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Overview of tracheostomy

The document provides a comprehensive overview of tracheostomy, including indications, complications, timing, techniques, and types of tracheostomy tubes. It emphasizes the complexity of early versus late tracheostomy timing and suggests that while earlier timing may correlate with certain benefits, it does not improve survival rates. Additionally, percutaneous dilatational tracheostomy is recommended as the preferred technique for most patients due to its safety and efficiency.

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• Overview of Tracheostomy • Dr. MOHAMMAD VAZIRI-Thoracic Surgeon • Iran University of Medical Sciences • Member of The • New York Academy of Sciences • European Society of Thoracic Surgeons • International Association for the Study of Lung Cancer • European Society of Medical Oncology • Clinical Research Associate – McMaster University
• OUTLINE • Indications for Tracheostomy • Complications of Tracheostomy • Timing of Tracheostomy • Tracheostomy Technique • Tracheostomy Decannulation • Tracheostomy Tubes • Changing the Tracheostomy Tube • Speaking Valve
• Indications for Tracheostomy • The most common indications for tracheostomy are (1) Acute respiratory failure and need for prolonged mechanical ventilation (2) Traumatic or catastrophic neurologic insult requiring airway, or mechanical ventilation or both. • Upper airway obstruction is a less common indication for tracheostomy. • 10% of mechanically ventilated patients undergo tracheostomy
Indications for Tracheostomy
Complications of Tracheostomy
Complications of Tracheostomy
• Timing of Tracheostomy • The question of early versus late tracheostomy is complex and requires a 2- part solution: (1) we must predict which patients will require prolonged ventilation, and (2) we must make a decision about when the tracheostomy should be performed.
• The definition of early tracheostomy differs between studies. • Of the papers surveyed from the past 10 y, early was generally defined as within 3–10 d of mechanical ventilation, whereas late was variously defined as any time outside the early period, within 7–14 d, 14–28 d, or 28 d after initiation of mechanical ventilation. • Earlier timing of tracheostomy correlated with shorter time on mechanical ventilation and shorter ICU and hospital stay, but was not associated with hospital mortality.
• Optimal Timing of Tracheostomy Based on Recent Randomized Controlled Trials • 2 recent randomized trials (Italian multi-center trialand TracMan United Kingdom multi-center trial) have consistent findings that earlier tracheostomy was not associated with improved survival and that clinicians cannot accurately predict which patients will require prolonged mechanical ventilation. • Based on the evidence to date, it is reasonable to wait at least 10 days to be certain that a patient has an ongoing need for mechanical ventilation
• Limitations of Tracheostomy Timing Studies • Small number of trauma and surgical patients • Different outcome measures: all-cause mortality versus VAP versus ICU/ventilator-free days • No standardization of tracheostomy technique (open or percutaneous in TracMan, Griggs vs PercuTwist in Italian multi-center trial) • No large United States RCT to date
• Patients Who Would Benefit From Early Tracheostomy • Trauma and neurologic damage from stroke, head injury, and spinal cord injury (SCI) represent a subset of patients for whom the benefits of early tracheostomy have been specifically investigated. • For these studies, 7–8 d was a relatively consistent cutoff
• Similar to trauma patients, retrospective studies report that early tracheostomy (within 7–8 d) in traumatic brain injury (TBI) patients is associated with some improved outcomes compared with delayed tracheostomy, but no large prospective randomized trials have yet validated these findings.
• Tracheostomy Technique . Patient selection is a significant factor during the consideration of whether to perform percutaneous or surgical tracheostomy • In most adult ICU patients requiring elective tracheostomy and without contraindications to percutaneous tracheostomy, it has been suggested that percutaneous dilatational tracheostomy (PDT) should be considered the procedure of choice.
• Indications and Contraindications to PDT • Three critically important preoperative criteria for PDT are: • Ability to hyperextend the neck • Presence of at least 1-cm distance between the inferior cricoid cartilage and the suprasternal notch, ensuring that the patient will be able to be re-intubated in case of accidental extubation. • Patient tolerance of transient hypercarbia and hypoxemia
• Relative contraindications to PDT are: • Emergency airway access • Difficult anatomy • Morbid obesity with short neck • Limited neck movement • Cervical spine injury, suspected or otherwise • Aberrant blood vessels • Thyroid or tracheal pathology
• Relative contraindications to PDT are: • Coagulopathy, clotting disorder Prothrombin time or activated partial thromboplastin time 1.5 time reference range Thrombocytopenia, platelet count 50,000 cells/L • Significant gas exchange problems, eg PEEP 10 cm H2O or FIO2 0.6 • Evidence of infection in the soft tissues of the neck at the insertion site • Need for proximal or distal extension tracheostomy tube placement
• The preponderance of evidence confirms that percutaneous tracheostomy is as safe as surgical tracheostomy and is associated with decreased procedural time and cost
• Asystematic review comparing different PDT techniques in critically ill adult patients examined data from 1,130 subjects in 13 randomized trials. • Multiple dilators, single-step dilatation, guide wire dilating forceps, rotational dilation, retrograde tracheostomy, and balloon dilation techniques were all performed bedside in the ICU. • The different techniques and devices appeared largely equivalent
Comparison of 2 single tapered dilator percutaneous tracheostomy sets. A: Ciaglia Blue Rhino. B: Portex ULTRAperc (White Rhino).
A) Placing the finder needle. (B) Identifying the finder needle in the trachea via bronchoscopy. (C) Inserting guidewire via needle with subsequent removal of needle.
Insertion of 12-F dilator with a straight path downward over the guidewire.
(A) The conical dilator is fed onto the guidewire so that wire can be seen on both sides. (B) Using an overhand motion, the conical dilator is advanced into the trachea. (C) The bronchoscopic image as conical dilator is advanced into the trachea.
• (A) The appropriately sized tracheostomy tube, with an obturator (blue) to keep it stiff, is fed onto the cannula–guidewire complex. • (B) This tube is then advanced en masse into the trachea. • (C) This is the bronchoscopic view of the tracheostomy with cuff not yet inflated. The obturator, cannula, and guidewire have been removed while the tracheostomy is stabilized with the nondominant hand. • (D) The cuff is inflated and bronchoscope is inserted via the tracheostomy to confirm position in the trachea. The endotracheal tube will then be removed.
Ciaglia Blue Dolphin percutaneous technique.
• Ciaglia Blue Dolphin percutaneous technique. • This is a safe and effective percutaneous tracheostomy technique that uses radial outward dilation to minimize bleeding and injury to tracheal rings. • A: Balloon inflation with normal saline to a maximum pressure of 11 atm using an inflation pump. The balloon protrudes 1–1.5 cm above the skin surface. • B: Ciaglia Blue Dolphin components: (1) introducer needle, (2) guide wire, (3) 14 French dilator, (4) balloon-tipped catheter loading dilator assembly, (5) Cook inflation device.
PercuTwist technique for percutaneous tracheostomy. A: PercuTwist dilator. B: CrystalClear cannula. C: PercuQuick cannula. D: PercuTwist set.
Tapered tracheostomy tubes for use with percutaneous dilatational tracheostomy to avoid poor fit with tapered dilators. A: Portex Per-Fit (courtesy Smiths Medical). B: VersaTube (courtesy Cook Medical). C: Shiley PERC (courtesy
Percutaneous dilatational tracheostomy limitations: need for proximal or distal extension tracheostomy. A: Proximal extension for full or thick neck. B: Distal extension for long tracheal anatomy, tracheal stenosis, or tracheomalacia.
• Need for Proximal or Distal Extension Tracheostomy. • Proximal extension tracheostomy may be required with thick neck anatomy and in obese patients • Distal extension tracheostomy may be required in patients with long tracheal anatomy, tracheal obstruction (to get the tip distal to the obstruction), or tracheomalacia
• High-Risk Patients and Percutaneous Dilatational Tracheostomy • The largest study examining this issue reported a single-center prospective analysis of 1,000 PDT procedures (2001–2009) in ICU subjects with increased bleeding risk or obesity. • They identified that increased international normalized ratio was the most important risk factor for bleeding followed by thrombocytopenia • Interestingly, platelet dysfunction associated with continuous renal replacement therapy was not associated with increased bleeding risk • The rate of complications in subjects with high body mass index was not increased.
• Tracheostomy Decannulation • Answer the following to determine readiness of patient • Have the indications for the tracheostomy placement resolved or significantly improved? • Is the patient tolerating a decannulation cap on an appropriately sized uncuffed tracheostomy tube without stridor? • Does fiberoptic laryngoscopy confirm airway patency to the level of the glottis and immediate subglottis?
• Tracheostomy Decannulation • Answer the following to determine readiness of patient • Does the patient have an adequate level of consciousness and laryngopharyngeal function to protect the lower airway from aspiration? • Does the patient have an effective cough while the tracheostomy tube is capped? • Have all procedures that require general endotracheal anesthesia been completed?
• If yes to all, proceed with the following decannulation process: • Remove the tracheostomy tube • Clean the site • Cover the site with a dry gauze dressing • Instruct the patient to apply pressure over the dressing with fingers when talking or coughing • Change dressing daily and as needed if moist with secretions until the site has healed • Monitor for decannulation failure
• Additional Recent Advances in Tracheostomy • Real-Time Ultrasound • There are currently no randomized trials to establish the safety or efficacy of preprocedural and/or real-time ultrasound guidance during PDT compared with the current standard of care.
Real-time ultrasound should be considered in Obese patients in whom surface landmarks are difficult to discern • Patients with altered cervical anatomy • Difficult tracheostomy procedures such as repeat tracheostomy.
• There are some potential advantages to the real-time ultrasound PDT technique, including • (1) Decreased hypercarbia and associated increased intracranial pressure in neurologic and TBI patients due to no bronchoscope in the airway • (2) Avoidance of vascular structures in the anterior neck, particularly the midline thyroid veins • (3) Direct visualization of the site of entry into the trachea and determination of which tracheal ring, which is particularly useful in patients with difficult surface anatomy, morbid obesity, and previous tracheostomy.
• In conclusion, there is no benefit to early tracheostomy in most ICU patients with acute respiratory failure, and waiting until 10 days of intubation and mechanical ventilation is recommended • Special patient populations may benefit from early tracheostomy, including • (1) high likelihood of prolonged mechanical ventilation (ARDS, COPD, failed primary extubation) • (2) SCI and chronic neurologic disorders • (3) TBI patients
• Recent large randomized trials have confirmed that clinicians and intensivists are poor in predicting who will need prolonged intubation • The optimal technique for tracheostomy is PDT with bronchoscopic guidance • Choice of technique must take into account both individual and institutional experience, body habitus, risk factors for bleeding, and pathophysiology
• It has been demonstrated that tracheostomy teams and a tracheostomy hospital service are associated with standardized protocols and improved outcomes. • The UK National Tracheostomy Safety Project has standardized resources
• Tracheostomy Tubes • The inner diameter, outer diameter, and any other distinguishing characteristics (percutaneous, extra length, fenestrated) are marked on the flange of the tube as a guide to the clinician.
Components of a standard tracheostomy tube.
• Anatomy of the Tracheostomy Tube • Tracheostomy Tube Material • Metal tubes are constructed of silver or stainless steel. • They are not used commonly due to expense, rigid construction, and lack of a cuff and a 15-mm connector to attach a ventilator. • Metal is durable, inhibits bacteria growth, does not react with tissues, resists biofilm formation, is easy to clean, and can be sterilized with heat or steam. • .
• Anatomy of the Tracheostomy Tube • Tracheostomy Tube Material • The most commonly used tracheostomy tubes are made from polyvinyl chloride (PVC), silicone, or polyurethane. • PVC softens at body temperature, conforming to patient anatomy and centering the tube in the trachea. • Silicone is naturally soft and unaffected by temperature, resists colonization and biofilm buildup, and can be sterilized.
• Tracheostomy Tube Dimensions • The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature. • The sizes of some tubes are given by Jackson size, which was developed for metal tubes and refers to the length and taper of the outer diameter. These tubes have a gradual taper from the proximal to the distal tip. • The Jackson sizing system is still used for most Shiley dual-cannula tracheostomy tubes , but the International Organization for Standardization (ISO) method of sizing as determined by the inner diameter of the outer cannula at its smallest dimension is used for most other tubes. • .
• Tracheostomy Tube Dimensions • For dual-cannula tubes, the diameter of the inner cannula is the functional inner diameter. The outer diameter is the largest diameter of the outer cannula. • Tracheostomy tubes that might at first seem similar may in fact be quite different in their dimensions . • When selecting a tracheostomy tube, the inner diameter, outer diameter, and length must be considered
• If the outer diameter is too large, the leak with the cuff deflated will be decreased, and this will affect the ability to use the upper airway with cuff deflation for speech. • A 10-mm outer diameter tube is usually appropriate for adult women, and an 11-mm outer diameter tube is usually appropriate for adult men
• Tracheostomy tubes are angled or curved • Because the trachea is essentially straight, the curved tube may not conform to the shape of the trachea, potentially allowing for compression of the membranous part of the trachea, while the tip may traumatize the anterior portion. • The angled tube may be better centered in the trachea and exert less pressure along the tracheal wall.
Shiley single-cannula tube (left) and Shiley percutaneous tube (right). Both are size 8 tubes, but note the differences in size and style between them.
• Extra Length Tracheostomy Tubes • If the tracheostomy tube is too short, the distal end can obstruct against the posterior tracheal wall • Extra length tubes are constructed with extra proximal length (horizontal extra length) or with extra distal length (vertical extra length). • Extra proximal length facilitates tracheostomy tube placement in patients with a large neck (eg, obese patients). • Extra distal length facilitates placement in patients with tracheomalacia or tracheal anomalies.
A: Endoscopic view showing a correctly positioned tracheostomy tube. B and C: malpositioned tracheostomy tubes
• The most common malposition resulted in the posterior tracheal wall occluding the distal tip of the tube. • There should be a high index of suspicion for tracheostomy tube malposition when patients demonstrate unanticipated difficulty in being liberated from mechanical ventilation following tracheostomy. • Several tube designs have a spiral wire-reinforced flexible design. • These tubes are not compatible with lasers, electrosurgical devices, or magnetic resonance imaging.
• Dual-Cannula Tracheostomy Tubes • The use of an inner cannula allows it to be cleaned or replaced at regular intervals without removing the tracheostomy tube from its stoma. • The inner cannula can be removed to restore a patent airway if the tube occludes, which may be an advantage for long-term use outside an acute care facility. • If a fenestrated tracheostomy tube is used, the inner cannula occludes the fenestrations unless there are also fenestrations on the inner cannula. • One potential issue with the use of an inner cannula is that it reduces the inner diameter
• Fenestrated Tracheostomy Tubes • The addition of an opening in the posterior portion of the tube above the cuff. • The patient can inhale and exhale through the fenestration and around the tube. This allows for assessment of the patient’s ability to breathe through the normal oral/nasal route (preparing the patient for decannulation) • The cuff must be completely deflated by evacuating all of the air before the tube is capped. The decannulation cap is then put in place to allow the patient to breathe through the fenestrations and around the tube • The fenestrations may cause the formation of granulation tissue, resulting in airway compromise. • Proper position of the fenestrations in the airway should be inspected regularly.
Fenestrated tracheostomy tube.
• Subglottic Suction Port • Tracheostomy tubes that provide a suction port above the cuff are available. • One such design is the Blom tracheostomy tube . • The subglottic suctioning cannula is located on the exterior surface of the cannula as a separate lumen, which can be connected to intermittent or continuous suction, and is intended for the evacuation of secretions situated above the tracheostomy tube cuff.
Tracheostomy Tube Cuffs . Uncuffed • Tubes allow airway clearance but provide no protection from aspiration. Cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated. • Specific types of cuffs used on tracheostomy tubes include high-volume low- pressure cuffs, tight-to-shaft cuffs (low-volume high-pressure), and foam cuffs. • Tracheal capillary perfusion pressure is normally 25–35 mm Hg. Because the pressure transmitted from the cuff to the tracheal wall is usually less than the pressure in the cuff, it is generally agreed that 30 cm H2O (22 mm Hg) is the maximal acceptable intracuff pressure.
• it is recommended that cuff pressure be maintained at 20–30 cm H2O (15–22 mm Hg) to minimize the risks for both tracheal wall injury and aspiration. • Intracuff pressure should be monitored and recorded regularly (eg, once per shift) • A common cause of high cuff pressure is that the tube is too small, resulting in overfilling of the cuff to achieve a seal in the trachea. • Another common cause of high cuff pressure is malposition of the tube (eg, cuff inflated in the stoma). • Other causes of high cuff pressure include overfilling of the cuff, tracheal dilation, and use of a low-volume high-pressure cuff.
• The tight-to-shaft cuff minimizes air-flow obstruction around the outside of the tube when the cuff is deflated. It is a low-volume high-pressure cuff intended for patients requiring intermittent cuff inflation. • When the cuff is deflated, speech and upper airway use are facilitated. The cuff is constructed of silicone. It should be inflated with sterile water because otherwise the cuff will automatically deflate over time due to gas permeability. • A foam cuff consists of a large-diameter high-residual volume cuff composed of polyurethane foam covered by a silicone sheath. The foam cuff was designed to address the issues of high lateral tracheal wall pressures that lead to complications such as tracheal necrosis and stenosis.
• Stomal Maintenance Devices • Several approaches can be used for stomal maintenance in patients who cannot be decannulated. • One of the easiest approaches is to use a small cuffless tracheostomy tube (eg, size 4 cuffless). • Another approach is to use a tracheostomy button
• This device consists of a hollow outer cannula and a solid inner cannula. It fits from the skin to just inside the anterior wall of the trachea. • With the solid inner cannula in place, the patient breathes through the upper airway. When the inner cannula is removed, the patient can breathe through the button, and a suction catheter can be passed through the button to aid airway clearance. • Since a tracheostomy button does not extend into the trachea and does not have a cuff, its use is limited when there is a risk of aspiration or during positive-pressure ventilation. • Other devices used for stomal maintenance include the Montgomery Safe-T- Tube and the Montgomery long-term cannula
Montgomery Safe-T-Tube (left) and long-term cannula (right).
• Changing the Tracheostomy Tube • The tracheostomy tube may be changed to another one for a number of reasons: to reduce the size of the tube, to change the length of the tube if it is malpositioned, because it is obstructed with secretions, because it is broken (eg, cuff leak), to change the type of tube, or as a routine change with a chronic tracheostomy. • It is advisable to have 2 people present. • Prior to removing the old tube, all components of the new tracheostomy tube should be checked for integrity
• The patient is placed either supine or semirecumbent, with the neck extended. Removal of a tube through a tight stoma with a bulky cuff can be facilitated using lidocaine jelly or water-soluble lubricant inserted around the stoma/tube interface. • The tube exchanger is passed through the tube into the trachea. The tube is then withdrawn while keeping the tube changer in place, and the new tube is passed over the tube changer into the trachea. • Changing the tracheostomy tube in the patient’s home is not recommended
• Shiley recommends changing their PVC tracheostomy tubes every 29 d. • The Portex Blue Line package insert recommends 30 d as the maximal recommended period of use. The Portex Bivona tube package insert recommends it be used for up to 29 d. • Many manufacturers recommend that a tube with an inner cannula should not be used for 30 d. • Several studies have reported material breakdown of tracheostomy tubes over time.
Algorithm to manage failure to replace a tracheostomy tube during a routine change.
• Decannulation • Decannulation be considered in patients once mechanical ventilation is no longer needed, upper airway obstruction is resolved, airway secretions are controlled, and swallowing has been evaluated. • Level of consciousness, ability to tolerate tracheostomy tube capping, cough effectiveness, and secretions as the most important factors in the decision to decannulate.
• Accidental Decannulation • Accidental decannulation occurring in a patient with a mature stoma and with normal neck anatomy should be a benign event because the tracheostomy tube can usually be easily reinserted • Factors associated with accidental decannulation include mental status changes, increased secretions, and shift change.
• Ward Versus ICU • There has been some concern raised about the safety of patients with a tracheostomy who are managed outside the ICU. • In a prospective observational survey from 31 ICUs in Spain, Fernandez et al reported that, after adjustment for the propensity score and Sabadell score, the presence of a tracheostomy cannula was not associated with any survival disadvantage.
• Speaking With a Tracheostomy Tube • Spontaneously Breathing Patients • With the cuff deflated (or with a cuffless tube), patients (or their caregivers) can place a finger over the proximal opening of the tracheostomy tube to direct air through the upper airway and thus produce speech. • In the spontaneously breathing patient, a speaking valve directs the exhaled gas through the upper airway, which may allow the patient to speak.
Equipment used to measure tracheal pressure when a speaking valve is applied.
• Speaking Valve Contraindications • Unconscious or comatose patients (relative) • Inflated tracheostomy tube cuff or foam-cuffed tracheostomy tube(absolute) • Thick and copious secretions (relative) • Severe upper airway obstruction (absolute) • Endotracheal tube rather than tracheostomy tube (absolute)
• The patient’s risk for aspiration should be evaluated before the speaking valve is placed • If the tracheal pressure is 5 cmH2O during passive exhalation (without speech) with the speaking valve in place, this may indicate excessive expiratory resistance. • If the tracheal pressure is high, consideration should be given to downsizing the tube.
• The ability of the patient to tolerate the speaking valve can be briefly assessed by finger occlusion of the tracheostomy tube after cuff deflation. • Oxygen can be administered while the speaking valve is in place using a tracheostomy collar or an oxygen adapter on the speaking valve. • Care must be taken to ensure that the cuff is deflated before the speaking valve is attached.
Blom speech cannula. Inspiratory pressure opens the flap valve and closes (expands) the bubble valve, sealing the fenestration so that all of the tidal volume goes to the lungs. As inspiration ends, the flap valve closes. Expiratory pressure collapses the bubble valve, which unblocks the fenestration and directs all of the exhaled air to the upper airway to allow phonation.
Overview of tracheostomy

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Overview of tracheostomy

  • 2.
    • Overview ofTracheostomy • Dr. MOHAMMAD VAZIRI-Thoracic Surgeon • Iran University of Medical Sciences • Member of The • New York Academy of Sciences • European Society of Thoracic Surgeons • International Association for the Study of Lung Cancer • European Society of Medical Oncology • Clinical Research Associate – McMaster University
  • 3.
    • OUTLINE • Indicationsfor Tracheostomy • Complications of Tracheostomy • Timing of Tracheostomy • Tracheostomy Technique • Tracheostomy Decannulation • Tracheostomy Tubes • Changing the Tracheostomy Tube • Speaking Valve
  • 4.
    • Indications forTracheostomy • The most common indications for tracheostomy are (1) Acute respiratory failure and need for prolonged mechanical ventilation (2) Traumatic or catastrophic neurologic insult requiring airway, or mechanical ventilation or both. • Upper airway obstruction is a less common indication for tracheostomy. • 10% of mechanically ventilated patients undergo tracheostomy
  • 5.
  • 6.
  • 7.
  • 8.
    • Timing ofTracheostomy • The question of early versus late tracheostomy is complex and requires a 2- part solution: (1) we must predict which patients will require prolonged ventilation, and (2) we must make a decision about when the tracheostomy should be performed.
  • 9.
    • The definitionof early tracheostomy differs between studies. • Of the papers surveyed from the past 10 y, early was generally defined as within 3–10 d of mechanical ventilation, whereas late was variously defined as any time outside the early period, within 7–14 d, 14–28 d, or 28 d after initiation of mechanical ventilation. • Earlier timing of tracheostomy correlated with shorter time on mechanical ventilation and shorter ICU and hospital stay, but was not associated with hospital mortality.
  • 10.
    • Optimal Timingof Tracheostomy Based on Recent Randomized Controlled Trials • 2 recent randomized trials (Italian multi-center trialand TracMan United Kingdom multi-center trial) have consistent findings that earlier tracheostomy was not associated with improved survival and that clinicians cannot accurately predict which patients will require prolonged mechanical ventilation. • Based on the evidence to date, it is reasonable to wait at least 10 days to be certain that a patient has an ongoing need for mechanical ventilation
  • 11.
    • Limitations ofTracheostomy Timing Studies • Small number of trauma and surgical patients • Different outcome measures: all-cause mortality versus VAP versus ICU/ventilator-free days • No standardization of tracheostomy technique (open or percutaneous in TracMan, Griggs vs PercuTwist in Italian multi-center trial) • No large United States RCT to date
  • 12.
    • Patients WhoWould Benefit From Early Tracheostomy • Trauma and neurologic damage from stroke, head injury, and spinal cord injury (SCI) represent a subset of patients for whom the benefits of early tracheostomy have been specifically investigated. • For these studies, 7–8 d was a relatively consistent cutoff
  • 13.
    • Similar totrauma patients, retrospective studies report that early tracheostomy (within 7–8 d) in traumatic brain injury (TBI) patients is associated with some improved outcomes compared with delayed tracheostomy, but no large prospective randomized trials have yet validated these findings.
  • 14.
    • Tracheostomy Technique .Patient selection is a significant factor during the consideration of whether to perform percutaneous or surgical tracheostomy • In most adult ICU patients requiring elective tracheostomy and without contraindications to percutaneous tracheostomy, it has been suggested that percutaneous dilatational tracheostomy (PDT) should be considered the procedure of choice.
  • 15.
    • Indications andContraindications to PDT • Three critically important preoperative criteria for PDT are: • Ability to hyperextend the neck • Presence of at least 1-cm distance between the inferior cricoid cartilage and the suprasternal notch, ensuring that the patient will be able to be re-intubated in case of accidental extubation. • Patient tolerance of transient hypercarbia and hypoxemia
  • 16.
    • Relative contraindicationsto PDT are: • Emergency airway access • Difficult anatomy • Morbid obesity with short neck • Limited neck movement • Cervical spine injury, suspected or otherwise • Aberrant blood vessels • Thyroid or tracheal pathology
  • 17.
    • Relative contraindicationsto PDT are: • Coagulopathy, clotting disorder Prothrombin time or activated partial thromboplastin time 1.5 time reference range Thrombocytopenia, platelet count 50,000 cells/L • Significant gas exchange problems, eg PEEP 10 cm H2O or FIO2 0.6 • Evidence of infection in the soft tissues of the neck at the insertion site • Need for proximal or distal extension tracheostomy tube placement
  • 20.
    • The preponderanceof evidence confirms that percutaneous tracheostomy is as safe as surgical tracheostomy and is associated with decreased procedural time and cost
  • 21.
    • Asystematic reviewcomparing different PDT techniques in critically ill adult patients examined data from 1,130 subjects in 13 randomized trials. • Multiple dilators, single-step dilatation, guide wire dilating forceps, rotational dilation, retrograde tracheostomy, and balloon dilation techniques were all performed bedside in the ICU. • The different techniques and devices appeared largely equivalent
  • 24.
    Comparison of 2single tapered dilator percutaneous tracheostomy sets. A: Ciaglia Blue Rhino. B: Portex ULTRAperc (White Rhino).
  • 25.
    A) Placing thefinder needle. (B) Identifying the finder needle in the trachea via bronchoscopy. (C) Inserting guidewire via needle with subsequent removal of needle.
  • 26.
    Insertion of 12-Fdilator with a straight path downward over the guidewire.
  • 27.
    (A) The conicaldilator is fed onto the guidewire so that wire can be seen on both sides. (B) Using an overhand motion, the conical dilator is advanced into the trachea. (C) The bronchoscopic image as conical dilator is advanced into the trachea.
  • 29.
    • (A) Theappropriately sized tracheostomy tube, with an obturator (blue) to keep it stiff, is fed onto the cannula–guidewire complex. • (B) This tube is then advanced en masse into the trachea. • (C) This is the bronchoscopic view of the tracheostomy with cuff not yet inflated. The obturator, cannula, and guidewire have been removed while the tracheostomy is stabilized with the nondominant hand. • (D) The cuff is inflated and bronchoscope is inserted via the tracheostomy to confirm position in the trachea. The endotracheal tube will then be removed.
  • 30.
    Ciaglia Blue Dolphinpercutaneous technique.
  • 31.
    • Ciaglia BlueDolphin percutaneous technique. • This is a safe and effective percutaneous tracheostomy technique that uses radial outward dilation to minimize bleeding and injury to tracheal rings. • A: Balloon inflation with normal saline to a maximum pressure of 11 atm using an inflation pump. The balloon protrudes 1–1.5 cm above the skin surface. • B: Ciaglia Blue Dolphin components: (1) introducer needle, (2) guide wire, (3) 14 French dilator, (4) balloon-tipped catheter loading dilator assembly, (5) Cook inflation device.
  • 32.
    PercuTwist technique forpercutaneous tracheostomy. A: PercuTwist dilator. B: CrystalClear cannula. C: PercuQuick cannula. D: PercuTwist set.
  • 33.
    Tapered tracheostomy tubesfor use with percutaneous dilatational tracheostomy to avoid poor fit with tapered dilators. A: Portex Per-Fit (courtesy Smiths Medical). B: VersaTube (courtesy Cook Medical). C: Shiley PERC (courtesy
  • 34.
    Percutaneous dilatational tracheostomylimitations: need for proximal or distal extension tracheostomy. A: Proximal extension for full or thick neck. B: Distal extension for long tracheal anatomy, tracheal stenosis, or tracheomalacia.
  • 35.
    • Need forProximal or Distal Extension Tracheostomy. • Proximal extension tracheostomy may be required with thick neck anatomy and in obese patients • Distal extension tracheostomy may be required in patients with long tracheal anatomy, tracheal obstruction (to get the tip distal to the obstruction), or tracheomalacia
  • 36.
    • High-Risk Patientsand Percutaneous Dilatational Tracheostomy • The largest study examining this issue reported a single-center prospective analysis of 1,000 PDT procedures (2001–2009) in ICU subjects with increased bleeding risk or obesity. • They identified that increased international normalized ratio was the most important risk factor for bleeding followed by thrombocytopenia • Interestingly, platelet dysfunction associated with continuous renal replacement therapy was not associated with increased bleeding risk • The rate of complications in subjects with high body mass index was not increased.
  • 37.
    • Tracheostomy Decannulation •Answer the following to determine readiness of patient • Have the indications for the tracheostomy placement resolved or significantly improved? • Is the patient tolerating a decannulation cap on an appropriately sized uncuffed tracheostomy tube without stridor? • Does fiberoptic laryngoscopy confirm airway patency to the level of the glottis and immediate subglottis?
  • 38.
    • Tracheostomy Decannulation •Answer the following to determine readiness of patient • Does the patient have an adequate level of consciousness and laryngopharyngeal function to protect the lower airway from aspiration? • Does the patient have an effective cough while the tracheostomy tube is capped? • Have all procedures that require general endotracheal anesthesia been completed?
  • 39.
    • If yesto all, proceed with the following decannulation process: • Remove the tracheostomy tube • Clean the site • Cover the site with a dry gauze dressing • Instruct the patient to apply pressure over the dressing with fingers when talking or coughing • Change dressing daily and as needed if moist with secretions until the site has healed • Monitor for decannulation failure
  • 40.
    • Additional RecentAdvances in Tracheostomy • Real-Time Ultrasound • There are currently no randomized trials to establish the safety or efficacy of preprocedural and/or real-time ultrasound guidance during PDT compared with the current standard of care.
  • 41.
    Real-time ultrasound shouldbe considered in Obese patients in whom surface landmarks are difficult to discern • Patients with altered cervical anatomy • Difficult tracheostomy procedures such as repeat tracheostomy.
  • 42.
    • There aresome potential advantages to the real-time ultrasound PDT technique, including • (1) Decreased hypercarbia and associated increased intracranial pressure in neurologic and TBI patients due to no bronchoscope in the airway • (2) Avoidance of vascular structures in the anterior neck, particularly the midline thyroid veins • (3) Direct visualization of the site of entry into the trachea and determination of which tracheal ring, which is particularly useful in patients with difficult surface anatomy, morbid obesity, and previous tracheostomy.
  • 43.
    • In conclusion,there is no benefit to early tracheostomy in most ICU patients with acute respiratory failure, and waiting until 10 days of intubation and mechanical ventilation is recommended • Special patient populations may benefit from early tracheostomy, including • (1) high likelihood of prolonged mechanical ventilation (ARDS, COPD, failed primary extubation) • (2) SCI and chronic neurologic disorders • (3) TBI patients
  • 44.
    • Recent largerandomized trials have confirmed that clinicians and intensivists are poor in predicting who will need prolonged intubation • The optimal technique for tracheostomy is PDT with bronchoscopic guidance • Choice of technique must take into account both individual and institutional experience, body habitus, risk factors for bleeding, and pathophysiology
  • 45.
    • It hasbeen demonstrated that tracheostomy teams and a tracheostomy hospital service are associated with standardized protocols and improved outcomes. • The UK National Tracheostomy Safety Project has standardized resources
  • 47.
    • Tracheostomy Tubes •The inner diameter, outer diameter, and any other distinguishing characteristics (percutaneous, extra length, fenestrated) are marked on the flange of the tube as a guide to the clinician.
  • 48.
    Components of astandard tracheostomy tube.
  • 49.
    • Anatomy ofthe Tracheostomy Tube • Tracheostomy Tube Material • Metal tubes are constructed of silver or stainless steel. • They are not used commonly due to expense, rigid construction, and lack of a cuff and a 15-mm connector to attach a ventilator. • Metal is durable, inhibits bacteria growth, does not react with tissues, resists biofilm formation, is easy to clean, and can be sterilized with heat or steam. • .
  • 50.
    • Anatomy ofthe Tracheostomy Tube • Tracheostomy Tube Material • The most commonly used tracheostomy tubes are made from polyvinyl chloride (PVC), silicone, or polyurethane. • PVC softens at body temperature, conforming to patient anatomy and centering the tube in the trachea. • Silicone is naturally soft and unaffected by temperature, resists colonization and biofilm buildup, and can be sterilized.
  • 51.
    • Tracheostomy TubeDimensions • The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature. • The sizes of some tubes are given by Jackson size, which was developed for metal tubes and refers to the length and taper of the outer diameter. These tubes have a gradual taper from the proximal to the distal tip. • The Jackson sizing system is still used for most Shiley dual-cannula tracheostomy tubes , but the International Organization for Standardization (ISO) method of sizing as determined by the inner diameter of the outer cannula at its smallest dimension is used for most other tubes. • .
  • 52.
    • Tracheostomy TubeDimensions • For dual-cannula tubes, the diameter of the inner cannula is the functional inner diameter. The outer diameter is the largest diameter of the outer cannula. • Tracheostomy tubes that might at first seem similar may in fact be quite different in their dimensions . • When selecting a tracheostomy tube, the inner diameter, outer diameter, and length must be considered
  • 53.
    • If theouter diameter is too large, the leak with the cuff deflated will be decreased, and this will affect the ability to use the upper airway with cuff deflation for speech. • A 10-mm outer diameter tube is usually appropriate for adult women, and an 11-mm outer diameter tube is usually appropriate for adult men
  • 54.
    • Tracheostomy tubesare angled or curved • Because the trachea is essentially straight, the curved tube may not conform to the shape of the trachea, potentially allowing for compression of the membranous part of the trachea, while the tip may traumatize the anterior portion. • The angled tube may be better centered in the trachea and exert less pressure along the tracheal wall.
  • 55.
    Shiley single-cannula tube(left) and Shiley percutaneous tube (right). Both are size 8 tubes, but note the differences in size and style between them.
  • 57.
    • Extra LengthTracheostomy Tubes • If the tracheostomy tube is too short, the distal end can obstruct against the posterior tracheal wall • Extra length tubes are constructed with extra proximal length (horizontal extra length) or with extra distal length (vertical extra length). • Extra proximal length facilitates tracheostomy tube placement in patients with a large neck (eg, obese patients). • Extra distal length facilitates placement in patients with tracheomalacia or tracheal anomalies.
  • 58.
    A: Endoscopic viewshowing a correctly positioned tracheostomy tube. B and C: malpositioned tracheostomy tubes
  • 59.
    • The mostcommon malposition resulted in the posterior tracheal wall occluding the distal tip of the tube. • There should be a high index of suspicion for tracheostomy tube malposition when patients demonstrate unanticipated difficulty in being liberated from mechanical ventilation following tracheostomy. • Several tube designs have a spiral wire-reinforced flexible design. • These tubes are not compatible with lasers, electrosurgical devices, or magnetic resonance imaging.
  • 60.
    • Dual-Cannula TracheostomyTubes • The use of an inner cannula allows it to be cleaned or replaced at regular intervals without removing the tracheostomy tube from its stoma. • The inner cannula can be removed to restore a patent airway if the tube occludes, which may be an advantage for long-term use outside an acute care facility. • If a fenestrated tracheostomy tube is used, the inner cannula occludes the fenestrations unless there are also fenestrations on the inner cannula. • One potential issue with the use of an inner cannula is that it reduces the inner diameter
  • 61.
    • Fenestrated TracheostomyTubes • The addition of an opening in the posterior portion of the tube above the cuff. • The patient can inhale and exhale through the fenestration and around the tube. This allows for assessment of the patient’s ability to breathe through the normal oral/nasal route (preparing the patient for decannulation) • The cuff must be completely deflated by evacuating all of the air before the tube is capped. The decannulation cap is then put in place to allow the patient to breathe through the fenestrations and around the tube • The fenestrations may cause the formation of granulation tissue, resulting in airway compromise. • Proper position of the fenestrations in the airway should be inspected regularly.
  • 62.
  • 63.
    • Subglottic SuctionPort • Tracheostomy tubes that provide a suction port above the cuff are available. • One such design is the Blom tracheostomy tube . • The subglottic suctioning cannula is located on the exterior surface of the cannula as a separate lumen, which can be connected to intermittent or continuous suction, and is intended for the evacuation of secretions situated above the tracheostomy tube cuff.
  • 64.
    Tracheostomy Tube Cuffs .Uncuffed • Tubes allow airway clearance but provide no protection from aspiration. Cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated. • Specific types of cuffs used on tracheostomy tubes include high-volume low- pressure cuffs, tight-to-shaft cuffs (low-volume high-pressure), and foam cuffs. • Tracheal capillary perfusion pressure is normally 25–35 mm Hg. Because the pressure transmitted from the cuff to the tracheal wall is usually less than the pressure in the cuff, it is generally agreed that 30 cm H2O (22 mm Hg) is the maximal acceptable intracuff pressure.
  • 65.
    • it isrecommended that cuff pressure be maintained at 20–30 cm H2O (15–22 mm Hg) to minimize the risks for both tracheal wall injury and aspiration. • Intracuff pressure should be monitored and recorded regularly (eg, once per shift) • A common cause of high cuff pressure is that the tube is too small, resulting in overfilling of the cuff to achieve a seal in the trachea. • Another common cause of high cuff pressure is malposition of the tube (eg, cuff inflated in the stoma). • Other causes of high cuff pressure include overfilling of the cuff, tracheal dilation, and use of a low-volume high-pressure cuff.
  • 66.
    • The tight-to-shaftcuff minimizes air-flow obstruction around the outside of the tube when the cuff is deflated. It is a low-volume high-pressure cuff intended for patients requiring intermittent cuff inflation. • When the cuff is deflated, speech and upper airway use are facilitated. The cuff is constructed of silicone. It should be inflated with sterile water because otherwise the cuff will automatically deflate over time due to gas permeability. • A foam cuff consists of a large-diameter high-residual volume cuff composed of polyurethane foam covered by a silicone sheath. The foam cuff was designed to address the issues of high lateral tracheal wall pressures that lead to complications such as tracheal necrosis and stenosis.
  • 67.
    • Stomal MaintenanceDevices • Several approaches can be used for stomal maintenance in patients who cannot be decannulated. • One of the easiest approaches is to use a small cuffless tracheostomy tube (eg, size 4 cuffless). • Another approach is to use a tracheostomy button
  • 69.
    • This deviceconsists of a hollow outer cannula and a solid inner cannula. It fits from the skin to just inside the anterior wall of the trachea. • With the solid inner cannula in place, the patient breathes through the upper airway. When the inner cannula is removed, the patient can breathe through the button, and a suction catheter can be passed through the button to aid airway clearance. • Since a tracheostomy button does not extend into the trachea and does not have a cuff, its use is limited when there is a risk of aspiration or during positive-pressure ventilation. • Other devices used for stomal maintenance include the Montgomery Safe-T- Tube and the Montgomery long-term cannula
  • 70.
    Montgomery Safe-T-Tube (left)and long-term cannula (right).
  • 71.
    • Changing theTracheostomy Tube • The tracheostomy tube may be changed to another one for a number of reasons: to reduce the size of the tube, to change the length of the tube if it is malpositioned, because it is obstructed with secretions, because it is broken (eg, cuff leak), to change the type of tube, or as a routine change with a chronic tracheostomy. • It is advisable to have 2 people present. • Prior to removing the old tube, all components of the new tracheostomy tube should be checked for integrity
  • 72.
    • The patientis placed either supine or semirecumbent, with the neck extended. Removal of a tube through a tight stoma with a bulky cuff can be facilitated using lidocaine jelly or water-soluble lubricant inserted around the stoma/tube interface. • The tube exchanger is passed through the tube into the trachea. The tube is then withdrawn while keeping the tube changer in place, and the new tube is passed over the tube changer into the trachea. • Changing the tracheostomy tube in the patient’s home is not recommended
  • 73.
    • Shiley recommendschanging their PVC tracheostomy tubes every 29 d. • The Portex Blue Line package insert recommends 30 d as the maximal recommended period of use. The Portex Bivona tube package insert recommends it be used for up to 29 d. • Many manufacturers recommend that a tube with an inner cannula should not be used for 30 d. • Several studies have reported material breakdown of tracheostomy tubes over time.
  • 74.
    Algorithm to managefailure to replace a tracheostomy tube during a routine change.
  • 75.
    • Decannulation • Decannulationbe considered in patients once mechanical ventilation is no longer needed, upper airway obstruction is resolved, airway secretions are controlled, and swallowing has been evaluated. • Level of consciousness, ability to tolerate tracheostomy tube capping, cough effectiveness, and secretions as the most important factors in the decision to decannulate.
  • 77.
    • Accidental Decannulation •Accidental decannulation occurring in a patient with a mature stoma and with normal neck anatomy should be a benign event because the tracheostomy tube can usually be easily reinserted • Factors associated with accidental decannulation include mental status changes, increased secretions, and shift change.
  • 79.
    • Ward VersusICU • There has been some concern raised about the safety of patients with a tracheostomy who are managed outside the ICU. • In a prospective observational survey from 31 ICUs in Spain, Fernandez et al reported that, after adjustment for the propensity score and Sabadell score, the presence of a tracheostomy cannula was not associated with any survival disadvantage.
  • 80.
    • Speaking Witha Tracheostomy Tube • Spontaneously Breathing Patients • With the cuff deflated (or with a cuffless tube), patients (or their caregivers) can place a finger over the proximal opening of the tracheostomy tube to direct air through the upper airway and thus produce speech. • In the spontaneously breathing patient, a speaking valve directs the exhaled gas through the upper airway, which may allow the patient to speak.
  • 82.
    Equipment used tomeasure tracheal pressure when a speaking valve is applied.
  • 83.
    • Speaking ValveContraindications • Unconscious or comatose patients (relative) • Inflated tracheostomy tube cuff or foam-cuffed tracheostomy tube(absolute) • Thick and copious secretions (relative) • Severe upper airway obstruction (absolute) • Endotracheal tube rather than tracheostomy tube (absolute)
  • 84.
    • The patient’srisk for aspiration should be evaluated before the speaking valve is placed • If the tracheal pressure is 5 cmH2O during passive exhalation (without speech) with the speaking valve in place, this may indicate excessive expiratory resistance. • If the tracheal pressure is high, consideration should be given to downsizing the tube.
  • 85.
    • The abilityof the patient to tolerate the speaking valve can be briefly assessed by finger occlusion of the tracheostomy tube after cuff deflation. • Oxygen can be administered while the speaking valve is in place using a tracheostomy collar or an oxygen adapter on the speaking valve. • Care must be taken to ensure that the cuff is deflated before the speaking valve is attached.
  • 86.
    Blom speech cannula.Inspiratory pressure opens the flap valve and closes (expands) the bubble valve, sealing the fenestration so that all of the tidal volume goes to the lungs. As inspiration ends, the flap valve closes. Expiratory pressure collapses the bubble valve, which unblocks the fenestration and directs all of the exhaled air to the upper airway to allow phonation.