Tracheostomy

Tracheostomy – Jared Freitas

Indications for Tracheostomy

  • prolonged mechanical intubation and weaning
  • acute airway obstructions (head and neck cancers)
  • tracheal stenosis
  • trauma
  • neuromuscular disease

 

 

Benefits of Tracheostomy vs ET tube

  • improved pt comfort and decreased need for sedation
  • reduced laryngeal damage
  • increased ability to communicate (i.e. speaking valve)
  • may decrease risk of developing ventilator associated pneumonia (mixed data)
  • may reduce time to wean from the vent and decrease time in the hospital (mixed data)

Timing of Tracheostomy:

  • no mortality difference or in hospital length of stay b/w  early (day 4) vs late (day 10)
  • Generally performed after 2 weeks of intubation, but not backed by data
  • Pts that might get tracheostomy earlier: anticipated prolonged mechanical ventilation (i.e. those with acute neurologic injury affecting spinal cord)

 

Types of Tracheostomy Tubes:

  • Different brands: most common in hospital = Shiley
  • Components:
    • Faceplate: keeps tube in place, has the model and size on it
    • Inner cannula: can be removed, cleaned and replaced in case of obstruction
    • Cuff (may or may not have): allows for positive pressure and for pt to be ventilated; may prevent some aspiration
    • Fenestration (may or may not have): allow speaking without valve
  • Common sizes:
    • Initial: 8-0; Standard downsizing: 6-0
    • Lengths: standard vs. larger XLT (P = longer proximal end, D = longer distal end)
  • Presenting on ICU rounds = size/cuff status/brand (e.g. 8-0 cuffed shiley)

 

Speaking Valves:

  • Passy Muir Valve (PMV) one-way button-shaped valve placed on the outer portion of the trach; air moves in with inspiration but is blocked and thus funneled up through the vocal cords during exhalation allowing for phonation
  • Contraindication: have severe upper airway obstruction or aspiration risk, copious secretions, decreased cognitive status, severe medical instability, or inability to tolerate cuff deflation (need PPV)
  • IMPORTANT SAFETY PRINCIPLE: cuff must be deflated, since air needs to be able to travel back up the airway, if the cuff is not deflated and you put the PMV on, then pt cannot exhale

 

Maintenance of Tracheostomy Tubes:

  • Inner cannula should be cleaned 2-3 times per day
  • Daily stoma care should be initiated to prevent pressure ulcers and stoma infections
  • As needed suctioning for secretions

 

Complications and airway emergencies in a tracheostomy pt:

  • Hemorrhage (mild bleeding from surface vessels and granulation tissue is common, major bleeding is rare think erosion into brachiocephalic [innominate] artery)
  • Airway damage subglottic or tracheal stenosis; tracheobronchitis
  • Fistulas (tracheoarterial, tracheoesophageal)
  • Unintended tracheostomy tube dislodgement:
    • Bag mask (use hand/gauze to occlude stoma) or intubate from above (i.e. through the mouth); if complete laryngectomy then must use stoma
    • Fresh trach (≤ 14 days): do NOT replace due to risk of misplacement into the mediastinum and loss of airway; airway management from above
    • Older trach: can be replaced at bedside with obturator by trained staff
    • All pts with trachs have a yellow sign above bed with date, type, size of trach as well as a replacement trach with obturator in the room

 

Strategies for Prolonged Ventilator Weaning

  • Typically done in a step wise fashion: move from mainly VC or PC setting pressure support trach collar (blow by oxygen) capping trials once passed capping trials successfully can possibly proceed to decannulation
  • After being on trach collar successfully, then can consider downsizing the trach

 

Causes of Prolonged Weaning

  • Cardiovascular: HF or ischemia may need diuresis or antiplatelet
  • Metabolic: check and replete phos, Mg, Ca, thyroid (all re: diaphragm weakness)
  • Sepsis: anaerobic state that drives metabolic acidosis leading to difficulty ventilating
  • Psychological: managing anxiety related to vent and handling secretions is important
  • Nutrition: protein catabolism can lead to diaphragmatic weakness
  • Physical deconditioning: PT to treat ICU polymyopathy and overall functional status

 

Secretion Management

  • Respiratory hygiene (“pulmonary toilet”): heated vent, guaifenesin, hypertonic saline, duonebs, cough assist device, appropriate suctioning (too much = worsen secretions), acapella, inspiratory spirometer, hyperinflation therapy