Trauma ICU Rounds – Demystifying Tracheostomies

Originally posted on Trauma ICU Rounds on May 17, 2020. Follow Trauma ICU Rounds (@traumaicurounds) and Dr. Kim (@dennisyongkim) to learn more on simplifying trauma critical care together.


Listen to the accompanying podcast HERE

Is there an ideal time to place a tracheostomy? What factors might influence my decision to proceed with an open versus percutaneous tracheostomy? In this episode, we discuss common perioperative considerations influencing our decision to proceed with tracheostomy in critically ill patients requiring prolonged mechanical ventilation. Over the course of rounds, I’ll share with you some “tricks of the trade” and review key management principles for safely dealing with potentially life-threatening tracheostomy complications in the postoperative period including unplanned early decannulation and bleeding.

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

Screen Shot 2020-05-07 at 6.30.01 PM.png

Shiley XLT Tracheostomy Tube Overview:

(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.

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

Tracheostomy

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