Andrew Varone, MD
Background
Understanding the utility of tracheostomy is very important as respiratory failure and weaning the ventilator takes up a significant portion of ICU length of stay, likely the most of any organ failure.
Issues with prolonged orotracheal or nasotracheal intubation:
-inability to wean sedation to assess neurologic status or progress
-inability to wean sedation to progress to pressure support and spontaneous breathing
-safety concerns with endotracheal tube dislodgement, self removal
-tube obstruction, narrowing from secretions which hinders weaning
-poor oral care and hygiene
-risk for subglottic stenosis
A tracheostomy is about 1/3 the length of an endotracheal tube so flow characteristics by Poiseuille’s law are more favorable. This reduces work of breathing significantly which further aids weaning. Decreased resistance to expiratory flow also reduces development of auto or intrinsic PEEP. A tracheostomy is also less likely to become deformed as is common with an endotracheal tube in the upper airway or at the lip. Inner cannulas also allow for cleaning of a tracheostomy which is not an option with an endotracheal tube.
A well written review of mechanical advantages of a tracheostomy, direct link to PDF:
Indications and timing of tracheostomy
In the SICU and TICU most patients that require tracheostomy fall into one of the following categories:
-Prolonged mechanical ventilation with decreased chest wall, diaphragm strength and inability to maintain work of breathing, secretion clearance off the machine. This is especially a problem in our elderly patients with rib fractures, multiple injuries that require operations or after abdominal surgery. Generally tracheostomy should be done or considered as they are approaching 7 days on the ventilator. Family conversations should be held and patients goals of care should be reviewed as early as possible.
-CNS injury. Patients with severe TBI, GCS remaining < 8 with plans to continue maximal care may benefit from “early” tracheostomy, before the 5th day on the ventilator. Shorter time on the ventilator, less days in the TICU, and lower VAP rates were noted in a review comparing early to late tracheostomy in trauma patients.
Early tracheostomy in trauma patients saves time and money. Hyde GA, Savage SA, Zarzaur BL, Hart-Hyde JE, Schaefer CB, Croce MA, Fabian TC. Injury. 2015 Jan;46(1):110-4.
We often receive consults from the other units(MICU, NCCU, CTIC) to do a tracheostomy. Indications in these units are broad and include CVA, TBI, primary respiratory failure from PNA, COPD, or other cardiopulmonary processes. When doing a consult in these units note the indication, the patient’s and family’s goals, whether discussion has occurred regarding tracheostomy, the patient’s degree of ventilator support, whether they are on anticoagulation or antiplatelet agents, and relevant anatomy.
Procedure
Usually performed at the bedside with respiratory therapy doing the bronchoscopy.
Order medications and notify the nurse before the procedure.
-midazolam(order up to 6 mg given in 2-3 mg doses)
-fentanyl(order up to 300 mcg given in 50-100 mcg doses)
-rocuronium(1 mg/kg)
Other options include propofol, ketamine.
Maintain wire access to the airway throughout the procedure.
Include the device placed and the distance to the carina in the procedure note.
All tracheostomy patients regardless of their location should have a post procedure check done at 4-6 hours.
What if a tracheostomy comes out accidentally?
If this occurs in the first few hours or days after placement it is an emergency. The in house surgical attending should be notified immediately. Plan should be to reintubate the patient by the endotracheal route. Call anesthesia staff for help. A redo tracheostomy can then be done at any time. A resident should not try to reintubate the tracheostomy into a likely immature tract.
What if the nurse reports a suction catheter cannot be passed through the tracheostomy?
This may indicate a dislodged tracheostomy or that it is in the subcutaneous tissue. The in house surgical attending should be notified immediately. If the patient is stable a bronchoscopy is an option or as above intubation by the endotracheal route may be needed.
Decannulation
Evidence for criteria for tracheostomy decannulation is limited unlike for extubation. Consider decannulation if the following are present:
-patient unlikely to return to OR
-patient able to clear secretions, generate a cough, do pulmonary toilet
-not requiring frequent suctioning(more than a couple times a day)