Episode 8 - Tracheostomies Demystified

From the classroom to the emergency room, OR and beyond. Trauma ICU. Welcome back to Trauma ICU Rounds. Today on rounds, I wanted to spend some time discussing tracheostomies, which are very common, if not the most common procedure. performed in critically ill patients requiring long term mechanical ventilatory support, and in fact was one of the very first surgical procedures that I participated in as a medical student at the bedside in the ICU.

Trachs may provide our patients with a host of benefits above and beyond being much more comfortable and better tolerated than say a a polyvonochloride tube shoved down your throat. These benefits may include but are not limited to the potential for decreased work of breathing. Decrease ventes. And shorter ICU as well as overall hospital length of stay. Now there have been multiple prospective randomized controlled trials looking at the timing of tracheostomy.

And early versus late trake, as well as the primary outcome measures, have varied across these studies. But for the purposes of our discussion today, I do want to talk about two trauma populations specifically when we get into the indications and timing for tracheostomies. As is the case with any surgical procedure, performance of a tracheostomy is accompanied by the potential for several early and delayed complications, some of which may be potentially fatal.

if not managed properly or if there's a delay in recognition. Further, identification of high risk factors preoperatively may influence our decision to proceed via an open versus percutaneous approach. So we have three key objectives for today's discussion, and by the end of rounds, you should be able to number one. Discuss the indications, timing, and perioperative considerations and more specifically high risk factors for performing a tracheostomy in critically ill patients.

Number two, 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. Tracheostomy or airway obstruction, as well as bleeding, particularly in the setting of a suspected tracheenominate fistula. Finally, you should be able to describe the process of quote unquote weaning a tracheostomy.

So regarding indications for performing a tracheostomy, trach may be performed for a number of reasons. For example, they may be performed as part of an elective procedure, as may happen in patients undergoing head and neck oncologic resections, such as a commando procedure, or combined mandibulectomy and neck dissection operations.

More commonly, however, trach are performed on a semi elective basis for patients with a quote unquote difficult airway, or in order to facilitate patient care management in patients who are expected to require poll mechanical ventilation And we're looking to get patients moving on to their next phase of care. Now, what do we mean by difficult airway? Well, airways may be difficult in the sense that an inadvertent or even planned extubation may result in the inability to reintubate.

This may include patients with severe maxillofacial trauma or distorted upper airway anatomy due to swelling, masses, or bleeding, for example. More commonly, however, we place trach to facilitate care among patients with multiple failed extubations, or in patients deemed to be at high risk for aspiration due to a potentially reversible neurocognitive insult.

And the classic patient population fitting this description in a trauma surgical ICU are going to be patients with a severe traumatic brain injury or STBI. Much less commonly, trach may be performed in an urgent or even emergent fashion, usually as an awake tracheostomy in patients with rapidly progressive upper airway loss, as may occur with obstructive upper airway tumors. And just to clarify, a tracheostomy or a wake trache is quite a bit different from a surgical cricothyroidotomy.

And I refer you to the show notes at www.traumaicrounds.ca to review some of the differences between these two emergent procedures.

In discussing indications for tracheostomy, it may actually help to discuss some of the benefits of a tracheostomy in comparison to translaryngeal intubation, and there are several of these. Because of its rigid design, shorter length and removable inner cannula, airflow resistance and associated work of breathing, as well as the amount of dead space may be less with trachs relative to an endotracheal tube.

And just as a reminder, when it comes to resistance to airflow in an artificial airway, this is going to be proportional to three key variables. Number one, air turbulence, number two, tube diameter, and number three, the tube length. In regards to air turbulence in endotracheal tubes, this may be increased due to extrinsic compression or kinks in the tube, as may occur if a patient is chewing on their tube or as a result of inspicated secretions.

And when it comes to tube diameter, uh in general, this is not gonna vary very much between an endotracheal tube and a tracheostomy. In fact, oftentimes when we're sizing tracheostomies, we just use the size of the patient's endotracheal tube. And in most adult males, this is somewhere on the order of around 8.0 to 8.5. And in adult females, somewhere between 7.5 and 8.0 millimeters.

One of the other benefits here is going to be the tube length, however, as tracheostomies are much shorter than the standard endotracheal tube. One of the other benefits of a tracheostomy is that they are much more comfortable and particularly in patients with a strong gag reflex, allow for rapid titration down of sedatives as well as analgesic. while also providing access for pulmonary toilet and clearance of secretion.

Third, there's a huge psychological benefit, both for patients and their loved ones. When a patient receives or undergoes tracheostomy, there's always the potential to number one, vocalize to eat. And it is easier to mobilize with tracheostomy versus an endotracheal tube. The other major benefit of performing a tracheostomy and peg tube insertion, which is usually done concomitantly

Is that patients actually look more like themselves? You know, once you get all those tubes and the tape and the anchor fast. off and away from the patient's face, you begin to recognize them again. And I think this makes a huge impact on patients' loved ones and family members. Finally, once a tracheostomy is placed, this really allows us to get much more aggressive in terms of our attempts to liberate patients from the ventilator.

Specifically, if a patient with a trach doesn't tolerate liberation from the ventilator or weaning trials, he or she simply gets reconnected to the ventilator circuit. In contrast, If a patient is intubated translaryngeally, we attempt to extubate them, whether we think they're ready or we're trying to be really aggressive about it, and they fail, well then they get resedated and re-intubated.

So concerns over the development of respiratory failure or a failed extubation really kind of disappear once patients are traged.

Now there's a a lot of debate out there regarding the timing of tracheostomy, and as I alluded to earlier, definitions of early versus late tracheostomy vary depending on what study you're looking at. And I think I just want to put out there right now that in general, in a mixed medical surgical patient population, there's really no optimal time for this transition to happen, and there is significant practice pattern variability among physicians.

I think overall the decision should be individualized in terms of timing of tracheostomy according to the clinical circumstances, as well as the patient's and family members' preference. Such that daily assessment of a patient's progress, readiness to extubate, and the need for tracheostomy are warranted.

In a twenty thirteen large multi-center study published in JAMA and conducted in the UK TRACMAN or the Tracheostomy Management and Critical Care Study, almost a thousand patients were randomized to undergo early tracheostomy. between one to four days versus late tracheostomy or greater than ten days of ventilatory support.

The vast majority of trachs in this study were placed percutaneously, and although tracheostomy timing had no effect on the primary outcome mortality or most secondary outcome measures, including ICU or hospital length of stay. Early tracheostomy in this study was associated with less use of sedation. Interestingly, like several other studies that preceded the Trackman study, A lot of these studies use really funny main outcome measures, things like mortality.

or VAP ventilator associated pneumonia. Now I never understood why these would ever be chosen as a primary outcome measure because whether or not you have a polyvonochloride tube shoved down your throat or a tracheostomy inserted through the neck, that really should not impact a patient's survival.

Furthermore, if patient stays on a ventilator, whether that's from above or through the neck, the incidence of ventilator associated pneumonia you really wouldn't think would be better with one root versus the other. In the trauma surgical ICU, there are two specific patient subsets that I feel warrant further discussion regarding timing of tracheostomy. And this includes patients with severe traumatic brain injuries, as well as patients with cervical spinal cord injuries.

With regards to patients with severe traumatic brain injury, current guidelines recommend performance of a tracheostomy within seven days of admission, and this is supported by several studies, one of which was published in twenty fourteen in the Journal of Trauma. by first author Alali out of Sunnybrook.

In this propensity match cohort study, patients with traumatic brain injury were divided up into either an early tracheostomy group defined as less than or equal to eight days versus a late tracheostomy group defined as greater than eight days. And in this observational study, early tracheostomy was associated with a shorter duration mechanical ventilation, ICU as well as hospital stay, but again with no significant impact on hospital mortality.

In terms of patients with cervical spinal cord injuries, one of my buddies, Doctor Tanya Anand out of the University of Arizona, just published a nice paper entitled Time to Tracheostomy Impacts Overall Outcomes in Patients with Cervical Spinal Cord injury. The study was presented at the AST last year and essentially is a five-year retrospective analysis of the ACST Quip database.

of adult patients with cervical spinal cord injuries. They looked at several outcomes and they defined early tracheostomy as less than or equal to four days. And late tracheostomy is greater than four days. When they looked across the major outcomes in terms of respiratory complications, Ventilator free days, ICU free days, and hospital length of stay, these were all decreased in the early tracheostomy group.

Another issue that does come up among patients with cervical spinochord injury arises in patients or that subset of patients who require an anterior cervical approach. to their spine for stabilization. In general, these days, I think most of us are happy to wait five upwards of seven days following fixation in order to perform a tracheostomy. And in general, we probably go with a percutaneous. versus an open surgical approach.

Regarding perioperative considerations for any and all the health staff that are listening, I think there's a few things to pay attention to when you do receive a consultation for potential tracheostomy insertion. In the first place, most of these will be bundled with a percutaneous endoscopic gastrostomy. So paying attention to the anatomy at both sites is very important.

A few of the things to note on physical exam is the anatomy, specifically with regards to neck mobility as well as the body habitus, particularly among patients who are morbidly obese. or patients with COPD or who are barrel chested where the trachea tends to be more intrathoracic. The presence of previous surgery or surgical scars is also important to note.

There has been at least one or two cases in my lifetime where we've kind of been in the operating room and realized that patients had had a previous tracheostomy, which ended up changing our overall approach. The presence or previous history of radiation to these areas is also very important.

In general, when it comes to high risk factors, there are several of these. Number one would be any patient in a cervical collar, and especially patients who are in a halo, or those with documented cervical spine injuries. Patients who are receiving systemic heparin drips, this is important to bear in mind. Trachs can be oozy, they can bleed, and that is a common postoperative complication in the immediate period. So holding these heparin drips prior to operation is something to consider.

Finally, in general want to avoid performing tracheostomies in patients who have high ongoing mechanical ventilatory needs, specifically with regards to the need for PEEP. And higher than normal FIO2s. Now, that's not to say that patients have to be on a PEEP of five with an FIO2 of 21%. But again, during the process of swapping out the airway, patients will derecruit.

And so if they do have ongoing significant shun physiology, there is the potential to rapidly become hypoxemic during the procedure.

Having an appreciation for high risk factors, I think, is important because this will help you in your decision making regarding the approach that you'll use, either open versus percutaneous. There are several factors that will determine the approach. And certainly there are going to be institutional as well as surgeon experience and preference variables that will come into play.

In terms of the pros and cons for open versus perk, I think it's pretty clear based on the literature and our widespread experience that perk trach offer several advantages over open trach. provided that they're done by experienced providers. And these advantages include number one, less time. Number two, they're cheaper. Number three, there's no need for transport or OR resources. And number four, potential fewer complications, especially when it comes to surgical site infections.

or wound infections. I think one of the major concerns over percutaneous tracheostomies is the potential increased risk for anterior tracheal injuries. as well as false tracts and posterior tracheal wall perforation, all of which are very uncommon. The other thing I have noticed is that if the person at the head of the bed working the fiber optic bronchoscope is inexperienced, every now and then you will have an unintentional extubation as the ETT is being pulled back.

So this is something important to bear in mind. And I would definitely refer you to a twenty eleven article published in JAX by Cornblith and colleagues. out of Denver General looking at the first 1,000 percutaneous tracheostomies performed at that institution. It's a fantastic read. It's pretty much got a step by step with great images. on how to perform a percutaneous tracheostomy for those of us who are unfamiliar with this non-invasive technique.

On the topic of technique, there are a few considerations or key points that I want to emphasize that would apply to both open as well as percutaneous traits before we move on to post-operative management principles. In the first place, regarding position, please do make sure that the patient's neck, where not contraindicated, is hyperextended. And again, this is best done with a roll between their shoulders. Second, regarding external anatomic landmarks.

When you're attempting to determine the site of entry, try to avoid using the cricoid cartilage or cricothyroid membrane as a reference point and consider the entry point relative to the sternal notch. If you're higher than one or two finger breadths above the notch, you're likely too high. Also, in morbidly obese patients, particularly in patients who have a lot of neck fat or a lot of submental fat or creases that distort the ability to palpate or feel the neck anatomy.

Make sure you grab a roll of paper tape or whatever tape you have and get that underneath that submental fat and pull it up. and away from the neck and I like to secure the ends of the tape to the head of the bed over the patient's shoulders. This really just kinda puts the skin on stretch. and can help tremendously so it frees up someone's hand. You don't have to constantly kind of pull up on that submental fat to be able to feel and visualize the anatomy.

Finally, when it comes to selection of the tracheostomy, there are a few considerations or things to bear in mind regarding number one, the trache size, number two, managing the trache cuff, and number three, the tracheostomy length. Regarding the tracheostomy size, in general go with the largest size possible. Oftentimes we'll just insert a tracheostomy that has a similar diameter to the

as the endotracheal tube that was inserted. But just remember, especially in the emergence setting, Sometimes our patients are intubated with a smaller than ideal endotracheal tube and this is gonna increase resistance to airflow. and potentially increase the work of breathing. And this also affects our ability to clear secretions if we have to use a smaller than normal bronchoscope to help with pulmonary toilet.

So an eightotracheostomy for the average adult patient is gonna be a great starting place. Remember that diameter, that eight millimeters, is based on the inner diameter of the actual tracheostomy itself. And once we insert an inner cannula, that will decrease the overall diameter from point five to one millimeters The nice thing about using a tracheostomy with an inner cannula is that if these become blocked or obstructed by concretions

or solidified mucus, these can easily be removed and then replaced with a fresh inner cannula. At the triom of tracheostomy, I would always suggest having more than one tracheostomy size ready to go. and ensure that the inner cannula is immediately available because once you insert your tracheostomy, there is no way to oxygenate and ventilate or connect that patient to the oxygen or ventilator circuit without that inner cannula.

Regarding the cuff, the one thing I would recommend here is once you've assessed it to ensure that it's holding air. As you're deflating the cuff with your non-dominant hand, kind of pull from the distal tip of the tracheostomy proximally. What this does is it number one helps to get air out of the cuff. But more importantly, number two, it actually helps to taper the balloon. Every now and then, if you don't do this, what happens is as you're trying to insert the tracheostomy,

Uh the balloon gets caught up. And so by giving it a tapered appearance, it will insert into the trachea much easier. As I mentioned earlier, you do want to have a variety of trach and trake sizes available. Hopefully, on the basis of your pre-operative assessment, you would have figured out whether or not you need an XLT. or extended length trach. And depending on the anatomy, these XLT trach may have a longer extra or longer intratracheal length.

So these are always handy to have, particularly in patients with complex, distorted, or difficult anatomy.

Regarding early postoperative complications, airway compromise in the form of premature extubation or an unplanned decannulation is the most life threatening. Like any ostomy, tracheostomies require time to mature and and form a well-heeled tract. And that's one of the reasons that we usually wait at least a week or seven days and oftentimes longer before we will consider swapping out or downsizing a trach.

So if you get called to the bedside for a patient with a fresh trach, and we'll define that as less than five to seven days with evidence of progressive respiratory compromise, what should you do? So if upon your clinical exam and assessment the tracheostomy has obviously fallen out of the trachea and is decannulated, the most important thing here outside of calling for help and supplying the patient with supplemental O2 via the face is to proceed with orotracheal intubation.

There is no mature tract, and blindly attempting to reinsert a tracheostomy ultimately will create a false tract. which you'll then confuse for being in the trachea. And I don't care if you have N title CO two in this situation or not. Don't waste time. Too many times in most institutions I've been at, I've heard horror stories of people becoming fixated on trying to reinsert these traits, and it always fails.

These patients require supplemental O2, a call for help, and re intubation via the orotracheal route. Now, we do place tracheostomy sutures in the case of surgical tracheostomies. And if there is senior help around, sometimes it is possible to refond these things, bring the trachea to the surface of the wound.

and reinsert the tracheostomy under direct visualization. But this is something that should only be done by experienced personnel or the attending surgeon who is comfortable and has experience doing this.

Now, if your patient is in acute respiratory failure in the immediate post tracheostomy time period without evidence of obvious decannulation or accidental removal of the tracheostomy. The other thing that you want to consider is tracheostomy obstruction.

So again, in these patients, you want to call for help. You want to ensure that they're being provided with supplemental oxygen. And very quickly you want to rule out a mechanical obstruction. On physical exam, these patients may have evidence of accessory muscle use. They may also have signs of upper airway obstruction. How would you notice this? Well, on inspiration, you may notice that they have indrying of their abdomen.

Further, when you listen, you may notice that there's really no evidence of air movement. The simplest thing in this particular scenario is to attempt to pass a suction catheter through the tracheostomy. And if it passes, well, that's positive. Again, you probably do want to ensure that there's N title CO2 to convince yourself that the tracheostomy is connected to the actual airway.

If that suction catheter is not passing, the simplest thing at this point is to simply remove the inner cannula and replace it with the new one and then reassess the patient. Again, at all time points the patient should be receiving supplemental oxygen, and if concerns persist, the simplest, most effective manner of managing this particular problem would be to again perform oral tracheal intubation from above.

Bleeding in the immediate post operative period is a not uncommon complication following tracheostomy, especially open or surgical tracheostomies. When we get called to assess a patient who's had a tracheostomy placed and they're bleeding from their tracheostomy site, or through their tracheostomy, one of the things that we always have in the back of our minds is the potential for a tracheoenominate fistula.

Again, this is an overall very rare occurrence in both pediatric and adult patient populations. The estimates vary from point one to one percent. It's probably more on the order of point zero one to point one percent. And in terms of the timing, uh the reports vary. Older literature suggested that these were more common in the first one to three weeks post operatively.

I just reviewed a systematic review of TIFs in the pediatric patient population, which involves 77 cases, and the mean time to diagnosis of a TIF in this series was actually in 395 days. In terms of clinical presentation, you may have heard of the often discussed sentinel or herald bleed, which may occur in up to a third of patients with TI fistulus. Essentially this is considered minor bleeding.

from within or around the tracheostomy site. And anytime we encounter this, we want to have TI fistula on the top of the differential because if this goes unrecognized, this will kill your patient. There's a lot of discussion out there regarding what's the optimal diagnostic modality for patients who have a herald or sentinel bleed.

From our institutional standpoint, we take all these patients to the operating room where we will perform a bronchoscopy both through the tracheostomy as well as from above. across and below the tracheostomy to look for stigmata or signs of a tracheoanomino fistula, which will typically be noted along the anterior portion of the trachea.

Now, if this is negative, then at that point, because we're already in the operating room, we'll perform a local wound exploration. And in general, there's something that needs to be tied off, packed, or cauterized. So the vast majority of these post tracheal bleeds will ultimately be related to something within the wound. But uh due diligence is required to rule out that one thing that may potentially kill your patient, and that is a TI fistula.

Is there a potential for endovascular interventions and what is the sensitivity and specificity of CT angio or a formal angiogram in the workup and diagnosis of TI fistulas? There are no data to support performing any of these other diagnostic modalities. And again, I think given the overall rarity, we simply do not have the numbers to assess. the accuracy of these other diagnostic or therapeutic modalities, although there are case reports out there.

Now, in the unfortunate circumstance that a patient does develop massive hemoptasis or bleeding in the setting of a TI fistula, next to calling for help, getting the OR ready, and considering getting the patient on emergent ECMO. You want to start by hyperinflating the tracheostomy cuff. The whole idea behind this is to potentially occlude the artery from bleeding against the posterior table of the manubrium or sternum.

If that is ineffective, then one can perform the Utley maneuver, which I call the common sense maneuver. Simply insert uh a finger behind the sternum and compress anteriorly. in an effort to occlude or at least compress the bleeding inominate or brachiocephalic artery.

Now, as you can imagine, this may be difficult to do if someone still has a tracheostomy inside to you. So while you're attempting to perform this hemorrhage control maneuver, Someone, ideally anesthesia or someone on the airway, should be attempting to intubate the patient oral tracheally. Provided that your patient does survive the trip down to the operating room, the quickest and most efficient way to get hemorrhage control will be through a median sternotomy.

And typically in this setting, we're gonna simply ligate the inominate artery, perform a damage control operation. ideally place some sort of a pedicled tissue flap between the trachea and the innominate artery, as there's usually some evidence of chronic infection or inflammation in this area.

And then get the patient back up to the ICU for resuscitation and ongoing monitoring. If your patient survives this, that is a huge win and is much better than my one hundred percent mortality in my experience of N of two.

So in the last five minutes around, let's quickly go over some of the methods of quote unquote weaning a patient's tracheostomy. In general, once patients no longer require mechanical ventilatory support, they continue to receive supplemental oxygen via a trach mask or a trach hood. which essentially is a shield that sits over the tracheostomy and is able to provide patients with ongoing O2 supplementation.

At some point, however, that tracheostomy hopefully will be able to be decannulated. And so what are the considerations when we think about decannulating the trach and what are the different options of doing so? I think the key point here is to remember that appropriate candidates for tracheal decannulation include patients with a couple of key criteria. Number one, there should be no evidence of upper airway obstruction. Number two, they should have the ability to ideally on demand.

Clear secretions which are neither too copious nor too thick. In other words, they should be able to manage their secretions. So provided that these criteria are met, there are a few different methods or ways of decannulating a patient or progressively downsizing them. And in general, this is something that's done in a protocolized fashion in conjunction with palm crit care, surge crit care, pulmonary, as well as ENT.

speech and respiratory care. So a multidisciplinary pathway for getting tracheostomies downsized or removed. In general, we'll proceed with either progressive downsizing Progressive capping trials or immediate decannulation, which is definitely the least common way of doing this. Progressive downsizing is exactly that. If a patient has an eight oh tracheostomy in, we'll proceed to downsize that tracheostomy to a six oh and sometimes even to a four oh prior to removal.

Before we downsize, again, most of these tracheostomies are going to be cuffed. And so we always want to trial uh cuff deflation to ensure that patients are able to handle their secretions. And there are some intricacies that go along with trials of cuff deflation, including oral suctioning. as well as subglottic port suctioning if the tracheostomy has that. This is a simple way of really just kind of weaning down the size of the tracheostomy to the point where it's no longer needed.

Capping trials involved prolonged periods of capping of the tracheostomy. Of course, if there's a cuff tube that needs to be uncuffed, so the air can move from the mouth down to the lungs and vice versa. These capping trials may proceed in a prolonged fashion from six to twelve, twenty-four, forty-eight hours. until the tracheostomy is deemed no longer to be required, at which point it's removed, covered with the four by four, as well as an adhesive dressing, and left to heal.

On the topic of capping, a commonly used uh modality is the passimir valve or PM valve or PMB. This is a one-way speaking valve. Essentially it allows air to be inspired. through the tracheostomy, but on expiration air preferentially goes out via the vocal cords and the mouth. As you can imagine, A patient's cuff must be Be deflated, or patients must have an uncuffed tracheostomy in order to use a PM valve safely.

You can imagine, because this is a one-way valve that only allows for inspiration from the atmosphere directly through the trach and into the tracheobronchial tree, that if there is an inflated cuff, Or if there is a very large number of Tracheostomy, which doesn't allow for airflow around and above the tracheostomy, patients will have progressive hyperinflation, which may potentially result in death if not recognized.

Fenestrated trach are another option to help patients vocalize and these essentially have a fenestration or hole. above the level of the cuff, if it's a cuffed fenestrated tube. And so this will allow for some air or expired air to move above the level of the cuff through the vocal cords, allowing patients to vocalize.

In terms of take-home points, there really are a few. Number one, remember that a careful and thoughtful pre-operative assessment is critical to identify high-risk factors that may influence not just the approach. But considerations regarding timing and type of tracheostomy device required. Number two, trach are not without complication, and in the case of an accidental dislodgement or early decannulation within the first seven days, attempts at blind reinsertion will be unsuccessful.

So provision of oxygen and immediate reintubation from above should be performed. Number three, if a patient experiences bleeding either in the immediate or in a delayed fashion postoperatively, it is important to bear in mind the potential for a tracheoenominate fistula. And the safest way of addressing this is to bring the patient to the operating room, perform a bronchoscopy both through and around the tracheostomy.

followed by efforts at hemorrhage control if there's bleeding from the surgical wound bed. Well that brings us to the end of today's rounds. I want to thank you for joining me. If you like what you're hearing, please do tell your friends. Also remember to subscribe and even better leave a comment. at Apple iTunes, I'd really appreciate that. Also please do visit the website at traumaicurounds.ca. Feel free to leave a comment or suggestion.

I'll be happy to address those as they come across my desktop. In the meantime, stay safe, keep reading, and we'll talk soon. Yeah.