B.C.
in ancient Egypt.
• is a surgical procedure to create an opening in the anterior
trachea to facilitate respiration.
• Historically, a tracheostomy represented the only treatment
available for upper airway obstruction, and this remains an
important indication for tracheostomy today, though there are
numerous others.
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4. • A tracheostomy may be required in an emergent setting to bypass
an obstructed airway, or (more commonly) may be placed
electively to facilitate mechanical ventilation, to wean from a
ventilator, or to allow more efficient management of secretions
(referred to as pulmonary toilet), among other reasons.
• Traditionally a tracheostomy is performed as an open surgical
procedure, however safe and reliable percutaneous tracheostomy
techniques have been relatively developed, allowing for the
bedside placement of a tracheostomy in many patients.[
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7. INDICATIONS
Indications for emergent tracheostomy include:
• Acute upper airway obstruction with failed
endotracheal intubation (foreign body,
angioedema, infection, anaphylaxis, etc.)
• Post-cricothyrotomy (if a cricothyrotomy has
been placed it should be immediately formalized
into a tracheostomy once an airway has been
secured)
• Penetrating laryngeal trauma
• LeFort III fracture
Indications for elective tracheostomy include:
• Prolonged ventilator dependence
• Prophylactic tracheostomy prior to head and
neck cancer treatment
• Obstructive sleep apnea refractory to other
treatments
• Chronic aspiration
• Neuromuscular disease
• Subglottic stenosis
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9. RATIONALE FOR TRACHEOSTOMY VS INTUBATION
• Reduced work of breathing
• Improved comfort and reduced need for sedation
• Facilitation of weaning
• Improved patient communication and swallowing
• improved mobility and, therefore, ability to participate in physical therapy [12],
• improved secretion clearance and oral hygiene, ability to manage patients outside the intensive care
unit (ICU)
• a lower likelihood of laryngeal injury
• easier replacement if accidental decannulation occurs (provided the tract is matured; typically ≥7 days)
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10. UNCLEAR BENEFITS
Risk of aspiration and pneumonia
• Suggesting that tracheostomy is associated with a higher rate of nosocomial pneumoniacohort study of over 800
mechanically ventilated patients -a six-fold increase in the risk of nosocomial pneumonia compared with
endotracheal intubation
• Suggesting that tracheostomy is associated with a lower rate of nosocomial pneumonia case-control study of 354
patients who were mechanically ventilated for more than seven days found a lower rate of nosocomial pneumonia in
patients who underwent tracheostomy compared with those who did not undergo tracheostomy
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11. Mortality
• Suggesting that tracheostomy may improve survival, an international prospective cohort study of 5081
mechanically ventilated patients found that tracheostomy was associated with decreased ICU but not
hospital mortality compared with ICU patients who did not undergo tracheostomy .
• A case-control study of over 500 patients found a decrease in both ICU and hospital mortality among
patients who required long-term mechanical ventilation and underwent tracheostomy (within 12 days
of initial intubation)
• Tracheostomy-related deaths are more frequent during the weekend and more common among
patients with cancer (especially oropharyngeal cancer), chronic lower respiratory tract disease, and
patients with complications of medical or surgical care
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13. OPTIMAL TIMING
• For patients who are unable to wean from invasive mechanical ventilation, tracheostomy and
transfer to a long-term assisted care facility for weaning is often considered.
• perform a daily assessment of the patient's progress and their readiness to wean and be
successfully extubated before making the decision that tracheostomy is warranted
• The decision of when to perform tracheostomy is a collaborative one and should be part of the
overall approach to patient-centered care in the intensive care unit (ICU).
• discuss with caregivers the value of tracheostomy in the context of the likelihood of weaning,
patient preferences, and expected outcomes, together with the alternatives of continued
intubation or palliation
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14. TIMING
• For most patients on mechanical ventilation, we suggest tracheostomy be
performed between 7 and 21 days .
• do not perform a tracheostomy before 10 days. This preference is based on the
rationale that early tracheostomy is of no proven benefit and may lead to
unnecessary surgery and prolonged mechanical ventilation in patients who may
otherwise be extubated.
• patients should not be ventilated via an endotracheal tube for longer than three
weeks unless they are either unstable or unlikely to benefit from tracheostomy.
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15. OPTIMAL TIMING
Predicted need for prolonged mechanical ventilation
Cervical spine trauma (especially trauma resulting in transection of the spinal cord at C3-5)
Traumatic or hypoxic brain injury
General and multiple traumas
Severe, progressive, or slowly resolving neuromuscular conditions (eg, bulbar amyotrophic lateral sclerosis, severe
Guillain Barré syndrome)
Prophylactic tracheostomy
• extensive head and neck or upper aerodigestive tumors or patients with extensive upper airway trauma or surgery
(eg, laryngectomy)
• in patients with cancer, a tracheostomy is often required in preparation for radiation-or surgical-related airway
edema.
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16. TYPES OF TRACHEOSTOMY
• Surgical tracheostomy
• Percutaneus tracheostomy
• Percutaneous tracheostomy is performed by anaesthesiologists or intensivists, usually under
fibreoptic bronchoscopic guidance.
• Open surgical tracheostomies are performed by ENT surgeons and in some countries, trauma
surgeons.
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17. SURGICAL TRACHEOSTOMY
• Thyroid notch - a palpable landmark to identify the superior aspect of the larynx in the
midline.
• Cricothyroid membrane - a palpable depression between cricoid and thyroid cartilages. This is
the location for an emergent cricothyrotomy.
• Cricoid cartilage - a palpable landmark to identify the junction of the larynx and trachea. The
skin incision is typically placed 1-2cm inferior to the cricoid.
• Sternal notch - a palpable landmark to identify the thoracic inlet. It is important to palpate here
to the possibility of a high-riding innominate artery that may be encountered during
tracheostomy.
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18. PERCUTANEUS TRACHEOSTOMY
• A percutaneous technique was described in 1985 by Ciaglia and colleagues.
• This method uses a dilatational process via a modified Seldinger technique under
bronchoscopic guidance.
• is more amenable to bedside performance, avoiding the transport of potentially critically ill
patients to the operating room.
• has also been associated with less blood loss and lower infection rates than the open technique.
• has been associated with several significant devastating complications such as tracheal
laceration, aortic injury, and esophageal perforation, which are extremely unusual after the
open procedure
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22. COMPLICATIONS
• Tracheostomy complications are frequent but serious complications are uncommon. Death is rare.
• The most common acute complications of tracheostomy (ie, <10 days) are hemorrhage, obstruction, pneumothorax,
infection, and accidental decannulation.
• Late complications of tracheostomy (ie, ≥10 days) are stenosis of the trachea and stoma, tracheomalacia,
tracheoarterial fistula as well as aspiration and pneumonia, tracheoesophageal fistula formation, dysphonia and
dysphagia, obstruction, and accidental decannulation.
• In patients with accidental decannulation, the approach depends upon tract maturity but the time when this is
established is controversial. We define it at 7 to 10 days, although other experts have varying definitions. When
decannulation occurs before the tract is mature (eg, during the first week), oral intubation with cuff placement
beyond the stoma is appropriate. This approach is based upon avoiding airway loss and reducing risk of creating a
false tract. For those with a mature tract, reinserting the tracheostomy is reasonable.
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23. • Massive hemorrhage due to a tracheoarterial fistula (typically tracheoinnominate artery) is a life-
threatening emergency.
• It may be preceded by a sentinel bleed. When a sentinel bleed is suspected, it should be
assessed using bronchoscopy, computed tomography, and/or angiography. When a fistula is
suspected, we perform innominate artery compression with cuff overinflation (eg, up to 50 mL)
and apply external pressure posteriorly on the sternal notch.
• If that fails, we perform oral intubation with cuff overinflation distal to the stoma, removal of
tracheostomy tube, and the placement of pressure on the bleeding artery using a finger through
the tracheostomy tube. Surgical repair is the only definitive treatment.
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26. TRACHEOSTOMY CHANGES
Tracheostomy tubes are mostly exchanged electively as part of long-term
maintenance, but exchange may also be required in emergency circumstances
(eg, accidental decannulation or obstruction) or for other reasons (eg, patient
discomfort, malposition, cuff leak, ventilator asynchrony, device-related
complications, asynchrony, and bronchoscopy
typically change tracheostomy tubes 7 to 30 days after initial insertion and then
every 30 to 90 days, although practice varies
typically perform most exchanges as an inpatient and less commonly as an
outpatient.
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27. DECANNULATION
Decannulation is the process by which a tracheostomy tube is removed
Decannulation can be performed when all of the following are present: mechanical ventilation is no longer required, upper
airway obstruction is absent, the cough is adequate, and secretions are well controlled.
assess readiness for decannulation by capping the tracheostomy tube (with the cuff deflated) for progressively longer periods
of time or by progressively decreasing the size of the tracheostomy tube.
Most tracheocutaneous tracts begin to close within the first 48 hours following decannulation and by seven days they should
be completely or almost completely closed.
A tracheocutaneous fistula is considered persistent if it remains open at three to six months following decannulation.
Treatment includes cauterization, excision, or rarely, surgical closure.
If a patient fails decannulation and the stoma remains open, a mini-tracheostomy tube may be placed for suctioning and
short-term ventilation and the stoma serially dilated; if the stoma is closed, then orotracheal intubation is required.
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Although there are few guidelines, we advocate a
multidisciplinary approach to tracheostomy care
One systematic review reported that a dedicated
interdisciplinary team approach to tracheostomy care
led to a reduction in adverse events, time to
decannulation, and length of stay
SUMMARY
