Tasty Morsels of Critical Care 013 | Tracheostomy – Putting it in

17 Dec

Welcome back to the tasty morsels of critical care podcast.

In a breaking from what could only loosely be described as tradition at this point, this podcast is going to be in 2 parts.

Intensivists have embraced the tracheostomy as an ICU procedure. It’s one of the most invasive and one of the riskier procedures we do. There is a substantial ANZICS document on tracheostomy that forms the structure for this tasty morsel.¬†

Timing

  • no mortality benefit shown of early (typically <10days) v late tracheostomy
  • TRACH Man is the big UK study here (n = 900) ¬†which was actually a trial of tracheostomy at 4 days vs after 11 days.

Techniques

A variety are available but to be honest , of the 5 ICUs I’ve worked in they’ve all used a percutaneous needle > wire > graduated dilator technique. And this seems to work exceptionally well. The minor variations I’ve noted include

  • swapping the ETT for an LMA and bronch down the LMA for positioning.
  • pulling the ETT just above the cords and hyperinflating cuff and downward pressure forming a sort of poor man’s LMA
  • varying degrees of blunt dissection before the graduated dilator goes in. Some do entirely percutaneous, some do a lot of blunt dissection.

Indications

  • Airway maintenance: obstruction or inability to protect
  • Prolonged ventilation: dependance on vent, secretions or projected course of underlying disease (eg neurological)

Contraindications

  • no consent
  • age <16
  • anatomical anomalies eg goitre/mass
  • bleeding disorder
  • infection at site

Risks/complications

  • 4-9% rate of complication which is mainly minor bleeding and desaturation
  • most serious is splitting the posterior trachea (through the trachealis muscle), usually when the back wall is inadvertently wired and dilated through and through. Bronchoscopy should stop this
  • pneumothorax/mediastiunum/sub cut emphysema all possible

Placement site

  • depends on technique but goal is between rings 2 and 3 or rings 1 and 2

Personnel required

  • competent intensivist
  • trainee who has previously been deemed competent otherwise under direct supervision

Bronchoscopy

  • should be available but not necessarily used. I found this a somewhat surprising statement as I assumed it was mandatory but i have worked with someone who never uses it and seems to get on just fine. I suppose this is somewhat similar to ultrasound for CVCs as plenty of people seem to cope perfectly well without it
  • no good data to guide a solid recommendation as yet. Unlike ultrasound in central lines where it seems that US has become the standard of care

Ultrasound in tracheostomy

  • mentioned by the statement but no recommendation either way
  • personally I remain unclear of its place as I have found vessels that have put me off doing the tracheostomy but I suspect if we hadn’t looked everything would have gone fine as we ploughed on in ignorance.

References and rationalisations:

ANZICS Statement

LITFL Resources

Furlow PW, Mathisen DJ. Surgical anatomy of the trachea. Ann Cardiothorac Surg. 2018 Mar;7(2):255-260. doi: 10.21037/acs.2018.03.01. PMID: 29707503; PMCID: PMC5900092.

Deranged Physiology

Epstein SK. Anatomy and physiology of tracheostomy. Respir Care. 2005 Apr;50(4):476-82. PMID: 15807905.

 

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