Percutaneous Tracheostomy

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Percutaneous Tracheostomy

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ANZICS Document – Percutaneous Dilatational Tracheostomy Consensus Statement

Tracheostomy = an airway that is inserted subglottically through neck tissues directly into the trachea.

Surgical Tracheostomy = dissection and incision of trachea under direct vision.
Percutaneous Tracheostomy = Seldinger technique and dilatation of trachea between rings.

- airway obstruction

- inability to protect the airway

- access for pulmonary toilet

- facilitate weaning from MV

- protection from aspiration

- patient or family refusal

- emergency

- paediatric patient (< 16 years)

- midline neck mass

- uncorrected coagulopathy or platelet dysfunction

- infection at site

- suspected or known difficult intubation

- poor respiratory function: FiO2 > 0.6, PEEP > 10

- difficult anatomy – obese/short neck/neck distortion

- tracheomalacia

- unstable c-spine or c-spine immobilisation (cervical fusion/instability, RA)

- assess for appropriateness of PDT

- consent

- fast

- IV access

- preoxygenate

- emergency re-intubation gear

- standard monitoring (including ETCO2)

- personnel: surgeon, anaesthesia + bronchoscopist (all with adequate experience or supervision)

- GA + LA

- pull ETT back to cords (?LMA use)

- sterile technique

Ciaglia Technique
- horizontal incision through skin (1.5cm) – traditional Ciaglia Technique was a vertical incision

- blunt dissection down to tracheal rings

- needle puncture through first and second tracheal ring

- once air aspirated insert cannular into trachea -> guidewire (Seldinger)

- check position with bronchoscope

- graduated dilation (modified technique = single dilator)

- tracheostomy insertion

Griggs (Portex) Technique
- once guidewire inserted use of guidewire dilating forceps

- Seldinger technique

- blades of dilating tracheotome slide over wire to dilate

- faster than Ciaglia but increased complication rate

Translaryngeal Approach
- ETT tube is pulled back to gain access to the trachea

- curved cannula introduced into the lumen between the second and third tracheal rings

- guidewire introduced and advanced retrogradely

- when wire in the pharynx it is grabbed using a Magills forceps

- patient then intubated with thin ETT

- tracheal cannula then attached to wire and passed distal to larynx

- tracheal cannula then pulled through anterior tracheal wall and cut at a predetermined length and rotated 180 degrees by means of an obturator

- thin ETT removed and tracheostomy cuff inflated

Advantages Disadvantages
Ciaglia - widely used - requires experienced operators

- well established - loss of PEEP

- low complication rate - damage to vocal cords with ETT position

- gradual dilation - takes minutes to dillate

- can insert any size trachy - spray of blood with inspiration

- damage to posterior wall of trachea

(can minimise with bronchoscope)

Griggs (Portex) - less steps - requires experienced operators

- faster dilation - sterilization of forceps

- can insert any size trachy - loss of PEEP

- damage of vocal cords with ETT position

- more abrupt dilation -> more damage

- spray of blood with inspiration

- damage to posterior wall of trachea

(minimise with bronchoscope)

- may want to insert different trachy-wastage

Translaryngeal Approach - low complication rate - less widely known outside Europe

- safely used in coagulopathy - more fiddly

- initial tracheal puncture - needs experienced operator

under vision from inside - requires lightsource and scope

trachea - V may be difficult

- avoids damage to posterior - pulling trachy through may damage V.C

tracheal wall - only able to insert one size of tube

- allows V throughout procedure

- can be done as one person - need to use a different technique

technique to change type of tube

- secure


- if accidental decannulation takes place in first 72 hours -> oral intubation

- reduced sedation requirement (greater comfort than oro-tracheal intubation)

- airway protection while unconscious

- allows gradual weaning of ventilatory support (reduced work of breathing)

- enhanced communication (written or phonation)

- decreased ICU mortality

- enhanced nursing care (mouth care and mobility)

- ease of replacement of tracheal tube

- can facilitate transfer to the ward

- requirement for a surgical procedure

- haemorrhage

- surgical emphysema

- pneumothorax

- air embolism

- ciricoid cartilage damage

- pretracheal dilation and placement

- endobronchial placement

- cuff herniation

- occlusion of tip by carina or tracheal wall

- damage to the posterior tracheal wall

- accidental decannulation

- …death

- infection (tracheostomy site, larynx, tracheobronchial tree, mediastinum)

- obstruction with secretions

- ulceration/perforation (mucosal, inominate artery, tracho-oesophageal fistula)

- dysphagia c/o mechanical compression of oesophagus (requires N/G or PEG for enteral nutrition)

- problems with de-cannulation -> emergency airway management

- tracheal granulomata

- tracheal or laryngeal stenosis

- persistent sinus @ tracheostomy site

- tracheomalacia

- aphonia/dysphonia (recovery of voice, laryngeal or cord dysfunction)

- tracheal dilatation

- 7-10 days after intubation is common but there is no consensus

- if it is clear that prolonged ventilation is inevitable (ie. GBS) -> can do early

- decreased ICU mortality

- no difference in nosocomial pneumonia

- no difference in outcome if early (< 7 days) or late (>7 days)

- no change in hospital mortality (Clec’h et al, Critical Care Med, 2007 Jan; 35(1):132)

- hang over from when all tracheostomies were surgically inserted (window cut into trachea) -> downsizing would allow gradual closure of tract and was less likely to result in fistula.

- no real place in percutaneous tracheostomies

- advantages: improved swallow

- disadvantages: increased WOB, repeat trauma to airway, not really needed

- for awake alert patients who want to phonate

- must have no risk of aspiration

- need to deflate cuff and insert a fenestrated inner

- prevents disuse atrophy of the vocal cords

- must warn patients that they will have sensation of air coming up through vocal cords

- may allow cough into mouth

- often suboptimal on non-surgical wards

- patient are by definition high risk patients

- if managed by outreach teams can improve outcomes (doctor, nurses, SLT, physio) – TRAM team

- absence of airway obstruction (tracheal stenosis or granulation tissue)

- sputum burden decreasing (2-4 hourly)

- patient co-operative

- good cough

- patient able to protect upper airway from aspiration

- no longer requires mechanical ventilation

Jeremy Fernando (2011)

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