TRACHEOSTOMY IN ICU:
WHO SHOULD DO IT ?
THE SURGEON OR THE
ANESTHESIOLOGIST ?
Dr. Ion MICLEA PhD, MD
Dr. Robu Cornel
Prof.Univ.Dr. Serban BUBENEK PhD, MD
Institutul de Urgenta pentru Boli Cardiovasculare “Prof.Dr.C.C.Iliescu”
Terminology
1649
The word “tracheostomy”
Derived from Greek
from words “tracheia arteria” – ”rough artery”
and “stoma” – “mouth”
History
• 1500 B.C.
• First reference
• Hindu book of medicine “Rig Veda”
• 330 B.C.
• Calistene described Alexander the Great “punctured the trachea of a soldier with
the point of his sword to relieve choking”
• 1546
• Antonio Musa Brasavolo
• First successful tracheotomy
• 1860
• Evans Conway
• Reported “only a 68% mortality”
• 1909
• Dr. Chevalier Jackson
• Established safe guidelines
• Basics still used today
• 1953
• Seldinger technique
• 1957
• Sheldon et al.
• First described Percutaneous Tracheostomy
History
• 1985
• Ciaglia et al.
• Described the percutaneous dilatational technique
• 1989
• Paul et al.
• First description of Bronchoscope-assisted percutaneous
tracheostomy
• Present days
• More than 600 publications on “percutaneous tracheostomy”
since 1985
• Dilatational technique - Gold standard (Ciaglia)
• Percutaneous tracheostomy gaining acceptance
Cheng E, Fee WE Jr.. Ann Otol Rhinol Laryngol. Sep 2000;109(9):803-7
Indications of tracheostomy
• Need for prolonged mechanical ventilation in cases
of
Pneumonia refractory to treatment
Severe chronic obstructive pulmonary disease
Acute respiratory distress syndrome
Severe brain injury
Multiple organ system dysfunction
The Council on Critical Care of the American College of Chest
Physicians recommends tracheostomy in patients who are expected to
require mechanical ventilation for longer than 7 days. (1999)
Indications of tracheostomy
Airway obstruction due to following
Inflammatory disease
Congenital anomaly (laryngeal hypoplasia, vascular web)
Foreign body that cannot be dislodged with Heimlich and
basic cardiac life support maneuvers
Supraglottic or glottic pathologic conditions (neoplasm,
bilateral vocal cord paralysis)
Laryngeal trauma or stenosis
Facial fractures that may lead to upper airway obstruction
Edema (trauma, burns, infection, anaphylaxis)
Scott E Brietzke MD, Michael S Kong MD, Annual Meeting of the American Academy of
Otolaryngology - Head and Neck Surgery Foundation, 2008
Indications of tracheostomy
Need for improved pulmonary toilet
Inadequate caugh due to chronic pain or weakness
Aspiration and the inability to handle secretions
Prophylaxis (preparation for extensive head
and neck procedures and the convalescent
period)
Severe sleep apnea not amendable to
continuous positive airway pressure devices
Benefits of tracheostomy
Facilitates
Weaning from positive pressure ventilation and sedation
Removal of secretion by aspiration
Long-term airway management
Prevents aspiration from the pharynx or
gastrointestinal tract
Separates the oropharyngeal flora from the
pulmonary flora
F. Blot, C. Melot, CHEST, 2005, 1347-1352
Contraindications of tracheostomy
Absolute contraindications
Patientsage younger than 8 years
Necessity of emergency airway access because of acute
airway compromise !?
Gross distortion of the neck anatomy due to
Hematoma
Tumor
Thyromegaly
High innominate artery
C. Russell, B. Matta, Cambridge University, 2004
Contraindications of tracheostomy
Relative contraindications
Patient obesity with short neck that obscures neck landmarks
Medically uncorectable bleeding diatheses
Prothrombin time or activated partial thromboplastin time
more than 1,5 times the reference range
Platelet count less than 50.000/µl
Bleeding time longer than 10 minutes
Need for positive end-expiratory pressure of more than 20
cm of water
Evidence of infection in the soft tissues of the neck at the
prospective surgical site
C. Russell, B. Matta, Cambridge University, 2004
Advantages of percutaneous
tracheostomy over surgical tracheostomy
A relatively simple technique suitable for trained staff in the
critical care setting
It does not require an operating theatre
Infection rates for percutaneous tracheostomy range from 0 to
3,3%, whereas those for open tracheostomy have been
reported to be as high as 36%
Stenosis rates for percutaneous tracheostomy range from 0 to
9%
Small stoma of dilatational tracheostomy generally results in
a more cosmetic scar
Freeman BD, Isabella K, Cobb JP, et al. A prospective, randomized study comparing percutaneous with
surgical tracheostomy in critically ill patients. Crit Care Med. May 2001;29(5):926-30
Advantages of surgical tracheostomy
over percutaneous tracheostomy
Emergency tracheostomy (controversial) ?
Difficult to palpate the anatomical landmarks
Very obese patients
Short or bull neck
Enlarged thyroid
Nonpalpable cricoid cartilage
Gross deviation of trachea
Infection at or near the intended site for tracheostomy
In pediatric age group (controversial)
Previous neck surgery may distort the anatomy
Unstable cervical spine fracture
Required PEEP>15 cm H2O, as oxygenation may be compromised during
the procedure ?
Malignancy at the site of tracheostomy
Uncontrolled coagulapathy, considered as a relative contraindication
Complications of percutaneous
tracheostomy
Similar to surgical procedure
The incidence is lower
Complications:
Early complications
Late complications
Michael W. Sicard, M.D. , Baylor Collage of Medicine, 1994
Early complications of tracheostomy
Hypoxia during the procedure, due to failure of ventilation
Pneumothorax, pneumomediastinum, creation of false passage, and
subcutaneous emphysema, due to the placement of the tracheostomy tube
in the paratracheal space
Damage or injury to the posterior tracheal wall may lead to tracheo-
oesophageal fistula
Major bleeding is unusual
Minor bleeding can usually be controlled by pressure or occasionally
suture
Haemorrhage into the airway is potentially dangerous as it may result in a
blood clot obstructing the airway
Needle puncture on the lateral wall of trachea may lead to stenosis
Secondary haemorrhage may occur from infection or erosion of vessels
Late complications of
tracheostomy
Subglottic stenosis – the incidence
of subglottic stenosis is lower in
percutaneous tracheostomy than that
in open surgical procedure
Equipment for percutaneous
tracheostomy
Portex kit for percutaneous tracheostomy
Scalpel
14 G Cannula with needle
10cc syringe
Guidewire with introducer
Dilator
Guidewire dilating forceps
Tracheostomy tube and obturator with lumen
Two cotton tapes
Portex
percutaneous tracheostomy set
Videolaryngoscopes
GlideScope®
GlideScope non-glare color Video Monitor
Video cable
Reusable GVL
Cobalt Video Baton
GlideRite rigid stylet
Anatomy of the larynx
GlideScope
videolaryngoscope
Videolaryngoscopy during
percutaneous tracheostomy
During percutaneous tracheostomy, correct
positioning of the endotracheal tube is important
During the procedure it is possible to puncture the
cuff with the needle
Tracheal tube cuff puncture can lead to
Failure of ventilation
Loss of positive end-expiratory pressure
Posible aspiration of gastric contents, blood or secretions
M. Gillies, J. Smith and C. Langrish - British Journal of Anaesthesia 2008 101(1):129
Videolaryngoscopy during
percutaneous tracheostomy
Under videolaryngoscopy the
endotracheal tube can be
withdrawn, until the cuff is
visible at the vocal cords
After that, the tube is manually
held in place and the procedure
can start
Videolaryngoscopy has been
demonstrated to give equivalent
or superior laryngeal
visualisation in routine and
difficult airways
Vocal cords view during
videolaryngoscopy
Advantages of this technique
Videolaryngoscopy offers good visualisation of
the larynx even with the cervical spine fully
extended
Tube position can be visualized continuously
The shape of the Glidescope blade causes
minimal interference with the conduct of the
tracheostomy
The screen can be positioned to be in view of both
operators
Richard M. Cooper, John A. Pacey Michael J. Bishop and Stuart A. McCluskey – Canadian Journal of
Anesthesia, 2005, 191-198
Description of the technique
The patient should be anesthetised,
to avoid movements, and
monitorised using standard
techniques
The neck is extended by placing a
fluid bag, or a sandbag, or a pillow
under the shoulders
The area around the intended site is
cleaned with antiseptic solution
The area is surrounded by sterile
drapes
Description of the technique
The anesthesiologist that
manages the airway of the
patient prepares the
videolaryngoscope
• He has aspiration equipment and
different sizes of endotracheal
tubes(just in case)
Description of the technique
The patient should be preoxygenated by
ventilation with 100% oxygen for at least 5
minutes before starting the procedure
The anesthesiologist that performs the
tracheostomy is sterile equiped
He is the one that surrounds the area with
sterile drapes
Description of the technique
The anesthesiologist that controls
the airway should:
Suction the pharynx
Deflate the cuff of the
endotracheal tube
Withdraw the tube, under
videolaryngoscopy, until the
cuff is seen between the vocal
cords
Reinflate with the cuff entirely
above the vocal cords
Continue mechanical
ventilation of the patient
Description of the technique
The anesthesiologist that performs the
tracheostomy should:
Locate the thyroid cartilage
between thumb and forefinger
Identify and mark the anatomical
landmarks
Thyroid cartilage
Cricoid cartilage
Tracheal rings
Sternal notch
Possible insertion sites
The ideal site is between the second
and third tracheal rings, although a
space one higher or lower may be
employed
Description of the technique
The anesthesiologist that
performs the tracheostomy
should:
Introduce the needle between the
tracheal rings until the position
of the needle tip in the trachea is
confirmed (loss of resistance)
The needle is withdrawn, the
14G cannula is left in place
the flexible guidewire is inserted
through the cannula, and the
position is checked using the
videolaryngoscope
The 14G cannula is withdrawn,
the guidewire is left in place
Description of the technique
The dilator is slid over the wire, through
the soft tissues into the trachea
With gentle rotating movement of the
dilator, push the dilator forward to
penetrate the anterior wall, dilating both
the tissues and tracheal wall
The dilator is now withdrawn, and the
guidewire dilating forceps is introduced
Using two hands, open the forceps to
dilate the tracheal wall sufficiently to
accept the tracheostomy tube
Withdraw the forceps in the open position
The tracheostomy cannula (tube) is slid
over the guidewire into the trachea
If correct positioned, the guidewire and
the obturator with lumen are withdrawn
Description of the technique
Inflate the cuff of the tracheal
tube
Suction the trachea and
tracheostomy tube to establish a
clear airway
Transfer the breathing system to
the tracheostomy tube
Description of the technique
Confirm successful tube
placement
Secure the tracheostomy tube
with the supplied cotton tapes
Description of the technique
Withdraw the
endotracheal tube
after confirmation
of correct placement
of the tracheostomy
tube under
videolaryngoscopy
Juan D. Pulido, MD*, Faisal Usman, MD, James D. Cury, MD, Abubakr A. Bajwa, MD, Kathryn Koch, MD and Luis Laos, MD -
University of Florida, Jacksonville, FL – 2009, CHEST
Our experience
ICU in cardiac surgery
2001- 2017 = 287 percutaneous tracheostomies
2001-2009 – a number of 118 percutaneous tracheostomies were
performed, with three incidents:
1-false passage
1-damage of the posterior tracheal wall with tracheo-oesophageal fistula
1-tracheal stenosis ( treated with surgery)
Nov.2009- March .2017- a number of 169 percutaneous tracheostomies
were performed under videolaryngoscopic guidance ( GLIDESCOPE®)
Results APTT
Results INR
When was tracheostomy performed?
15.07 (±8.41) days
EARLIER is BETTER !
Results
No incidents resulting from the technique were
observed
No failure of the ventilation/ loss of the airway
access
No bleeding at the insertion site
No infection at the insertion site
Comments
Mean days until tracheostomy
15.07 (±8.41) days
After reintubation
Long sedation due to neurological disfunction after deep
hypotermic cardiocirculatory arrest(dissection of the aorta)
Intra aortic baloon pump maintained for 7 days in
cardiogenic shock
Severe sepsis/septic shock occuring after SIRS+low/
inadequate cardiac output
Surgical complications at distance from initial intervention
Stroke
Surviving rate 48 %
Conclusions
Video assisted laryngoscopy - traheostomia
•Safe and comfortable maneuver for the second operator
•Confidence for the first operator
•No risk of “short time crisis”
•No air leak in ventilation
•!!!!!! ICU patient- possible difficult (re)intubation
•Tube position can be visualized continuously
•minimal interference with the conduct of the tracheostomy
•eliminates the need for bronchoscopic guidance
•Low complications risk
Endconclusion
End
In the absence of absolute contraindications
THE ANESTHESIOLOGIST SHOULD PERFORM
ALL TRACHEOSTOMIES IN THE ICU
UNDER VIDEOLARONGOSCOPY.
THANK YOU !
