Trauma ICU Rounds – Demystifying Tracheostomies
- Jul 3rd, 2020
- Dennis Kim
- categories:
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
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Tracheostomies are most commonly performed via a percutaneous technique
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Patient outcomes are improved with early tracheostomy among patients with severe TBI and cervical spinal cord injuries
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Preoperative identification of high risk factors may alter one’s approach to tracheostomy
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Common complications in the early postoperative period are decannulation and obstruction
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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
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.
