Episode 8 - Demystifying Tracheostomies

Summary

In this episode, we review the indications, timing, and perioperative considerations for performing a tracheostomy. We discuss the importance of the preoperative assessment of patients being considered for a tracheostomy with a focus on high-risk factors for a difficult case. Further, I’d like to share with you a few common tricks of the trade, whether you are performing a percutaneous or open tracheostomy. Further, we’ll review how to identify and immediately intervene upon life-threatening complications of tracheostomy including early unplanned decannulation, obstruction, and bleeding. A brief review of weaning procedures are also discussed.

Learning Objectives

1. Discuss the indications, timing, and perioperative considerations, and more specifically high-risk factors, for performing a tracheostomy in critically ill patients 

 2. You should also understand key postoperative management principles as they relate to recognizing and intervening upon early and late life-threatening complications. These include early unplanned decannulation, obstruction, as well as bleeding, particularly in the setting of a suspected tracheoinnominate fistula (TIF)

3. Finally, you should be able to describe the process of “weaning” a tracheostomy 

Take Home Points

• Tracheostomies are most commonly performed via a percutaneous technique

• Patient outcomes are improved with early tracheostomy among patients with severe TBI and cervical spinal cord injuries

• Preoperative identification of high risk factors may alter one’s approach to tracheostomy

• Common complications in the early postoperative period are decannulation and obstruction

• Bleeding may occur early or late and the presence of a sentinel or herald bleed should alert you to the potential for a tracheo-innominate fistula

Time Stamps

00:12 Introduction

01:46 Objectives

02:33 Indications for Tracheostomy

04:31 Benefits of Tracheostomy

07:50 Early versus Delayed Tracheostomy

10:20 Early Tracheostomy in Patients with Severe Traumatic Brain Injury (sTBI)

11:01 Timing of Tracheostomy in Patients with Cervical Spinal Cord Injury

12:20 Perioperative Considerations

13:26 High Risk Factors

14:30 Open versus Percutaneous Tracheostomy

16:25 Tricks of the Trade

16:35 Positioning & Site of Entry

17:08 Excessive Submental or Neck Adipose Tissue -Move It Out of the Way

18:06 Tracheostomy Size -Bigger the Better

19:45 Tracheostomy Cuff -Taper the Balloon

20:21 Tracheostomy Length - XLT for You and Me

20:54 Early Complications - Unplanned Decannulation

23:09 Early Complications - Obstructed Trach

24:35 Early & Late Complications - Bleeding & Tracheo-innominate Fistula

29:30 Considerations for Decannulating a Tracheostomy

31:05 Progressive Downsizing

31:50 Capping Trials

32:25 Passy-Muir Valve

33:32 Fenestrated Trachs

33:55 Take Home Points

34:59 Outro

Difference between Tracheostomy versus Cricothyroidotomy

Shiley XLT Tracheostomy Tube Overview:

https://www.youtube.com/watch?v=LWWZtvuVqzc

(Audio and narration is a little weird with this one but gets the point across re: XLT tubes)

Passy-Muir Valves

Remember these are 1-way valves (air may move through the PMV and tracheostomy on inspiration only)!!! Therefore, if a patient has a cuffed tracheostomy, the cuff of the tracheostomy MUST BE fully deflated prior to placement of a PMV on the tracheostomy.

Recommended Readings

Critical Care Airway Management The CCAM Course

https://www.ccam.net.au/handbook/tracheostomy/