Tracheostomy and Emergency Airway Management

Terminology

  • Tracheotomy: Procedure for accessing the trachea through a neck incision.
  • Tracheostomy: Opening created by the tracheotomy procedure.
  • Laryngectomy: Removal of the airway, separating it from the mouth and nose.
  • Cricothyrotomy: Incision through the cricothyroid membrane to establish an airway in life-threatening situations.

Objectives

  • Understand indications for tracheostomy.
  • Learn insertion techniques (bedside vs. surgical).
  • Know the role of RRT (Respiratory Therapy) in tracheostomy insertion.
  • Recognize contraindications and complications.
  • Explore other emergency airway management techniques.

Key Consideration

  • Question: When to switch from translaryngeal airway control to transtracheal airway control?

Timing of Tracheostomy

  • Delayed tracheostomy does not offer advantages in morbidity or mortality.
  • Best practice suggests aiming for tracheostomy within 10 days of endotracheal intubation to improve mortality and decrease inpatient care duration.
  • High-risk patients (e.g., obese, large ETT) may benefit from early tracheostomy to prevent laryngotracheal stenosis.

Indications for Tracheostomy

  • Change from oral/nasal ETT to trach based on:
    • Estimated time needing the artificial airway.
    • Tolerance of the endotracheal tube.
    • Overall health (nutritional, cardiovascular, infection status).
    • Risks of continued ETT vs. tracheostomy.

Advantages of Tracheostomy

  • Preferred for upper airway obstruction/trauma.
  • Suitable for long-term ventilatory requirements.
  • Particularly beneficial in managing neuromuscular disease patients.
  • Reduces complications from endotracheal intubation:
    • Laryngeal/pharyngeal injuries.
    • Vocal cord paralysis.
    • Infections.

Surgical Tracheostomy Procedure

  • The procedure involves:
    • Retracting cervical fascia and neck muscles to expose the trachea.
    • Creating a three-sided cut into the tracheal wall to form a “trap door”.
    • Suturing the tracheal tissue to ensure airway patency and prevent false passages.

Potential Results of a False Passage

  • Risks include:
    • Hypoxia, Hypercapnea.
    • Pneumothorax, Pneumomediastinum, Subcutaneous Emphysema.
    • Damage to the esophagus.
    • Injury to the recurrent laryngeal nerve affecting vocal cords.

Bedside Tracheostomy Procedure (PDT)

Benefits

  • Less invasive with various approaches (PDT vs. TLT).
  • More cost-effective, performed in ICU without needing an OR or anesthesia team.
  • Reduces transportation complications for critically ill patients.
  • Smaller scar, less bleeding, and lower infection rates.

Equipment & Preparation

  • Essential equipment includes:
    • Flexible bronchoscope.
    • Percutaneous dilatation kit.
    • Appropriately sized tracheostomy tubes.
  • Patient preparation involves cleaning the site and ensuring preoxygenation.

Placement Steps

  • Sedate the patient, clean the site, and prepare equipment.
  • The physician instills a catheter into the trachea under bronchoscopic guidance.
  • A wire is placed using the Selldinger Technique, ensuring it remains in the lumen.
  • The stoma is dilated, and a preloaded tracheostomy tube is inserted.

Contraindications for PDT

  • Inability to extend the neck (C-spine precautions).
  • Neck tumors, edema, or significant burns.
  • Active infections, uncorrected coagulopathy, or hemodynamic instability.
  • Not suitable for pediatric patients.

Complications with Tracheostomy

  • Bleeding: Slight at the site post-procedure; significant internal bleeding indicates a serious injury.
  • Accidental Decannulation: A medical emergency if it occurs within 72 hours post-placement.
  • Stomal Infection: Treated with antibiotics and wound care.

References

  1. Cochrane Database Systematic Review (Andriolo et al., 2015)
  2. Systematic review and meta-analysis (Liu et al., 2015)
  3. JAMA on early vs. late tracheostomy (Young et al., 2013)