Tracheostomy and Emergency Airway Management

Terminology

  • Tracheotomy: Procedure for establishing access to the trachea through a neck incision.
  • Tracheostomy: The opening created by the tracheotomy procedure.
  • Laryngectomy: Removal of the airway, separating it from the mouth and nose.
  • Cricothyrotomy: Incision through the skin and cricothyroid membrane to establish a patent airway in life-threatening situations (e.g., airway obstruction).

Objectives

  • Understand indications for tracheostomy.
  • Learn insertion techniques (both bedside and surgical).
  • Understand the role of the RRT in assisting with tracheostomy insertion.
  • Identify contraindications and complications associated with tracheostomy.
  • Explore other emergency airway management techniques.

Key Consideration

  • When to switch from translaryngeal airway control and ventilation to transtracheal airway control and ventilation?

Optimal Timing for Tracheostomy

  • Evidence on patient outcomes regarding timing of tracheostomy varies.
  • There is no evidence suggesting that delayed tracheostomy benefits morbidity or mortality.
  • An upper limit of 10 days for endotracheal intubation is advised, which has shown improved overall mortality and shorter inpatient stays.
  • High-risk groups (e.g., obese patients with large endotracheal tubes) may benefit from early tracheostomy due to a higher risk of laryngotracheal stenosis.

Indications for Switching to Tracheostomy

  • Projected duration of need for an artificial airway.
  • Patient's tolerance of the endotracheal tube.
  • Overall condition (nutritional, cardiovascular, infection status).
  • Ability to tolerate the procedure.
  • Risks of continued endotracheal tube intubation vs. tracheostomy.

Advantages of Tracheostomy

  • Preferred for upper airway obstruction or trauma.
  • Necessary for long-term ventilation needs.
  • Essential for managing neuromuscular disease (NMD) patients.
  • Facilitates phonation.
  • Helps avoid complications of endotracheal intubation, such as:
    • Laryngeal and pharyngeal injury.
    • Vocal cord paralysis.
    • Infections.

Surgical vs. Bedside Tracheostomy

  • Surgical Tracheostomy:
    • ENT surgical procedure, either elective or emergency.
    • Indicated when patients are not suitable for bedside methods.
  • Bedside Tracheostomy:
    • Less invasive with fewer tissue dissection complications.
    • More cost-effective and can be done in an ICU bed, avoiding the need for full general anesthesia.
    • Reduces complications related to patient transport, such as accidental extubation.

Bedside Tracheostomy Procedure (PDT) Preparation

  • Equipment Required:
    • Flexible bronchoscope.
    • Percutaneous dilatation kit.
    • Appropriately sized tracheostomy tubes.
    • Airway equipment (BVM, suction, intubation gear).
  • Patient Preparation:
    • Fasted for at least 6 hours (cease enteral feeds).
    • Review relevant bloodwork (INR, HCT, ABG, etc.).
    • Administer pharmacology as needed: sedatives, analgesics, local anesthesia.
    • Positioning for adequate neck extension.

PDT Placement Procedure

  1. Position and clean the site.
  2. Physician preloads the tracheostomy tube.
  3. RRT loosens ETT tapes, suction patient, and withdraws ETT just below vocal cords.
  4. Physician introduces a catheter into the tracheotomy site using a needle and visualizes the placement with a bronchoscope.
  5. Using the Selldinger Technique, wire is fed into the trachea.
  6. The dilator is used to enlarge the stoma, ensuring not to aerosolize blood during ventilation management.
  7. The tracheostomy tube is inserted, cuff inflated, and ventilation resumed.

Contraindications for PDT

  • Inability to extend neck due to cervical spine precautions.
  • Enlarged thyroid glands, neck tumors, edema.
  • Significant head/neck burns.
  • Active infection at the insertion site.
  • Uncorrected coagulopathy.
  • Hemodynamic instability.
  • Not suitable for pediatric patients.

Complications Associated with Tracheostomy

  • Bleeding: Minor bleeding may occur at the insertion site initially but should resolve.
  • Accidental Decannulation: Life-threatening if it occurs within 72 hours after placement.
  • Stomal Infection: Treated with wound care and systemic antibiotics.

References

  • Andriolo et al. (2015). Early vs late tracheostomy for critically ill patients.
  • Liu et al. (2015). Systematic review and meta-analysis on early vs late tracheostomy.
  • Young et al. (2013). Effect of timing of tracheostomy on survival in mechanical ventilation patients.