Tracheostomy

First Things First (assess & treat for the following)

• Overview
  • Once used primarily for emergency mgt of upper airway obstruction; has evolved into an elective, bedside procedure in patients requiring prolonged ventilatory support
  • Open tracheostomy (OT): open procedure performed at bedside or in OR. Allows direct visualization of trachea during cannulation.
  • Percutaneous dilational tracheostomy (PDT): alternative to OT; can be performed at bedside or in OR. Seldinger technique used for tracheal dilatation & tracheostomy tube placement.
• Indications
  • Prolonged ventilatory support
    • Ventilatory support >10-14 days
    • Early tracheostomy (< 3 days) in patients with suspected devastating injuries (neurologic or multi-system trauma)
      • May decrease risk of pneumonia, number of ventilator days & length of ICU stay
  • Upper airway obstruction or trauma
  • Excessive and difficult-to-manage secretions
• Contraindications
  • Absolute
    • Percutaneous
      • Inability to identify laryngeal and tracheal landmarks
  • Relative
    • Percutaneous
      • Difficult airway
      • Small ETT (< 7 mm); will make bronchoscopy and ventilation difficult
      • Previous neck surgery including tracheostomy
    • Both open and percutaneous
      • PEEP >15 cm of water
      • FiO2 >80%
      • Patient requiring non-conventional ventilation mode to maintain oxygenation or ventilation
      • Coagulopathy
      • Active neck infection