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.
- 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.
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.
- Airway maintenance: obstruction or inability to protect
- Prolonged ventilation: dependance on vent, secretions or projected course of underlying disease (eg neurological)
- no consent
- age <16
- anatomical anomalies eg goitre/mass
- bleeding disorder
- infection at site
- 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
- depends on technique but goal is between rings 2 and 3 or rings 1 and 2
- competent intensivist
- trainee who has previously been deemed competent otherwise under direct supervision
- 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:
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.
Epstein SK. Anatomy and physiology of tracheostomy. Respir Care. 2005 Apr;50(4):476-82. PMID: 15807905.