Tasty Morsels of Critical Care 013 | Tracheostomy – Putting it in
Welcome back to the tasty morsels of critical care podcast. In a breaking from what could only loosely be described as tradition at this point, this podcast is going to be in 2 parts. Intensivists have embraced the tracheostomy as an ICU procedure. It’s one of the most invasive and one of the riskier procedures we do. There is a substantial ANZICS document on tracheostomy that forms the structure for this tasty morsel. Timing * no mortality benefit shown of early (typically <10days) v late tracheostomy * TRACH Man is the big UK study here (n = 900) which was actually a trial of tracheostomy at 4 days vs after 11 days. Techniques A variety are available but to be honest , of the 5 ICUs I’ve worked in they’ve all used a percutaneous needle > wire > graduated dilator technique. And this seems to work exceptionally well. The minor variations I’ve noted include * swapping the ETT for an LMA and bronch down the LMA for positioning. * pulling the ETT just above the cords and hyperinflating cuff and downward pressure forming a sort of poor man’s LMA * varying degrees of blunt dissection before the graduated dilator goes in. Some do entirely percutaneous, some do a lot of blunt dissection. Indications * Airway maintenance: obstruction or inability to protect * Prolonged ventilation: dependance on vent, secretions or projected course of underlying disease (eg neurological) Contraindications * no consent * age <16 * anatomical anomalies eg goitre/mass * bleeding disorder * infection at site Risks/complications * 4-9% rate of complication which is mainly minor bleeding and desaturation * most serious is splitting the posterior trachea (through the trachealis muscle), usually when the back wall is inadvertently wired and dilated through and through. Bronchoscopy should stop this * pneumothorax/mediastiunum/sub cut emphysema all possible Placement site * depends on technique but goal is between rings 2 and 3 or rings 1 and 2 Personnel required * competent intensivist * trainee who has previously been deemed competent otherwise under direct supervision Bronchoscopy * should be available but not necessarily used. I found this a somewhat surprising statement as I assumed it was mandatory but i have worked with someone who never uses it and seems to get on just fine. I suppose this is somewhat similar to ultrasound for CVCs as plenty of people seem to cope perfectly well without it * no good data to guide a solid recommendation as yet. Unlike ultrasound in central lines where it seems that US has become the standard of care Ultrasound in tracheostomy * mentioned by the statement but no recommendation either way * personally I remain unclear of its place as I have found vessels that have put me off doing the tracheostomy but I suspect if we hadn’t looked everything would have gone fine as we ploughed on in ignorance. References and rationalisations: ANZICS Statement LITFL Resources Furlow PW, Mathisen DJ. Surgical anatomy of the trachea. Ann Cardiothorac Surg. 2018 Mar;7(2):255-260. doi: 10.21037/acs.2018.03.01. PMID: 29707503; PMCID: PMC5900092.