Tracheostomies
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Basics of tracheostomies from a surgical perspective meant for medical students and junior residents, with slight focus on comparing open vs. percutaneous tracheostomies.
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Tracheostomies
- 1. TRACHEOSTOMIES: WHY, WHEN, HOW GAZI M. RASHID, MD
- 2. OUTLINE Why? • Indications When? • Timing How? • Open • Percutaneous • Comparison
- 3. THE PARTS
- 4. INDICATIONS FOR A TRACHEOSTOMY • Oxygenation • Ventilation • Airway Protection • Patients with impending airway obstruction • Planned surgical loss of airway • Pulmonary toilet – if having excessive secretions An elective, urgent, or emergent surgical airway for long-term support for: Indications for Tracheostomy?
- 5. • check INR, PT, platelets & correct as needed Major coagulopathy • PEEP – generally want lower (5-7.5) to avoid alveolar collapse once ETT is out • FiO2 – generally want lower (30-50%) to avoid fire injuries in the airway Significant ventilator support Pre-tracheal soft-tissue infection Laryngeal cancer (increased risk of stomal recurrence) Patient goals of care Contraindications for Tracheostomy?
- 6. TIMING No definitive evidence, guidelines for staying intubated vs. doing trach Outcomes: Weaning off ventilator, length of hospital and ICU stay, nosocomial infections, rates of subglottic stenosis Early: Better for severe injuries, neuro dz (ALS, etc), likely will need long-term ventilation or has permanent inability to protect airway 7-10 days intubated: Might be more beneficial than doing it too early (see: The TracMan RCT) to give pt chance to be extubated “Late” > 10-14 days: risks of less likely to wean from vent, longer ICU stays and sedation, more cost, increased risk of stenosis Timing?
- 7. ANATOMY
- 8. OPEN TRACHEOSTOMY 1. Performed in OR under GA 2. Horizontal vs. Vertical Incision 2 fingerbreadths above sternal notch 3. Dissect through skin, subcutaneous, platysma 4. Vertical incision in fascia between strap muscles, retract laterally 5. Divide the isthmus of the thyroid (allows for great exposure) 6. Horizontal incision in between 2nd, 3rd tracheal ring 7. Flap (often Bjork) + Place stay sutures and dilate the incision 8. Through incision, visualize withdrawal of ET tube 9. Once ET tube proximal to incision, quickly place trach tube 10. Confirm placement (CO2) and secure
- 10. 1. Can be done at bedside with conscious sedation, relaxation 2. Bronchoscopy done to visualize most steps of the procedure 3. Horizontal incision at skin and superficial dissection with Kelly 4. Direct palpation and visualization 5. Withdrawal of ET tube proximal 6. Seldinger technique – introducer needle, catheter, guidewire, dilation with Rhino (all under direct visualization) 7. Tracheostomy Tube introduced 8. Visualize placement and secure PERCUTANEOUS TRACHEOSTOMY
- 12. COMPARISON PROS CONS Open Direct visualization Better control of bleeding Better for anatomically difficult patients Less time with ineffective ventilation – is pulled only when incision dilated enough, so will have poor ventilation for ~ < 1 min Higher risk of post-op complications like tracheal stenosis, infections Perc Decreased risk of infection Decreased post-op complications Less likely to bleed Cheaper – faster, less staff, resources Cannot visualize tissues, vasculature Bronchoscopy required Higher risk of intraoperative complications Longer time with ineffective ventilation – ET needs to be pulled proximally for visualization from start of the case; that makes it hard to ventilate lungs from so far from carina -> makes perc trach worse option for someone with high vent setting requirements
- 13. • PTX • Damage to RLN • Posterior wall perforation • Bleeding • Fire (keep FiO2 < 0.4) • Lose Airway • Decannulation!!! • Minor Bleeding (pressure) • Plugging • Significant bleeding - consider Tracheo - Innominate Fistula • Minor Bleeding • Tracheal Stenosis Weeks Intraoperative Days Long Term COMPLICATIONS
- 14. SUMMARY Indications for tracheostomy are long-term oxygenation, ventilation, airway protection, pulm hygiene There are no absolute contraindications, but relative contraindications exist and are specific to different approaches and the patient No consensus for timing, but generally aim for between after 7-14 days of being intubated Open trach better for visualization, difficult necks, and patients who need higher ventilator settings Perc trachs better for simple necks and are generally cheaper/faster/less resource intensive Decannulation in <7d is an airway emergency and management depends on patient condition
- 15. RESOURCES https://tracheostomyeducation.com/tracheostomy-tubes/ Terris, David, Tracheostomy in Current Surgical Therapy LITFL: https://litfl.com/percutaneous- tracheostomy/#:~:text=Tracheostomy%20is%20an%20airway%20that,dilatation%20of%20trachea%20be tween%20rings. https://resusreview.com/2015/perc-trach-tutorial/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6197980/ http://www.emdocs.net/core-em-common-tracheostomy-issues/ http://www.surgicalcriticalcare.net/Guidelines/Timing%20of%20tracheostomy%202020.pdf
Editor's Notes
- Parts: - Phalange/faceplate – the same hing Length of tube is critical – standard is 77 mm; want it long enough that it will traverse the neck in an obese patient; but not too long that it goes past the carina into a bronchus Hub – standardized one-size-fits-all part that connects to vents, caps, voice valves - Inner cannula – is disposable; allows for replacing if it gets too clogged up; NOT all tubes have inner cannulas; Bivona TTS in trauma do NOT - Cuffless for neonates to avoid tracheal injuries - Fenestrated allows for voicing; but can cause granulation tissue at the site of the fenestration if it’s not cleaned properly; generally, fenestrated tubes are placed later on, once patient is more stable
- Neuro diseases and injuries, severe traumatic injuries: situations with little to no chance of improvement of respiratory status Impending – tumor, caustic ingestion, edema, trauma, bleeding Loss of airway in facial trauma reconstructions, laryngectomy Improved suctioning of bronchopulmonary secretions
- No absolute contraindications These are all relative
- Research is based on guidelines comparing outcomes from when the trach is done https://www.thebottomline.org.uk/summaries/icm/tracman/ No benefit in doing trach on day 4 vs. day 10 and potential benefit given risk of complications vs. some may not need it if wait till day 10 http://www.surgicalcriticalcare.net/Guidelines/Timing%20of%20tracheostomy%202020.pdf
- Sternal notch Thyroid cartilage Cricoidthyroid membrane Cricoid cartilage Tracheal rings Thyroid isthmus (over 2nd)
- Vertical incision less common, but can visualize anterior jugulars better to avoid bleeding; incision can also be extended up or down if initial cut too low/high Horizontal incisions along skin tension lines – more commonly taught; better for very difficult necks or disaster cases, ie if an incision needs to be widened laterally; if very large, can have better cosmesis outcomes with horizontal Stay sutures help to guide replacement of the trach tube in case of dislodgement
- Mayo clinic ENT team https://www.youtube.com/watch?v=77Wi5Z3FOGk&ab_channel=MayoClinic
- Perc trach was introduced in the 50s but mortality and morbidity improved by dilational techniques in the 80s and bronch visualization in the 90s https://resusreview.com/2015/perc-trach-tutorial/
- https://www.youtube.com/watch?v=zLhdZqy8wDY&ab_channel=Dr.MuraliChandNallamothu
- https://derangedphysiology.com/main/required-reading/airway-management/Chapter%202.1.3/percutaneous-versus-surgical-tracheostomy
- PTX if lung is violated Recurrent laryngeal lies in TE groove Perforation can risk in TE fistula or mediastinitis FiO2 < 4 minimizes risk Minor bleeding – usually from skin incision or thyroid isthmus -> packing Displacement – no mat -- RF are manipulation during hooking up to ventilator, transport of the patient, obese body; < 7d, blind re-insertion dangerous, stay sutures can help - BVM and stay sutures if stable vs. re-intubate if unstable