Tracheostomy:When to perform and How to manage?

Tracheostomy; When to Perform and How to

Manage

Gamal Rabie Agmy, MD,FCCP

Professor of Chest Diseases

,Assiut University

Tracheostomy History

The Tracheostomy is

one of the oldest

surgical procedures.

It can be traced back

to Egyptian tablets

from 3600 B.C.

Who famous person died of

an upper airway obstruction

because their M.D. was

unwilling to perform his 1st

tracheostomy on a person

of such stature??

*George Washington

toured his estate on

horseback one cold

and rainy day in 1799.

*The next day he had

severe upper airway

swelling.

Antonio Musa Brasavola, an Italian

physician, performed the first

documented case of a successful

tracheotomy. He published his account

in 1546. The patient, who suffered from

a laryngeal abscess and recovered from

the procedure

26% 25%

20%

27%

Rate of Tracheostomy 11% vs 12.5%

1998 vs 2004

Evolution of Mechanical Ventilation in

Response to Clinical Research Esteban A et al. Am J Respir Crit Care Med 2008; 177: 170–177

WHY ?

WHEN ?

WHICH ?

WHO and HOW?

• Prolonged intubation

• Facilitation of ventilation support

• Inability of patient to manage secretions

• Upper airway obstruction

• Inability to intubate

• Adjunct to major head and neck surgery

• Adjunct to management of major head

and neck trauma

INDICATIONS FOR TRACHEOSTOMY

Facilitate prolonged assisted ventilation

- Coma

• Major Head injury

• Cerebral bleed/infarct/lesion

• Encephalitis

- High spinal cord injury

- Neuromuscular disorder

• Guillain-Barre syndrome

• Critical Care Polyneuropathy

- COPD

Why Tracheostomy

Pelosi P et al Crit Care 2004; 8:322-324

Inability to prevent pulmonary

aspiration

- Posterior fossa/infratentorial lesions

• Cerebellum/brain stem

• Basilar/posterior cerebral artery

• Encephalitis

- Cranial nerve dysfunction

Why Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324

Upper airway obstruction

- Maxillofacial surgery or trauma

- Congenital malformation

- Facilitate upper cervical surgery

- Vocal cord paralysis

Why Tracheostomy Pelosi P et al Crit Care 2004; 8:322-324

Predictors of Outcome for Patients With COPD

Requiring Invasive Mechanical Ventilation Nevins ML et al Chest 2001;119;1840-1849

- Previous Mechanical Ventilation

- FEV1/FVC < 30% predicted

- COPD Exacerbation

- Low Ht (< 35%) and Albumin (< 2.5 g/dL)

- APACHE (> 15, 6 hrs after MV)

- Active Malignacy

TRACHEOSTOMY VS

TRANSLARYNGEAL INTUBATION

– Increased patient mobility

– More secure airway

– Increased comfort

– Improved airway suctioning

– Early transfer of ventilator-dependent patients from the intensive care unit (ICU)

– Less direct endolaryngeal injury

– Enhanced oral nutrition

– Enhanced phonation and communication

– Decreased airway resistance for promoting weaning from mechanical ventilation

– Decreased risk for nosocomial pneumonia in patient subgroups

Heffner, Hess.Clinics in Chest Medicine 22 , 2001.

- Tracheal complications

- Aggressive procedure

- Risk of stomal infection

- Esthetic sequelae

- Bleeding

- Psychological trauma

- Delayed ICU discharge

- Organizational difficulties

- Increased risk in ward

Disadvantages of Tracheostomy

Pelosi P et al Crit Care 2004; 8:322-324

Blot F et al. Chest 2005; 127:1347–1352

Absolute contraindications (rare):

- Soft tissue infections of the neck

- Anatomic aberrations

Relative controindications:

- Severe respiratory distress with

refractory hypoxemia and hypercapnia

- Hematologic and coagulation disorders

Contraindications for tracheostomy (?) Groves DS et al Curr Opin Crit Care 2007, 13:90–97

Reduction of dead space

Reduction of airway resistance and dead space Reduced rate of VAP

Less need for sedation

Shortened weaning period

Shortened ICU stay

Lower mortality

Direct effects Indirect effects

Postulated

Diehl JL et al.Am J Respir Crit Care Med 1999, 159:383-388

Tracheostomy: WOB and PEEPi

Is tracheostomy associated with better

outcomes for patients requiring long-term

MV ? Combes A et al. Crit Care Med 2007; 35:802–807

Tracheostomy does not improve the outcome of

patients requiring prolonged MV: A propensity

analysis Clec’h C et al Crit Care Med 2007; 35:132–138

Odds ratios for post-intensive care unit mortality

associated with tracheostomy in patients matched on

propensity scores

- All patients 2.57 1.20-5.48 0.01

- Patients decannulated

before discharge 1.43 0.42-4.90 0.56

- Patients not decannulated

before discharge 3.73 1.41-9.83 0.008

OR 95% CI p Value

- If the need for an artificial airway

is anticipated to be greater than 21

days

Plummer AL, Gracey DR. Consensus conference on artificial

airways in patients receiving mechanical ventilation. Chest

1989; 96:178–180

Indications for tracheostomy

Chastre J, Bedock B, Clair B, et al. Which tracheal route

should be used for mechanical ventilation in the critically ill?

Thirteenth consensus conference on resuscitation and

emergency medicine. Rean Urg 1998; 7:435–442

Indications for tracheostomy

- Mechanical ventilation anticipated to

last between 10 and 21 days

- The decision left to the attending MD

- Daily assessment was recommended

as to the need for continued intubation

MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for

weaning and discontinuing ventilatory support: a collective task force

facilitatedby the American College of Chest Physicians; the American

Association for Respiratory Care; and the American College of Critical

Care Medicine. Chest 2001; 120 (6 Suppl):375S–395S.

Indications for tracheostomy

- After an initial period of stabilization

on the ventilator (generally, within 3–7

days)

- When apparent that the patient will

require prolonged ventilator

assistance

Tracheostomy in the critically ill:

indications, timing and techniques

Groves DS et al Curr Opin Crit Care 2007, 13:90–97

Prolonged

Mechanical

Ventilation

How Is Mechanical Ventilation Employed

in the Intensive Care Unit ?

Esteban A et al Am J Respir Crit Care Med 2000; 161; 1450–1458

Percentage of pts with tracheostomy

Outcome of mechanically ventilated

patients who require a tracheostomy Frutos-Vivar F et al. Crit Care Med 2005;

33:290 –298

Tracheostomy performed

at a median

time of 12 days (7–17) from

beginning mechanical

ventilation.

Incision 1 cm below the cricoid or halfway between the cricoid and the sternal notch.

Retractors are placed, the skin is retracted, and the strap muscles are visualized in the midline. The muscles are divided along the raphe, then retracted laterally

The thyroid isthmus lies in the field of the dissection. Typically, the isthmus is 5 to 10 mm in its vertical dimension, mobilize it away from the trachea and retract it, then place the tracheal incision in the second or third tracheal interspace

• Shiley

tracheostomy tube:

#6

• Shiley

tracheostomy tube:

#8 for

bronchoscopy.

Guidewire and catheter are advanced

together into the trachea as far as the

skin positioning marks on the guide

catheter to the skin.[

Guidewire introduction, with removal

of sheath

PERCUTANEOUS DILATIONAL TRACHEOTOMY

PERCUTANEOUS DILATIONAL TRACHEOTOMY

Guidewire and catheter are advanced together into the trachea as far as the skin positioning marks on the guide catheter to the skin

Guidewire, guide catheter, and dilator unit are advanced together into the trachea to the skin positioning mark

PERCUTANEOUS DILATIONAL TRACHEOTOMY

The tracheotomy tube is loaded onto a dilator and advanced into the trachea over the guidewire and catheter. The guidewire and catheter are removed, leaving only the tracheostomy tube in the trachea

PERCUTANEOUS DILATIONAL

TRACHEOTOMY

Cook Ciaglia percutaneous dilatational tracheostomy kit

Percutaneous trachesotomy techniques "classical" Ciaglia technique

Ciaglia P, Firsching R, Syniec C.

Elective percutaneous dilatational tracheostomy a new simple bedside

procedure: preliminary report.

Chest 1985; 87:715-719

Griggs forceps technique

Griggs WM, Gilligan JE, Myburg JA.

A simple percutaneous tracheostomy technique

Surgery 1990; 170:543-544

PercuTwist

Frova G, Quintel M.

A new simple method for percutaneous tracheostomy: controlled

rotating dilation

Intensive Care Med 2002; 28:299-303

Fantoni - translaryngeal technique

Fantoni A, Ripamonti D.

A non-derivative, non surgical tracheostomy: the translaryngeal method.

Intensive Care Med 1997; 27:386-392

Criggs

Ciaglia

Frova

Blue Rhino

T-Dagger

Blue Dolphin

Seldinger guide wire Carina

Technical approach

Management

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

ANGLED

CURVE

Specific case of thorax deformity

INNER CANNULA

Jackson

size

ID with inner

cannula

ID without

inner cannula

ED

4 5.0 mm 6.7 mm 9.4 mm

6 6.4 mm 8.1 mm 10.8

mm

8 7.6 mm 9.1 mm 12.2

mm

10 8.9 mm 10.7 mm 13.8

mm

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

20-30 cmH20

DEFLATED CUFF INFLATED CUFF

INFLATED DEFLATED

DEFLATED CUFF INFLATED CUFF

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

TUBE REPLACEMENT

• FIRST CHANGE ADVISABLE > 10-15

DAYS AFTER TRACHEOSTOMY

• NO FIXED SCHEDULE FOR

REPLACEMENT BUT HIGHLY

DEPENDENT ON LOCAL POLICY

• CLOSELY LINKED TO THE TYPE OF

CANNULA (INNER CANNULA etc) AND

TO THE QUALITY OF DOMICILIARY

MANAGEMENT

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

PHYSIOLOGIC CHANGES

AFTER TRACHEOTOMY

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

Tracheotomy and dysphagia

58%26%

16%

OF

NGP

PEG

RESPIRATORY INTENSIVE CARE UNIT

PAVIA 2000-2008 (710 patients)

TRACHEOSTOMY AND

DYSPHAGIA

• EPIGL. BACKWARD FOLDING 80%

• RETENTION IN VALLECULAE 70%

• LARYNX ELEVATION 40%

• GAG REFLEX 30%

• VOCAL CORDS ADDUCTION 30%

• ORAL TRANSPORT PHASE 20%

• COUGH REFLEX 20%

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

PHONATION

• REQUIRED A SUBGLOTTIS

PRESSURE OF AT LEAST 2-3

cmH2O

• REQUIRED A FLOW THROUGH THE

UPPER AIRWAY > 3 L/min

Speaking during spontaneous breathing

One way Passy Muir

Valve to speak under

mechanical ventilation

INSPIRATION ESPIRATION - ZEEP

ESPIRATION

+ PEEP

LONG-TERM MANAGEMENT

• CHOICE OF CANNULA

• CUFF MANAGEMENT

• MALPOSITION

• REPLACEMENT

• HUMIDIFICATION

• DYSPHAGIA

• PHONATION

• WEANING

Tracheotomy at discharge

57%

43%

NO

YES

RESPIRATORY INTENSIVE CARE UNIT

PAVIA 2000-2008 (618 patients)

Patients weaned from tracheotomy

5%

34%

32%

29%

NM

PA

PC

PO

RESPIRATORY INTENSIVE CARE UNIT

PAVIA 2000-2008 (352 patients)

CONCLUSIONS

Complications of

Tracheostomy

• Complications 5-40%

• Mortality <2%

• Complications are more frequent in

emergency situations, severely ill

patients and small children.

Complications of

Tracheostomy

– Stoma

• Stoma site infection

• Stomal hemorrhage

• Poor stoma healing after decannulation with scar, keloid, or tracheocutaneous fistula

Complications of

Tracheostomy

–Trachea

• Granuloma

• Tracheoesophageal fistula fewer than 1% of patients as a result of

pressure necrosis of the tracheal and

esophageal mucosa from the tube cuff

risks: high cuff pressures, presence of a

nasogastric tube, excessive tube movement,

and underlying diabetes mellitus

Complications of

Tracheostomy

• Tracheoinnominate fistula: 0.4% with mortality rate of 85% to 90%.

Major airway hemorrhage may occur first within several days or as long as 7 months after performance of a tracheostomy.

Risk factors : excessive tube movement, low placement of the tracheostomy, sepsis, poor nutritional status, and corticosteroid therapy

• Tracheal stenosis: can develop from 1 to 6 months after decannulation

risk for tracheal stenosis ranges between 0% and 16%

• Tracheomalacia