Tracheostomy

Alice Kennedy

Indications for Tracheostomy

  • Prolonged mechanical intubation and weaning (typically consider ~ day 14)
  • Prior failed extubation attempt(s)
  • Tracheal stenosis
  • Upper airway obstructions (e.g., head and neck cancers, severe infections, congenital obstructions)
  • Trauma
  • Neuromuscular disease

Benefits of Tracheostomy vs ET tube

  • Lower risk of laryngeal and vocal cord damage
  • Improved ability to communicate (i.e. speaking valve)
  • Improved pt comfort and decreased need for sedation
  • Lower airway resistance -> reduced work of breathing
    • May reduce time to wean from the vent and hospital LOS (mixed data)
  • Potential improvement in patient mobility
  • Easier access to trachea for suctioning/airway hygiene
  • May decrease risk of ventilator associated pneumonia (Mixed data)

*NOTE: No proven reduction in short-term mortality

Timing of Tracheostomy

  • Generally performed after 2 weeks of intubation (timing not backed by data)
  • Pts that might get tracheostomy earlier: Anticipated prolonged mechanical ventilation (i.e. those with acute neurologic injury affecting spinal cord)
  • Research: No benefit in 30-day mortality rates or hospital length of stay for early (day 4) vs late (day 10) tracheostomy in TracMan trial (Tracheostomy Management trial, 2013)

*NOTE: Many patients in late trach group did not end up requiring one

Tracheostomy Tubes

  • Most common in hospital = Portex (Previously Shiley)

  • Components:

    • Faceplate/Flange: Keeps tube in place, has the model and size on it
    • Inner cannula: Can be removed, cleaned, and replaced in case of obstruction
    • Cuff (may or may not have): Allows for pt to be ventilated; may prevent some aspiration. Pressure needs to be assessed qshift and kept <30mmHg
    • Fenestration (i.e. holes in the cannula) (may or may not have): Allow speaking without valve
    • Obturator/Trocar: Kept at the bedside to assist with trach insertion/removal
    A drawing of the components of tracheostomy tubes
  • Common sizes:
    • Initial: 8-0; Standard downsizing: 6-0 (Sizing: Comparable to ETT size for Portex)
    • Lengths: Standard vs. larger XLT (P = longer proximal end, D = longer distal end)
  • Presenting on ICU rounds = size/cuff status/brand (e.g. 8-0 cuffed Portex)
  • “Trach collar” means pt is receiving just humidified O2/room air, cuff should be down

Speaking Valves

  • Passy Muir Valve (PMV): One-way valve placed on the outer portion of the trach; air moves in with inspiration but is blocked and thus funneled up around/outside the trach and through the vocal cords during exhalation allowing for phonation
  • Contraindications: Severe upper airway obstruction or aspiration risk, copious secretions, decreased cognitive status, severe medical instability, or inability to tolerate cuff deflation
  • IMPORTANT SAFETY PRINCIPLE: Cuff must be deflated when PMV is on. Since air needs to be able to travel back up the airway, if the cuff is not deflated and you put the PMV on then pt cannot exhale. Must remove when asleep.

Maintenance of Tracheostomy Tubes

  • Inner cannula should be cleaned 2-3 times per day or swapped (disposable)
  • Daily stoma care to prevent pressure ulcers and stoma infections
  • As needed suctioning for secretions

Complications and airway emergencies in a tracheostomy pt

  • Hemorrhage (mild bleeding from surface vessels and granulation tissue is common, major bleeding is rare - think erosion into brachiocephalic [innominate] artery)
    • Causes for alarm: Drop in sats/Hgb, new tachycardia or hypotension, increasing PIP, new/worsening bleeding, or large clots
  • Airway damage - subglottic or tracheal stenosis, tracheobronchitis
  • Fistulas (tracheoarterial, tracheoesophageal)
  • Unintended tracheostomy tube dislodgement:
    • All pts with trachs have a yellow sign above bed with date, type, size of trach as well as a replacement trach with obturator in the room
      • Fresh trach (≤ 14 days): do NOT replace due to risk of misplacement into the mediastinum and loss of airway; airway management from above
      • Older trach: can be replaced at bedside with obturator by trained staff
    • In the case of an EMERGENCY:
      • Bag mask (use hand/gauze to occlude stoma) or intubate from above (i.e. through the mouth); if complete laryngectomy then must use stoma
      • Contact Surgical Airway Emergency Team +/- Team that placed it

Secretion Management

  • Respiratory hygiene (“pulmonary toilet”): heated vent, guaifenesin (may not have an effect), hypertonic saline, DuoNebs, cough assist device, appropriate suctioning (too much -> worsens secretions), acapella, IS

Decannulation

  • Candidates: Need to protect their airway and be on minimal FiO2 settings
    • Should pass capping trials and tolerate PMV for most of the day
  • Avoid if imminently discharging/planning for procedures
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