Tracheostomy Overview

Definitive airway produced by inserting a tube subglottically through the anterior neck directly into the trachea. May be:

This covers the management of a tracheostomy, including considerations for their use. Tracheostomy weaning and insertion of percutaneous tracheostomy are covered elsewhere.

Indications

Factors to consider: Percutaneous versus surgical tracheostomy
Favours Percutaneous Favours Surgical
↓ Bleeding Vascular insertion site on ultrasound
↓ Infection Complex neck anatomy
↓ Tracheal stenosis Less risk of death/cardiac arrest
Better cosmetic result Greater airway backup (anaesthetist/surgeon)
Logistics (no waiting on surgical lists) Does not require bronchoscope
No risk of intrahospital transfer Emergent
  • A
    • Surgical
      e.g. Laryngectomy.
  • B
    • Long-term mechanical ventilation
      Useful for patients requiring long-term ventilation, and to aid respiratory weaning by:
      • ↓ Sedation requirements
        Facilitates spontaneous ventilation, ↑ proportion of respiratory work done by the patient. May lead to ↓ total time on mechanical ventilation.
      • ↓ Work of breathing
        ↓ Airway resistance and (marginally) ↓ dead space relative to ETT.
      • ↓ Airway trauma
        ↓ Risk of laryngeal stenosis, vocal cord ulceration, and improves voice recovery. These risks rise after 1 week of oral intubation.
      • ↓ Aspiration risk
        Glottic competence is restored, so the tube cuff is not the only thing preventing aspiration.
      • Better secretion management
        Awake patients can cough more effectively. Potentially less VAP.
      • Better oral care
        Can brush teeth.
  • D
    • ↓ Sedation requirements
      Better tube tolerance and patient comfort compared to oral ETT.
      • Improved communication
        • Desedation facilitates interaction
        • Lip-reading
          Easier without an ETT.
        • Talking
          With the cuff down, and with or without a speaking valve. Requires generating subglottic pressure of >2cmH2O.
      • Facilitate neurological assessment
    • Quality of life
  • E
    • Facilitate physiotherapy
      Positioning, rehabilitation, coughing.

Considerations

Considerations for tracheostomy insertion include:

Timing of tracheostomy insertion is difficult. In general:

  • Clinicians are bad at predicting who will need a tracheostomy
  • Routine early tracheostomy therefore leads to large numbers of unnecessary tracheostomies
  • An approach:
    • Early if prolonged ventilation inevitable
      e.g. GBS.
    • >10 days following mechanical ventilation, without imminent extubation
  • A
    • Neck anatomy
      • Vascularity
      • Length of accessible trachea
        Patients without much extra-thoracic trachea will be more difficult with both insertion and management.
    • Intubation grade
    • C-spine stability
  • B
    • Respiratory function
      Ideally:
      • FiO2 <0.6 Risk of airway fire with electrocautery, and indicates tolerance of interruption of ventilation during insertion.
      • PEEP <10cmH2O Tolerance of de-recruitment and interruption of ventilation during insertion.
  • H
    • Coagulopathy
  • I
    • Infection
      At site of insertion.

Components

Components of the tracheostomy setup:

  • Tracheostomy tube
    May be:
    • Fenestrated
      Tube has holes above the cuff.
      • Permits coughing, phonation, and aspiration
        Outer portion needs to be blocked to divert gas flow via vocal cords.
      • Aids respiratory weaning
      • Patient must protect own airway
      • Improves swallow
      • Inner cannula can be:
        • Fenestrated
          Allows tube to function as a fenestrated tube.
        • Unfenestrated
          Blocks fenestration, which permits mechanical ventilation. Mechanical ventilation of a fenestrated tube results in significant circuit leak and a distressed, continually-exhaling patient.
    • Unfenestrated
  • Inner cannula
    Inner tube placed inside the tracheostomy tube to prevent it being contaminated.
    • Easy cleaning
      Just remove the inner cannula, clean, and replace.
    • ↓ Internal dimensions/↑ airway resistance
      Degree depends on the catheter size.
  • Speaking (Passy Muir) valve
    One-way valve that allows a patient to inspire through the tracheostomy, and then expire via the native away, allowing phonation. The valve:
    • Requires the cuff to be deflated
      Or the patient will be unable to exhale.
    • A humidifier can (and should) be used
      An HME will be ineffective as the patient exhales via a different route.
    • Can be used with or without a ventilator
      The ventilator will need to be set accordingly, to prevent continual alarms.
  • Tracheostomy cap
    Occlusive cover for the tracheostomy tube, preventing inspiration via the tracheostomy tube, turning the tube into a partial upper airway obstruction. This requires the patient to inspire and expire via the native airway, and also the cuff to be deflated.

Management

Caring for a tracheostomy tube:

Tracheostomy patients are high risk and should be managed by trained staff. An ICU outreach team is beneficial.

  • A
    • Cuff pressures
      Keep <30mmHg to reduce the risk of tracheal ulceration and stenosis.
    • Cleaning
      Inner cannula (if present) should be cleaned when necessary.
    • Suctioning
      • Shallow tracheal suctioning (to the length of the tube) to remove secretions, particularly if cough is inadequate
      • Suction channels (above the cuff) should be suctioned at least Q4H
    • Wound care
      The wound must be kept clean to prevent infection.
  • B
    • Humidification
      Should be routine, including if patient is using trache hood or Swedish nose. Important for:
      • Patient comfort
      • Secretion management
        ↓ Viscosity.

Facilitating Speech

Speech greatly improves the quality of life of a patient with a tracheostomy. All methods of phonation require gas to be exhaled via the native airway.

Contraindications to speaking:

  • High aspiration risk
    • Unconscious/comatose
    • Loss of upper airway reflexes
    • High secretion load
  • Unable to exhale via native airway
    • Upper airway obstruction
    • Inadequate lung mechanics
      ↑ Resistance, ↓ compliance.
Methods to Facilitate Speech
Approach Considerations Advantages Disadvantages
Cuff down, with: Nothing else
  • Simple, possible with any tracheostomy
  • Low resistance to expiration and inspiration
  • Speech predominantly occurs in inspiration
    Low-resistance pathway via tracheostomy.
  • High leak volume if on ventilator
  • Aspiration risk
Finger occlusion
  • Simple, possible with any tracheostomy
  • Low-resistance to inspiration
  • Coordination required
  • Cannot use ventilator
  • Aspiration risk
Speaking valve
  • Appropriate diameter of upper airway
  • ↑ Work of breathing
  • No coordination required
  • High expiratory flow
  • ↑ Secretion clearance, if strength adequate
  • ↓ Aspiration risk compared to no occlusion, as ↑ flow via native airway
  • Extensive leak if on ventilator
  • ↑ Work of breathing
Cuff up, with: Fenestrated tracheostomy
  • Fenestrations can be occluded with an inner cannula
  • ↓ Aspiration risk compared to cuff down techniques
  • Speech can occur throughout the respiratory cycle
  • May require tracheostomy change
  • Fenestrations are small and vulnerable to blocking
  • Soft vocalisation
    Low gas flow exhaled rate in native airway.
Above cuff vocalisation
  • Limit gas flow into subglottic suction port to 5L/min
  • Wait 72 hours prior to initiation
  • Use humidified gas or for short periods only
  • ↓ Aspiration risk
  • Audible speech
  • No tube change required
  • May improve secretion clearance
  • Soft vocalisation
  • Aerophagia

Combining a fenestrated tube and a speaking valve significantly prolongs expiration time, which may ↑ FRC and prevent small airway collapse.

Effect of a Speaking Valve with Fenestrated Tracheostomy on Chest Wall Movement

Electrographic chest wall movement:

  • Top: Standard tracheostomy tube
  • Bottom: Fenestrated tube with speaking valve

Complications

In-situ tracheostomy:

  • A
    • Dislodgement
      Risks include:
      • Patient
        • Agitation
        • Large s
      • Equipment
        • Poorly sized tube
      • Staff
        Inadequate:
        • Training
        • Numbers
    • Bleeding
      ~5% of cases.
      • Early
        Bleeding within 48 hours is likely venous.
      • Late
        Due to erosion of the tracheostomy into a vascular structure.
        • Tracheo-innominate fistula
          Erosion (classically of the cuff) into the innominate artery.
          • Leads to catastrophic:
            • Bleeding and airway soiling
            • Air entrainment
        • Any bleeding between 3 days and 6 weeks should be investigated for a fistula
          Either bronchoscopically or via CT.
    • Obstruction
      • Bleeding
      • Secretions
        ↑ Risk if dehumidified.
  • B
    • Failure to wean
      If the patient is unable to wean from the ventilator despite the tracheostomy, this may be an unsatisfactory outcome for both patient and family.
    • Pneumonia
      ↑ Risk due to bypass of normal upper respiratory protective mechanisms. Occurs in ~25% of patients.
  • D
    • Quality of life
      Generally worse in patients who have received a tracheostomy, compared to patients who did not.
  • G
    • Swallowing difficulty
  • I
    • Infection
      Either of the stoma, or contamination of wounds (sternal, CVC) with secretions.

Post-tracheostomy:

  • A
    • Tracheal stenosis
      Commonly occurring (1-2%), rarely significant. Risk ↑ with:
      • Procedural
        • Tracheal ring fracture
      • Equipment
        • Oversized cannula
      • Patient
        • Male
        • Elderly
        • Prolonged duration of use
    • Tracheomalacia
      Loss of tracheal cartilage (usually ischaemic), leading to collapse under negative-pressure inspiration.
    • Persistent stoma
      May require surgical repair.

Key Studies

  • TRACMAN (2013)
    • ~900 intubated Britons on day 4 of intubation whose treating clinician believed they will need ⩾7 further days of mechanical ventilation, and a tracheostomy is not otherwise indicated or contraindicated
    • Multicentre, randomised trial
    • 80% power for 8.3% ARR ↓ in 30 day mortality (!!), assuming baseline of 31.5%
      Multiple readjustments due to changing baseline mortality and recruitment fatigue.
    • Early (day 4) vs. Late (⩾10 day) tracheostomy
      • Early
        • 85% received tracheostomy
        • 7% never received tracheostomy
        • 7.5% received late tracheostomy
      • Late
        • 40% received tracheostomy after day 10 of admission
        • 53% did not receive a tracheostomy as it was no longer indicated
        • 7% received tracheostomy before day 10
    • No change in 30 day mortality (30.8% vs. 31.5%)
    • No difference in secondary outcomes, including ICU length of stay or ventilated days
    • ~6% complication rate
    • Overall: We are not successful at predicting need for tracheostomy, there are not insignificant procedural risks, and early tracheostomy does not appear to have benefits in accelerating ventilator weaning

References

  1. De Leyn, Paul, Lieven Bedert, Marion Delcroix, Pieter Depuydt, Geert Lauwers, Youri Sokolov, Alain Van Meerhaeghe, Paul Van Schil, and Belgian Association of Pneumology and Belgian Association of Cardiothoracic Surgery. “Tracheotomy: Clinical Review and Guidelines.” European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery 32, no. 3 (September 2007): 412–21.
  2. Dulguerov, Pavel, Gysin, Claudine, Perneger, Thomas, MD, PhD, Chevrolet, Jean-Claude. Percutaneous or surgical tracheostomy: A meta-analysis. Crit Care Med. 1999;27(8):1617-1625.
  3. Hess, Dean R. “Facilitating Speech in the Patient With a Tracheostomy.” Respiratory Care 50, no. 4 (April 1, 2005): 519–25.
  4. Ailawadi, Gorav. “Technique for Managing Tracheo-Innominate Artery Fistula.” Operative Techniques in Thoracic and Cardiovascular Surgery 14, no. 1 (March 1, 2009): 66–72. .
  5. Donaldson, Lachlan, and Raymond Raper. “Successful Emergency Management of a Bleeding Tracheoinnominate Fistula.” BMJ Case Reports 12, no. 12 (December 2019): e232257. https://doi.org/10.1136/bcr-2019-232257.
  6. Young D, Harrison DA, Cuthbertson BH, Rowan K, for the TracMan Collaborators. Effect of Early vs Late Tracheostomy Placement on Survival in Patients Receiving Mechanical Ventilation: The TracMan Randomized Trial. JAMA. 2013;309(20):2121-2129. doi:10.1001/jama.2013.5154
  7. McGrath B, Lynch J, Wilson M, Nicholson L, Wallace S. Above cuff vocalisation: A novel technique for communication in the ventilator-dependent tracheostomy patient. Journal of the Intensive Care Society. 2016;17(1):19-26.
  8. Fukumoto M, Ota H, Arima H. Ventilator weaning using a fenestrated tracheostomy tube with a speaking valve. Critical Care and Resuscitation. 2006;8(2).