5. Who famous person died of
an upper airway obstruction
because their M.D. was
unwilling to perform his 1st
tracheostomy on a person
of such stature??
6. *George Washington
toured his estate on
horseback one cold
and rainy day in 179
9.
*The next day he had
severe upper airway
swelling.
7. Antonio Musa Brasavola, an Italian
physician,
performed
the
first
documented case of a successful
tracheotomy. He published his account
in 1546. The patient, who suffered from
a laryngeal abscess and recovered from
the procedure
8. Evolution of Mechanical Ventilation in
Response to Clinical Research
Esteban A et al. Am J Respir Crit Care Med 2008; 177: 170–177
26%
25%
27%
20%
Rate of Tracheostomy
1998 vs 2004
11% vs 12.5%
10. INDICATIONS FOR TRACHEOSTOMY
•
•
•
•
•
•
•
Prolonged intubation
Facilitation of ventilation support
Inability of patient to manage secretions
Upper airway obstruction
Inability to intubate
Adjunct to major head and neck surgery
Adjunct to management of major head
and neck trauma
11. Why Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324
Facilitate prolonged assisted ventilation
- Coma
• Major Head injury
• Cerebral bleed/infarct/lesion
• Encephalitis
- High spinal cord injury
- Neuromuscular disorder
• Guillain-Barre syndrome
• Critical Care Polyneuropathy
- COPD
12. Why Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324
Inability to prevent pulmonary
aspiration
- Posterior fossa/infratentorial lesions
• Cerebellum/brain stem
• Basilar/posterior cerebral artery
• Encephalitis
- Cranial nerve dysfunction
13. Why Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324
Upper airway obstruction
- Maxillofacial surgery or trauma
- Congenital malformation
- Facilitate upper cervical surgery
- Vocal cord paralysis
14. Predictors of Outcome for Patients With COPD
Requiring Invasive Mechanical Ventilation
Nevins ML et al Chest 2001;119;1840-1849
- Previous Mechanical Ventilation
- FEV1/FVC < 30% predicted
- COPD Exacerbation
- Low Ht (< 35%) and Albumin (< 2.5 g/dL)
- APACHE (> 15, 6 hrs after MV)
- Active Malignacy
15. TRACHEOSTOMY VS
TRANSLARYNGEAL INTUBATION
–
–
–
–
–
–
–
–
–
–
Increased patient mobility
More secure airway
Increased comfort
Improved airway suctioning
Early transfer of ventilator-dependent patients
from the intensive care unit (ICU)
Less direct endolaryngeal injury
Enhanced oral nutrition
Enhanced phonation and communication
Decreased airway resistance for promoting
weaning from mechanical ventilation
Decreased risk for nosocomial pneumonia in
patient subgroups
Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
16. Disadvantages of Tracheostomy
Pelosi P et al Crit Care 2004; 8:322-324
Blot F et al. Chest 2005; 127:1347–1352
- Tracheal complications
- Aggressive procedure
- Risk of stomal infection
- Esthetic sequelae
- Bleeding
- Psychological trauma
- Delayed ICU discharge
- Organizational difficulties
- Increased risk in ward
17. Contraindications for tracheostomy (?)
Groves DS et al Curr Opin Crit Care 2007, 13:90–97
Absolute contraindications (rare):
- Soft tissue infections of the neck
- Anatomic aberrations
Relative controindications:
- Severe respiratory distress with
refractory hypoxemia and hypercapnia
- Hematologic and coagulation disorders
18. Postulated
Direct effects
Indirect effects
Reduction of dead space
Reduction of airway
resistance and dead space
Less need for sedation
Reduced rate of VAP
Shortened weaning period
Shortened ICU stay
Lower mortality
19. Tracheostomy: WOB and PEEPi
Diehl JL et al.Am J Respir Crit Care Med 1999, 159:383-388
20. Is tracheostomy associated with better
outcomes for patients requiring long-term
MV ?
Combes A et al. Crit Care Med 2007; 35:802–807
21. Tracheostomy does not improve the outcome of
patients requiring prolonged MV: A propensity
analysis
Clec’h C et al Crit Care Med 2007; 35:132–138
Odds ratios for post-intensive care unit mortality
associated with tracheostomy in patients matched on
propensity scores
OR
- All patients
- Patients decannulated
before discharge
- Patients not decannulated
before discharge
95% CI
p Value
2.57
1.20-5.48
0.01
1.43
0.42-4.90
0.56
3.73
1.41-9.83
0.008
22. Indications for tracheostomy
Plummer AL, Gracey DR. Consensus conference on artificial
airways in patients receiving mechanical ventilation. Chest
1989; 96:178–180
- If the need for an artificial airway
is anticipated to be greater than 21
days
23. Indications for tracheostomy
Chastre J, Bedock B, Clair B, et al. Which tracheal route
should be used for mechanical ventilation in the critically ill?
Thirteenth consensus conference on resuscitation and
emergency medicine. Rean Urg 1998; 7:435–442
- Mechanical ventilation anticipated to
last between 10 and 21 days
- The decision left to the attending MD
- Daily assessment was recommended
as to the need for continued intubation
24. Indications for tracheostomy
MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for
weaning and discontinuing ventilatory support: a collective task force
facilitatedby the American College of Chest Physicians; the American
Association for Respiratory Care; and the American College of Critical
Care Medicine. Chest 2001; 120 (6 Suppl):375S–395S.
- After an initial period of stabilization
on the ventilator (generally, within 3–7
days)
- When apparent that the patient will
require prolonged ventilator
assistance
25. Tracheostomy in the critically ill:
indications, timing and techniques
Groves DS et al Curr Opin Crit Care 2007, 13:90–97
Prolonged
Mechanical
Ventilation
26. How Is Mechanical Ventilation Employed
in the Intensive Care Unit ?
Esteban A et al Am J Respir Crit Care Med 2000; 161; 1450–1458
Percentage of pts with tracheostomy
27. Outcome of mechanically ventilated
patients who require a tracheostomy
Frutos-Vivar F et al. Crit Care Med 2005;
33:290 –298
Tracheostomy performed
at a median
time of 12 days (7–17) from
beginning mechanical
ventilation.
28. Incision 1 cm below the cricoid or
halfway between the cricoid and the
sternal notch.
Retractors are placed, the skin is
retracted, and the strap muscles
are visualized in the midline. The
muscles are divided along the
raphe, then retracted laterally
29. The thyroid isthmus lies in the field of the dissection.
Typically, the isthmus is 5 to 10 mm in its vertical dimension,
mobilize it away from the trachea and retract it,
then place the tracheal incision in the second or third tracheal interspace
31. PERCUTANEOUS DILATIONAL TRACHEOTOMY
Guidewire introduction, with removal
of sheath
Guidewire and catheter are advanced
together into the trachea as far as the
skin positioning marks on the guide
catheter to the skin.[
32. PERCUTANEOUS DILATIONAL TRACHEOTOMY
Guidewire and catheter are
advanced together into the
trachea as far as the skin
positioning marks on the guide
catheter to the skin
Guidewire, guide catheter, and
dilator unit are advanced
together into the trachea to the
skin positioning mark
33. PERCUTANEOUS DILATIONAL TRACHEOTOMY
The tracheotomy tube is loaded onto a dilator
and advanced into the trachea over the
guidewire and catheter. The guidewire and
catheter are removed, leaving only the
tracheostomy tube in the trachea
35. Percutaneous trachesotomy techniques
"classical" Ciaglia technique
Ciaglia P, Firsching R, Syniec C.
Elective percutaneous dilatational tracheostomy a new simple bedside
procedure: preliminary report.
Chest 1985; 87:715-719
Griggs forceps technique
Griggs WM, Gilligan JE, Myburg JA.
A simple percutaneous tracheostomy technique
Surgery 1990; 170:543-544
Fantoni - translaryngeal technique
Fantoni A, Ripamonti D.
A non-derivative, non surgical tracheostomy: the translaryngeal method.
Intensive Care Med 1997; 27:386-392
PercuTwist
Frova G, Quintel M.
A new simple method for percutaneous tracheostomy: controlled
rotating dilation
Intensive Care Med 2002; 28:299-303
50. Jackson ID with inner
ID without
size
cannula
inner cannula
ED
4
5.0 mm
6.7 mm
9.4 mm
6
6.4 mm
8.1 mm
8
7.6 mm
9.1 mm
10
8.9 mm
10.7 mm
10.8
mm
12.2
mm
13.8
mm
66. TUBE REPLACEMENT
• FIRST CHANGE ADVISABLE > 10-15
DAYS AFTER TRACHEOSTOMY
• NO FIXED SCHEDULE FOR
REPLACEMENT BUT HIGHLY
DEPENDENT ON LOCAL POLICY
• CLOSELY LINKED TO THE TYPE OF
CANNULA (INNER CANNULA etc) AND
TO THE QUALITY OF DOMICILIARY
MANAGEMENT
99. Complications of
Tracheostomy
– Stoma
• Stoma site infection
• Stomal hemorrhage
• Poor stoma healing after
decannulation with scar, keloid, or
tracheocutaneous fistula
100. Complications of
Tracheostomy
– Trachea
• Granuloma
• Tracheoesophageal fistula
fewer than 1% of patients as a result of
pressure necrosis of the tracheal and
esophageal mucosa from the tube cuff
risks: high cuff pressures, presence of a
nasogastric tube, excessive tube movement,
and underlying diabetes mellitus
101. Complications of
Tracheostomy
• Tracheoinnominate fistula:
0.4% with mortality rate of 85% to 90%.
Major airway hemorrhage may occur first within several
days or as long as 7 months after performance of a
tracheostomy.
Risk factors : excessive tube movement, low placement of
the tracheostomy, sepsis, poor nutritional status, and
corticosteroid therapy
• Tracheal stenosis:
can develop from 1 to 6 months after decannulation
risk for tracheal stenosis ranges between 0% and 16%
• Tracheomalacia
