Tracheostomy

Types of tracheostomy:

• Upper airway absent (after laryngectomy) - an end stoma
• Upper airway present

Indications for tracheostomy:

• Need for prolonged mechanical ventilation (acute or chronic resp failure)
  • Seems to be about day 10-14 after intubation currently
  • Allows reduction in sedation
• Airway protection (neurologic catastrophe or copious/tenacious secretions)
• Upper airway obstruction
• Emergency tracheostomy when not possible to perform translaryngeal intubation

Contraindications

• Absolute
  • Overlying soft tissue infection
  • Operator inexperience
  • Inability to tolerate short apnoea
  • Haemodynamic instability
• Relative
  • Very high ventilator support settings
  • Uncorrected coagulopathy (aim PLT > 50, INR < 1.6, not be on anticoagulants/antiplatelets)
  • Laryngeal cancer prior to definitive treatment

Choice of procedure (methods from Shields)

Percutaneous

• • Favoured in most situations except emergencies
  • Same complication rate as an open tracheostomy, and can be done bedside in ICU
  • Do it under bronchoscopy guidance
  • Prep as for open
  • Visualise retraction of ETT to just below cords
  • 22-guage needle into the intercartilaginous space between second and third rings
  • J-wire fed through needle
  • Horizontal 1cm incision centred on wire
  • 14Fr dilation over wire
  • Appropriate size dilator in the kit then inserted and the tracheostomy placed into airway
  • Wire and dilator removed
  • Flange sutured to skin

Open

• • Check tracheostomy sizing and check cuff
  • Supine with neck extended with shoulder roll, and slight reverse Trendelenburg
  • Prep skin from nipple to mandible
  • Pre-oxygenate and sedate
  • LA
  • Mark thyroid and cricoid cartilages with dots, and a 2cm transverse incision above the second or third tracheal ring, about 2cm below cricoid
  • Divide subcutaneous tissues and platysma
  • Retract strap muscles laterally to expose thyroid isthmus from first to fourth tracheal ring - blunt dissection in midline
  • Move thyroid isthmus out of the way (usually second cartilaginous ring)
    • Dissect it off trachea with right angle
    • Ligate with 0 vicryl ties on either side
    • Divide in middle
  • Check oxygen off and diathermy away
  • Warn anaesthetist and incise trachea horizontally with 11 blade between the second and third rings - may need to use scissors too.
  • Oropharyngeal tube out. Place new tracheostomy tube and inflate cuff, sometimes over a bougie. Check ventilation and that it is above carina.
  • Flange sutured to skin in all four quadrants (2/0 Prolene)
  • Close any excess skin to provide a snug fit around the tube

Cricothyroidotomy (upper airway obstruction and unable to establish an oral airway OR for mini-tracheostomy to aid in removal of airway secretions)

• • Prep as for open tracheostomy
  • Palpate cricothyroid membrane (feel Adam's apple as thyroid cartilage, then move down to just below that, above cricoid cartilage)
  • Make a horizontal incision directly over the cricothyroid membrane (can also do vertical, between sternal notch and hyoid)
  • Lateralise strap muscles and trachea exposed
  • Stabilise trachea/thyroid cartilage with non-dominant hand
  • Horizontal cut in trachea using 10 (or 11) blade in the cricothyroid membrane
  • Finger dilate
  • Size 6 ETT

Immediate issues

• Bleeding
  • Most common source anterior jugular veins
  • Ligate and divide if needed
  • Ensure all bleeding controlled prior to incising trachea - hard to see after putting tracheostomy tube in
• Obese or large-necked patients may need a longer tube
• Air leak with ventilation - a self-inflating Bivona tracheostomy tube, or one with a longer cannula

Tracheostomy management

• Humidification and regular suction
• Apply CCrISP algorithm if problems arise
• Don't change too soon - 3/7 post open, 1/52 post perc to ensure tract forms
• Should have inner canulae if on wards due to risk of blockage
• Routine changes
  • Every 30-90 days
  • 7-30 days post initial insertion
• Decannulation
  • Indications
    • No upper airway obstruction
    • Ability to clear secretions that are neither too copious nor too thick
    • Presence of an effective cough
  • Weaning
    • Progressive decrease in size of tracheostomy tube
    • Progressive capping trials until tolerated for 12, 24 or 48 hours
  • Usual progression:
    • De-shield
    • Cuff down trial
    • Cuff down
    • Swallowing assessment
    • Consider decannulation
• Procedure
  • Equipment
  • Monitoring
  • Supplemental oxygen via tracheostomy mask
  • Neck extended slightly
  • Suction
  • Deflate cuff
  • Remove tube
  • Dress and occlude stoma
  • Observe for signs of respiratory distress

Cuff: essential to provide PPV, also reduces risk of aspiration. Some traches don't have a cuff.

• Deflating cuff allows patient to breathe through mouth, and phonate (when they occlude the trache tube)

Inner cannula: allows the tube to be changed and cleaned without having to take the whole thing out

• However, it decreases the effective diameter of the tube, so they get more resistance to airflow.

Common problems

• The most common complications are DOH!
  • Displacement
  • Obstruction
  • Haemorrhage
• Secretion buildup in tube - narrows effective diameter, leading to respiratory distress.

Early complications

• Blockage/obstruction
  • Presents with airway compromise
  • Use CCrISP algorithm
  • Is tube displaced or blocked?
    • If displaced, pt will be breathing through nose/mouth
      • Generally safer to remove, give oxygen, monitor. Don't reinsert until experienced help arrives.
      • If bag/valve/mask - need to occlude stoma
      • If upper airway patent - oropharyngeal intubation on ward
      • If upper airway not patent - reintubate in theatre - if the tissue is friable you may need to use something softer to guide it in like NGT, if normal tissue use a bougie
    • If partially blocked
      • Cough
      • Suction
      • Oxygen via tracheostomy and facemask
      • Remove/change inner canula
    • Completely blocked
      • CALL FOR HELP
      • Try suctioning - if you can pass the suction, it's not completely blocked
      • Remove inner cannula if present, or if not, saline lavage and suctioning
      • Establish an airway by other means
• Subcutaneous emphysema/PTX
• Bleeding (<48 hours)
  • Usually trauma to anterior jugular or inferior thyroid veins
• Early displacement
  • Default and safest option - re-intubate the patient orally, then evaluate for replacement. Can safely put a new tube in, preferably via Seldinger.

Late complications

• Tracheal stenosis and malacia
• Bleeding
  • Tracheoarterial fistula
    • See full topic under 'vascular trauma'
    • Sentinel bleeds are common!
      • If you suspect sentinel bleed, do a CT angio (?high-riding innominate artery - ?relationship of wall to artery) and bronchoscopy
    • Survival 14%
    • Erosion into anterior tracheal wall, resulting in fistulous connection with innominate artery
    • Ward:
      • Resuscitation
      • Bleeding from stoma site - apply pressure, silver nitrate
      • Bleeding from deep to stoma - overinflate cuff to compress artery. Can also try inserting ETT and inflating cuff distal to bleed. Otherwise put a finger through the hole then pull anteriorly. And put pressure above sternal notch to compress innominate artery.
    • Operative management:
      • Utley maneuvre - involves dissection to innominate artery
      • Definitive control will probably require sternotomy
• Reduced phonation
• Late displacement
  • Check cuff, tube, other components
  • Preoxygenate via stoma
  • Use obturator to reinsert - stop if resistance