| Maintain airway patency | Protect the airway | Bronchial toileting | Weaning from prolonged IPPV |
| Reduced consciousness | Neurological disease e.g. bulbar palsy | Excessive secretions | Improved patient comfort |
| Upper airway obstruction e.g. tumour, burns, infection | C-spine injury | Inadequate cough | Reduced sedation requirements |
| Difficult intubation | Severe OSA | Reduces dead space and WOB | |
| Following upper airway surgery inc. laryngectomy |
Tracheostomy
Tracheostomy
Tracheostomies are pertinent to both the ICM and Airway sections of the curriculum, although previous SAQ/CRQ questions have appeared as ICM questions.
Feedback on the 2019 CRQ (48% pass rate) on tracheostomies mostly lamented candidates' exam technique, although the latter half of the question appeared to be about emergency tracheostomy management.
The 2014 SAQ on the topic saw the marks divvied up between indications, contraindications, early and late complications.
Resources
- Update on management of tracheostomy (BJA Education, 2019)
- Percutaneous tracheostomy (BJA Education, 2014)
- Guidelines for the management of tracheal intubation in critically ill adults (BJA, 2017)
- Tracheostomy emergencies: bleeding (NTSP, 2018)
- Timing of tracheostomy in the ICU (Deranged Physiology, 2023)
- 12,000 tracheostomies are inserted annually in the UK; about 2/3rds take place as percutaneous tracheostomies on critical care
- Indeed, between 7% and 19% of critical care patients undergo tracheostomy
General contra-indications
| Absolute | Relative |
| Patient refusal | Difficult anatomy |
| Localised sepsis/infection | Proximity to recent trauma/surgical site |
| Uncontrolled coagulopathy | Severe gas exchange issues |
| Effects of surgery itself | Age <12yrs |
| Potential to aggravate morbidity | |
| Moderate coagulopathy |
Contra-indications specifically to percutaneous tracheostomy
- Significant gas exchange issues e.g. FiO2 >0.6, PEEP >10cmH2O
- Difficult anatomy e.g. short neck, thyroid pathology, aberrant or overlying vasculature, C-spine injury, limited neck movement
Surgical tracheostomy
- Approximately 30% of new tracheostomies are inserted surgically
- It is typically an elective process, either as part of a planned procedure or for critical care patients unsuitable for perc tracheostomy
- Emergency surgical tracheostomy may also occasionally be required e.g. CICO scenario, upper airway obstruction
- There is an increased incidence of difficult airway during surgical tracheostomy insertion
- The NCEPOD 'On The Right Trach' study (2014) found 20% required difficult airway equipment and 6% had ≥1 failed attempt at intubation
Percutaneous tracheostomy
- Approximately 66% of new tracheostomies are inserted percutaneously by intensivists in critically ill patients
- Specific techniques include:
- Seldinger guidewire technique using a single (Rhino) dilator
- Seldinger guidewire technique using sequential (Ciaglia) dilators
- Guidewire and Grigg's dilating forceps technique
- Percutwist one-step dilator
- The landmark TracMan RCT (JAMA, 2013) found that early (<4 days) vs. late (>10 days) tracheostomy did not improve:
- 30-day mortality
- 2-year mortality
- Median length of ICU stay
- Tracheostomy complication rate
- These results were somewhat echoed in more recent trials:
- The SETPOINT2 RCT (JAMA, 2022) appeared to demonstrate similar results in patients with severe stroke
- An observational study (BJA, 2022) concluded early tracheostomy for patients >70yrs with Covid-19 did not affect 3-month mortality
- Conversely, a 2015 Cochrane review found the evidence was "suggestive" of a statistically significant long-term mortality benefit from early tracheostomy (NNT = 11)
- A more recent meta-analysis (2021) suggests early tracheostomy reduces the duration of both mechanical ventilation and ICU stay, even if not mortality or complication rates
- A Bayesian analysis (2022) based on said meta-analysis concluded there is at least some benefit to early tracheostomy (even if small) across all outcomes
- The physiological basis for a benefit from early tracheostomy is plausible, namely less sedation to facilitate an ETT leads to better:
- Mucociliary function
- Patient communication
- Early mobilisation
- This in turn reduces VAP rate, duration of mechanical ventilation, duration of ICU stay and mortality
- Up to 30% of patients with a tracheostomy may have a significant complication
- The most common complication is displacement, although blockage and haemorrhage are also common
- In NAP4, tracheostomies accounted for 50% of ICU airway incidents
| Early | Short-term | Long-term |
| Haemorrhage | Blockage/obstruction | Tracheomalacia |
| Aspiration | Tube displacement | Tracheal stenosis |
| Pneumothorax | Pneumothorax | Tracheo-cutaneous fistula |
| Failure of procedure | Surgical emphysema | Decannulation issues |
| Damage to structures | Infection | Mortality (1 in 1,000) |
| Delayed haemorrhage | ||
| Tracheal necrosis | ||
| Tracheo-arterial fistula |
Obstructed/blocked tube
- Management follows the National Tracheostomy Safety Project algorithm
- There's a separate algorithm for laryngectomy patients, although it is mostly the same (just skipping parts that do not apply e.g. oral airways)
- I won't reproduce the algorithm here, save to share the mnemonic which I use as an aide memoire in such emergencies: "O2 CISCO"
- O2 - apply 100% oxygen to both the tracheosomy site and the face
- C - Check the cuff is still up, remove any caps and check CO2 trace is present
- I - Remove the inner tube ± replace with a new one
- S - Attempt to pass a fine-bore suction catheter down the tracheostomy
- C - Take the cuff down
- O - Consider oral airway
Bleeding
- The aforementioned 2014 NCEPOD study found minor bleeding occurs in 4.4% of patients, and major bleeding in 1.2%
- Morbidity and mortality are increased significantly if an episode of tracheostomy-related bleeding occurs as an in-patient
- Bleeding can be classified by:
- Volume of blood lost
- Small volume (<10mls)
- Large volume (>10mls)
- Small volume bleeds may herald a major haemorrhage
- Timing of the bleeding:
| Early bleeding (<4 days) | Late bleeding (>4 days) |
| Skin-related | Erosion into large artery e.g. innominate artery (<1%) |
| Thyroid-related | Granulation tissue |
| Effect of anti-platelet/-coagulant therapy | Mucosal trauma inc. that from suction catheters |
- Management is often with basic measures such as:
- Sit the patient up and administer oxygen
- External haemorrhage control e.g. with compression, TXA- or adrenaline-soaked gauze
- Check and correct clotting abnormalities
- Make risk-benefit decision about ongoing formal anticoagulation
- Temporary cuff hyperinflation to tamponade bleeding (inflate slowly)
- One should ask the friendly neighbourhood ENT surgeon to review the tracheostomy too
Surgical emphysema
- The risk is increased by:
- Tight closure of the stoma site around the tube
- Short tubes
- Fenestrated tubes
- Tube displacement
- Management involves ensuring appropriate positioning, changing tube size if required, CXR to exclude pneumothorax and conservative management of emphysema
Cuff-related issues
- Excessively high cuff pressures predispose to tracheal stenosis, fistulae or tracheomalacia
- Too low a cuff pressure can cause air leak and risks micro-aspiration + consequent VAP
- Regular monitoring and inflation to a pressure of 20 - 30cmH2O is advised