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

There's more to see -- the rest of this topic is available only to subscribers.

Last updated: May 13, 2010