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  • INSERTION CONSIDERATIONS

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Indications & Timing

What are the indications for a tracheostomy?

Overcome Upper Airway Obstruction (Actual or Potential)
  • Tumour
  • Bilateral recurrent laryngeal paresis
  • Oral / facial trauma
  • Infection in oral cavity, pharynx or larynx
  • Burns
  • Following certain head and neck surgery
Facilitate Airway Protection and Secretion Management
  • Laryngeal incompetence due to critical illness, polyneuropathy, or bulbar dysfunction
  • Neurological disease
  • Traumatic brain injury
Facilitate Weaning from Mechanical Ventilation
  • Any reversible condition requiring ventilatory support
Provide Lifelong Ventilation
  • High C-spine injury

What are the advantages of a tracheostomy?

 

  • Reduction in laryngeal and vocal cord trauma
    • Prolonged intubation associated with injury such as pressure necrosis and mucosal abrasions
  • Reduced sedation requirement (better tolerated than ETT)
  • Facilitation of gradual weaning from mechanical ventilation:
    • Reduced work of breathing
    • Reduced resistance and dead space
  • Improved oral hygiene
  • Allows rehabilitation:
    • Improved mobility, speaking, oral intake
    • Improved patient communication (written or spoken)
  • Improved patient comfort
  • Reduced LOS in ICU
  • Reduced nursing care required

Is emergency tracheostomy the surgical procedure of choice in patients with apneoa and acute upper airway obstruction when intubation fails?

 

  • Cricothyroidotomy is the procedure of choice
    • Provides greatest likelihood of successful airway placement
    • Has superficial location with easily identifiable landmarks
  • Complications of tracheotomy increase fivefold when used in an emergency situation

Is there any evidence to suggest early tracheostomy is superior to late tracheostomy to aid weaning from ventilation?

  • No high-quality studies have definitively answered the question of whether routine, early tracheostomy improves clinical outcomes:
    • Studies are difficult to design
    • Doctors are poor at predicting which patients may undergo successful extubation within the next few days, thereby avoiding unnecessary tracheostomy
  • Accumulated evidence and expert opinion suggest early tracheostomy does not improve survival or even shorten hospital stay
  • The largest trial to explore the question is the TRACMAN trial:
Population
Intervention
Conclusion

RCT: TRACMAN

Young et al
JAMA (2013)

View Paper

  • Intubated and ventilated patients expected to require at least seven further days of ventilation
  • Excluded those with potential indications for early tracheostomy (airway obstruction, neurological illness, TBI)
  • Early (within four days of admission) vs. late (on/after day 10) tracheostomy
  • Primary outcome 30-day mortality
  • No difference in mortality at any point over the two-year follow-up
    Early group:
  • Non-significant trend towards shorter duration of mechanical ventilation
  • Significantly fewer days of sedation administration
    Late group:
  • Only 43% of the patients in the late group went on to receive a tracheostomy (many not intubated)
  • 6.3% complication rate for the tracheostomies that were performed
The Bottom Line Review

Meta-analysis: Cochrane Review

Andriola et al
Cochrane Database (2015)

View Paper

  • Eight RCTs with a total of 1,977 participants
  • Early tracheostomy (two to 10 days after intubation) vs. late tracheostomy (> 10 days after intubation) for critically ill adult patients
  • Results from seven RCTs (n = 1903) showed lower mortality rates in the early as compared with the late tracheostomy group (risk ratio (RR) 0.83, P value 0.03)
  • However due to low quality evidence review concluded results "no more than suggestive of the superiority of early over late tracheostomy"

When should tracheostomies be performed during an admission?

  • Timing of tracheostomy should be decided on a case-by-case basis
    • Balance between the risks of an invasive and potentially unnecessary procedure with risks that of prolonged endotracheal intubation and sedation
    • Should be considered when a need for prolonged ventilation becomes apparent
  • Any decisions should involve the patient and the multidisciplinary team:
    • Significant lifestyle considerations and burdens for both the patient and their family should be discussed
    • All reasonable efforts should be explored to establish patients’ wishes
  • Given lack of clear evidence guiding timing of insertion some clinicians advocate waiting at least two weeks until reaching a decision
    • Some clear early indications such as airway obstruction, neurological illness, TBI)
  • Most patients can undergo spontaneous breathing trial before the decision for tracheostomy
    • 2014 NCEPOD report highlighted a significant proportion of patients undergo procedure without an attempt at primary extubation

How should consent be gained for tracheostomy?

  • Procedure in the critically ill should almost always be planned:
    • Benefits and burdens weighed up by the MDT over a period of days
    • Allows ample time to explain the procedure to the patient and relatives
  • Consent is considered mandatory:
    • Majority of cases will use a consent form 4 for patients that lack capacity
    • Where possible, attempts should be made to utilise communication aids and support to determine patient capacity and facilitate consent

Contraindications

What are the contraindications to tracheostomy insertion?

Absolute Contraindications
  • Patient Refusal
  • Unstable fractures of the cervical spine
  • Severe local infection of the anterior neck
  • Uncontrollable coagulopathy
Relative Contraindications
  • Lack of need:
    • Unlikely to survive >48 hours
    • Unlikely to require >2 weeks ventilation
  • Controlled local infection
  • Coagulopathy:
    • PT or APTT >1.5
    • Platelets <50
  • High PEEP (>10) or FiO2 (>0.6) requirements
  • Difficult anatomy (contraindication to percutaneous tracheostomy, surgical tracheostomy advised):
    • Abnormal or prominent vasculature at insertion site
    • Morbid obesity
    • Short thick neck
    • Reduced neck extension
    • Excessive goiter
    • Tracheal deviation
    • Previous radiotherapy
    • Proximity to extensive burns or surgical wounds
  • Elevated intracranial pressure
  • Haemodynamic instability

Complications

What are the complications of tracheostomy insertion?

Immediate (During Insertion)
  • Arrest and Death (1/600)
  • Haemorrhage (minor or severe) - 4.8%
  • Misplacement (pre-tracheal tissues or to main bronchus)
  • Hypoxia
  • Injury to local structures:
    • Pneumothorax and surgical emphysema
    • Oesophageal perforation
    • Vascular injury
    • Thyroid injury
    • Posterior tracheal wall injury
    • Laryngeal nerve damage
    • Tracheal ring fracture
  • Air embolism
  • Equipment issues:
    • Incorrect tube / size
    • Equipment malfunction
Delayed (Post Insertion)
  • Tube blockage with secretions (may be sudden or gradual)
  • Tube migration to pre-tracheal space
  • Accidental decannulation
  • Infection:
    • Stoma site
    • Bronchial tree
    • VAP
  • Erosion related:
    • Tracheal ulceration or necrosis
    • Tracheo-oesophageal fistula formation
    • Tracheo-innominate fistula
Late (Post Decannulation)
  • Tracheal injury / dysfunction:
    • Tracheal stenosis at the cuff site
    • Tracheomalacia
    • Vocal cord dysfunction
    • Persistent sinus at the tracheostomy site
  • Granulomata of the trachea
  • Tracheo-innominate fistula
  • Psychological impact related to stoma

Techniques & Advantages

What are the different techniques for a surgical airway?

Surgical Tracheostomy
  • An open surgical procedure that allows insertion of a tracheostomy tube into the trachea between cartilaginous rings.
Percutaneous Dilatational Tracheostomy
  • Refers to various procedures that have in common either a modified Seldinger technique for placing a modified tracheostomy tube or a forceps technique to cannulate and dilate tracheal tissue between cartilaginous rings
  • Used for over 90% of ICU tracheostomies with over two-thirds of all tracheostomy procedures are now performed by intensivists in ICUs rather than by surgeons
Cricothyroidotomy
  • Technique for placement of an airway into the trachea through the cricothyroid space
  • Can be performed as a surgical procedure through an incision, as a percutaneous procedure by a Seldinger technique, or as a needle cricothyroidotomy for emergency airway access.
Mini Tracheostomy
  • Allows percutaneous placement of a 7F cannula through the tracheal rings to allow suctioning for patients with difficulty clearing airway secretions

What are the advantages and disadvantages of surgical or percutaneous tracheostomies?

Percutaneous
Surgical
Advantages
  • Relatively quick in experienced hands
  • Avoids need for transfer of unstable patients
  • Does not require involvement of surgeons
  • Cheaper
  • Smaller scar
  • Tighter stoma that decreases stomal bleeding and provides better fit
  • Can be performed when percutaneous contraindicated:
    • Short or thick neck, obese
    • Coagulopathy
    • Unstable spine
    • Previous neck / thyroid surgery
    • Abnormal vessels
  • Resources available to control bleeding
  • Potentially easier management in event of early tube dislodgment or tube exchange:
    • Stoma stitched open
    • May have stay sutures to elevate the trachea
Disadvantages
  • Suboptimal conditions for management of bleeding, especially if major vessel injured
  • Blind techniques can be incorrectly positioned
  • Tracheal ring fracture can occur
  • Late tracheal stenosis (as per surgical tracheostomy)
  • Lack of surgical dissection can increase risk of vascular or thyroid injury
  • Potentially more difficult management in event of early tube dislodgment or tube exchange:
    • Tissues will tend to ‘spring’ closed when tube removed in first 7–10 days
  • Requires operating theatre leading to delays in insertion
  • Requires patient transfer
  • More expensive

Procedure (Ciagla Technique)

How do you perform a percutaneous tracheostomy?

  • ICS / FFICM or Local Safety Checklist
  • Intravenous anaesthesia, muscle relaxant and vasopressors
  • Local anaesthetic with adrenaline
  • Syringe and needle
  • Sterile gloves and gown
  • Protective face shield or goggles
  • 2% chlorhexidine / isopropyl alcohol cleaning swabs
  • Sterile procedure pack:
    • Drape with window
    • Gauze swabs
  • Percutaneous tracheostomy set:
    • Appropriately sized tracheostomy tube and spare one size smaller
    • Obturator
    • Needle /cannula and syringe
    • Guidewire
    • Scalpel
    • Dilators
    • Sterile saline
    • Lubricating gel
  • Suture (if using)
  • Tube ties or device to secure
  • Fibreoptic laryngoscope/bronchoscope
  • Catheter mount to accept scope
  • Airway equipment:
    • Emergency airway trolley
    • Direct +/- video laryngoscope
    • I-gel or LMA
    • Yankauer sucker
    • Spare endotracheal tube
  • Document assent and complete appropriate consent form
  • Arrange a time during daytime hours 
  • Gather information about the patient:
    • Review recent blood results and drug chart
    • Review recent chest imaging
    • Determine the optimal depth of ETT and recent ventilatory requirements
  • Stop enteral feed and ensure NG tube aspirated
  • Consider ultrasound of the neck as part of risk assessment
  • Ensure skilled assistant present and assign roles
  • Prepare IV access, fluids and emergency drugs
  • Ensure appropriate sedation and muscle relaxation:
    • Consider use of BIS to guide deep sedation
  • Ensure full monitoring including EtCO2 (turned to face the operator)
  • Set the ventilator:
    • Pre-oxygenate with FiO2 of 1.0
    • Mild hyperventilation often used with volume control ventilation
  • Position the patient:
    • Use a head ring
    • Neck extended using pillow or bag of fluids under the shoulder blades
    • Sitting up 30 degrees reduces venous distension and bleeding risk
  • Complete safety checklist
  • Ensure full asepsis –
    • Gown/gloves/mask.
    • Use of a face visor is advisable
  • Prepare the site with chlorhexidine skin preparation
  • Infiltrate local anaesthetic:
    • Often performed prior to fully prepping the patient to allow full effect
    • Use up to 20ml of 0.1% xylocaine with adrenaline
    • Initially infiltrate just under skin, then a little in subcutaneous tissue allowing the skin to blanch
  • Position the ETT under direct vision with laryngoscope:
    • Withdraw until top of cuff just visible above the cords
    • If difficult view use the bronchoscope
    • Alternative is to use LMA
  • Position bronchoscope to directly visualise intended insertion site within the trachea
  • Insert the cannula under bronchoscopic vision
    • Ideally between the second and third tracheal rings
    • Aim for the midline but accept 11-1 o’clock for first puncture
    • Insert the needle at 90 ° to the skin holding the trachea stable
    • Aspirate continuously (with a syringe containing 2 ml of saline) until the trachea is entered and air is aspirated
    • Remove the needle from within the cannula
  • Insert the guide wire
    • Remove the cannula
    • Check the position of the wire with a bronchoscope
  • Make a vertical incision:
    • Approximately 10-15 mm), through the skin in the midline
  • Perform initial dilatation:
    • Use the short, narrow, stiff initial dilator
    • Ensure the wire moves freely within the dilator at all times to avoid kinking of the wire
    • Keep the dilator vertical initially, then adjust caudally
  • Perform further dilatation
    • Ensure the long white tube is used as it stiffens the wire and prevents kinking
    • Push the tapered “rhino” dilator and the white tube firmly and smoothly together over the guidewire into the trachea, in a caudal direction
    • Stop pushing when the skin is aligned with a black marker 
  • Insert the tracheostomy:
    • Remove the tapered dilator, leaving the wire and white tube in situ
    • Place the tracheostomy tube onto the loading obturator and slide both onto the wire and white tube
    • Using a smooth firm action, push the tube into the trachea
    • Remove the guidewire, white tube and the loading obturator
  • Check the position:
    • Consider using the bronchoscope to check down the tracheostomy prior to ventilation
    • Using careful hand ventilation, check for rise and fall of the chest and the presence of end-tidal CO2
  • Secure in place
  • Perform a chest x-ray :
    • Confirms position of tracheostomy
    • Reveals complications such as pneumothorax
  • Ensure full documentation
  • Ensure bedhead sign and tracheostomy box placed with patient

Airway & Ventilatory Management

How is the airway managed during percutaneous tracheostomy insertion?

  • Should be managed by a team member trained and competent to do so
  • Equipment should be available for repeat intubation 
  • End-tidal CO2 is mandatory for the procedure
  • Position the ETT under direct vision with laryngoscope:
    • Withdraw until the top of cuff just visible above the cords
    • Video laryngoscopy can make manipulations of the ETT easier
    • If difficult use of a fibreoptic bronchoscope may be beneficial
    • An alternative technique is to remove the ETT and use an LMA
  • Fibreoptic bronchoscope is then used:
    • Ensure correct initial placement of the introducer needle in the midline and between second and third tracheal rings
    • Passed through the tracheal tube and the anatomy of the airway visualised
    • Can be used to monitor dilation and confirm placement

How should the ventilator be set during percutaneous tracheostomy?

  • The ventilator should be set appropriately prior to commencing the procedure
  • Ensure 100% oxygen given throughout
  • Consider using a volume-controlled mode and a 1:1 I:E ratio

Applied Anatomy & Landmarks

What is the preferred site of insertion for percutaneous tracheostomy and why?

  • Preferred site of tracheostomy is between the 2nd and 3rd tracheal rings in the midline
  • Tracheostomy above this site:
    • Can lead to damage to the cricoid cartilage and first tracheal ring
    • Results in increased risk of subglottic stenosis which is difficult to treat
  • Tracheostomy below this site:
    • Can lead to damage to the thyroid and great vessels at the root of the neck
    • Results in increased risk of significant bleeding

What is the structure and course of the trachea?

 

  • Tube of cartilage with a membranous lining continuous with the larynx
    • Composed of 16–20 C-shaped cartilaginous rings
    • Trachealis muscle completes the posterior wall
  • Around 10-12 cm in length
    • Extends down from cricoid at C6
    • Terminates at carina at T5-
  • Moves anteriorly to posteriorly from the cricoid distally
    • Enters the chest behind the sternal notch

Which structures are in close relationship to the trachea?

Anterior Relations
  • Skin and fascia
  • Isthmus of thyroid
  • Sternothyroid and sternohyoid muscles
  • Manurbrium sternum
  • Thymus gland
Lateral Relations
  • Lobes of thyroid
  • Carotid sheath
  • Lungs and pleura
  • Arch of aorta, brachiocephalic and subclavian arteries
Posterior Relations
  • Oesophagus
  • Recurrent laryngeal nerve

Which vessels are at risk of damage during tracheostomy?

  • Anterior jugular veins:
    • Run vertically close to the midline
  • Thyroid ima artery :
    • Ima is ‘lowest’ in Latin
    • Anatomical variant in 3–10% of the population
    • More common British Asian populations
    • Arises mainly from the brachiocephalic trunk and ascends along the front of the trachea
  • Inferior thyroid veins
  • Other vessels more lateral: internal jugular vein, carotid artery, external jugular vein

What is the relationship of the thyroid to the trachea?

  • Lobes lie laterally to the trachea and extend to the 6th tracheal rings
  • Isthmus crosses the midline in the region of the 2-4th tracheal rings
  • Pyramidal lobe, an anatomical variant, may extend superiorly from the isthmus to the cricoid

Which palpable surface landmarks in the anterior neck are useful when determining the correct site for a percutaneous tracheostomy?

Tube Selection

What is the ideal size of a tracheostomy tube for a patient?

  • No ideal size for all patients and varies according to patient and clinical situation
  • The best approximation is a tube with an outer diameter two thirds the inner calibre of the patients trachea
  • Smaller tracheal tubes:
    • May decrease the risk of tracheal stenosis given as smaller incision required
    • Present issues with suctioning, ventilation and bronchoscopy
    • May require higher cuff inflation pressures and potential damage to mucosa
  • Larger tracheal tubes:
    • Require wide stomas
    • Prevent adequate cuff inflation to cushion against the rigid tube

Which factors may influence the type of tube inserted?

Secretion Management
  • Tubes with sub-glottic suction port useful in patient with
  • May be part of standard VAP intervention bundle
Abnormal Airway Anatomy
  • Standard tubes may be unsuitable in abnormal anatomy
  • Obese patients may require tube with extended proximal length (adjustable flange)
  • Patients with fixed flexion deformity may not accommodate tubes with a fixed angulation
Airway Pathology
  • Pathology such as tracheomalacia or granuloma formation may necessitate the use of a tracheostomy tube that has a longer distal length
Weaning and Vocalisation
  • Patient who are being 'weaned' may benefit from tubes that are a smaller size than initially inserted or are uncuffed
  • Allows greater gas flow and increased ease of vocalisation and laryngeal rehabilitation
Clinical Support
  • For patients on less respiratory support where the risks of cleaning an inner tube are reduced, a double lumen tracheostomy tube with an inner cannula is recommended to reduce the risk of obstruction

Use of Ultrasound

What are the advantages of using ultrasound prior to a percutaneous tracheostomy?

  • Determine appropriate size
  • Assess appropriate site of insertion:
    • Determine level of tracheal cartilages to avoid puncture above 1st ring 
    • Determine midline
    • Determine depth to trachea
  • Assess for possible abnormal anatomy:
    • Presence of thyroid tissue
    • Large thyroid or anterior jugular vessels in the midline
  • Early recognition of pneumothorax
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Author

The Guidewire
Trainee in ICM & Anaesthesia

Reviewer

The Guidewire
Trainee in ICM & Anaesthesia

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