Tracheostomy has been traditionally performed to bypass upper airway obstruction.1 In the ICU, 10–24% of patients require tracheostomy for prolonged respiratory support or weaning.2 Most critically ill patients tolerate short-term tracheal intubation with minimal complications. Prolonged (longer than 1–2 weeks) tracheal intubation and mechanical ventilation are associated with adverse outcomes.3 Patients requiring prolonged mechanical ventilation often need a tracheostomy for airway suction, to aid respiratory weaning, and for airway protection.
Surgical tracheostomy is most often performed in the operating theatre. In 1985, Ciaglia et al.4 introduced the bedside percutaneous dilatational tracheostomy. The tracheostomy was convenient to perform at the bedside without requiring complex instrumentation and lighting and so avoiding the need to transport the critically ill patient to the operating theatre. Open surgical tracheostomy is associated with an increased incidence of infection at the stoma site. Percutaneous tracheostomy has since become a popular choice and in many countries the majority of tracheostomies on ICUs are performed in this way.5 Surgical tracheostomy is reserved for difficult cases, when percutaneous tracheostomy is contra-indicated or has failed. This review will outline the recent advances in timing, techniques and safety of percutaneous tracheostomy.
Indications for tracheostomy
In the ICU, tracheostomy is used in patients who require prolonged weaning, have one or more failed trials of extubation, are predicted to be a difficult reintubation, are unable to protect their airway or require prolonged tracheobronchial suction6 (see below).
Proposed indications for tracheostomy are as follows:
- failed trials of extubation/failed weaning attempts from assisted ventilation;
- prolonged mechanical ventilation;
- tracheal access to remove thick pulmonary secretions (easier suction than with translaryngeal intubation);
- airway protection and prevention of pulmonary aspiration (e.g. patients with laryngeal incompetence and bulbar dysfunction from cerebrovascular accidents, severe brain injury or high spinal cord injury);
- bypass of upper airway obstruction (e.g. patients with trauma, infection, malignancy, laryngeal or subglottic stenosis, bilateral recurrent laryngeal nerve palsy, severe sleep apnoea);
- trauma or surgery in the face/neck region.
Tracheostomy is also considered in patients predicted to require prolonged mechanical ventilation to minimize or avoid laryngeal injury secondary to an extended period of translaryngeal intubation.7 This can also avoid the undesirable side-effects of ongoing sedation allowing for increased patient comfort, cough, respiratory drive, mobility and gut function. Emergency tracheostomy is required for critical upper airway obstruction or the lost airway in the ‘cannot ventilate, cannot intubate’ scenario.
Translaryngeal intubation and tracheostomy provide the same function, namely a patent artificial airway for ventilation, access for removal of secretions and a partially sealed system to limit pulmonary aspiration. Both methods bypass the normal protective mechanisms of an intact upper airway with a propensity to increase the risk of aspiration and ventilator-associated pneumonia. Each technique will have specific advantages and disadvantages (see below).
Proposed advantages of a tracheostomy are as follows:
- easier mouth care;
- speeds enteral nutrition;
- earlier mobilization of patients;
- more comfortable than translaryngeal tubes;
- reduces need for sedative or analgesic drugs;
- more effective cough and better co-operation with physiotherapy;
- reduced frequency of accidental extubation and endobronchial intubation;
- reduced complications of long-term translaryngeal intubation (such as laryngeal damage, subglottic stenosis);
- lower airway resistance, smaller dead space, reduced work of breathing–improved weaning from assisted ventilation;
- fenestrated tracheostomy tube or cuff deflation allows phonation and better communication;
- potential earlier discharge from the ICU to a level II care unit or suitable ward;
- seamless transition between intermittent positive pressure ventilation and continuous positive airway pressure, noninvasive ventilation and other modes of respiratory support.
Disadvantages of a tracheostomy are as follows:
- invasive operative procedure;
- scarring in neck, heals by granulation, often infected/colonized (percutaneous tracheostomy better than ST in this respect);
- may be unnecessary if patient improves quickly;
- procedural costs;
- may be left in situ too long;
- occasional severe long-term complications including tracheomalacia, blocked tubes, haemorrhage and tracheal stenosis;
- portal for infection.
The main complications of prolonged translaryngeal intubation are injury to the upper airway, ventilator-associated pneumonia and adverse effects associated with sedation required for tube tolerance. Serious airway complications including subglottic stenosis are more likely if tracheal intubation is continued for more than 2 weeks. In a cohort of patients with subglottic stenosis, it was found that 86% of them had a history of prolonged translaryngeal intubation even longer than 17 days (mean duration).8
Why perform a tracheostomy?
The suggested benefits of tracheostomy include protection from direct laryngeal injury and facilitation of airway suctioning, mouth hygiene and increased patient comfort. It has been claimed that tracheostomy decreases sedation/analgesic requirements and allows earlier patient mobilization, feeding and physical therapy. Tracheostomy appears to facilitate weaning by decreasing the work of breathing especially in patients with limited respiratory reserve.9 Other suggested benefits include fewer ventilator days and a reduced incidence of ventilator-associated pneumonia.10,11 Patients with tracheostomy who need prolonged ventilatory support can be transferred onto a bilevel positive airway pressure or continuous positive airway pressure without a sequence of trial extubation and reintubation and are more likely to be accepted for level II care. The benefits of tracheostomy are summarized in the Indications for tracheostomy section. Although tracheostomy has several advantages over standard intubation, having a tracheostomy is also associated with numerous short-term and long-term complications.12 It may prove unnecessary, especially in cases where decannulation occurs soon after the procedure, and there is also a tendency to prolong the time to decannulation after tracheostomy. The disadvantages are summarized in the Indications for tracheostomy section.
The timing of tracheostomy
The timing of tracheostomy in critically patients is difficult and subjective. This has recently become an area of significant investigation. The decision to perform a tracheostomy remains one of professional judgement, and physicians use their clinical expertise to determine who has the potential to benefit from a tracheostomy and when it should be performed. It is important to define objective criteria to identify patients most likely to benefit from this procedure. However, the current trend seems to be ‘early’ tracheostomy – within the first week of tracheal intubation.13,14 This is partly because percutaneous tracheostomy has lowered the threshold for performing the procedure.
In 1981, a prospective study compared the complication rates of prolonged tracheal intubation with those of tracheostomy. Patients who underwent tracheostomy had a high rate of complications.7 This study concluded that tracheostomy should not be recommended during the first 3 weeks of tracheal intubation, and these recommendations continued for some years because there was insufficient evidence to support the hypothesis that the timing of tracheostomy alters the duration of mechanical ventilation or the extent of tracheal injury.15 Since then no other study has found such a high complication rate, suggesting an improvement in standards of care, but further studies have not been able to show a benefit.14
Recently, several studies10,13,16,17 have supported the use of ‘early’ tracheostomy in ICU patients. The definition of ‘early’ remains unclear, with no consensus in the literature; definitions vary between 2 and 10 days. Tracheostomies performed before day 10 were claimed to be associated with lower costs of hospitalization and shorter duration of mechanical ventilation10 and, when performed within 48 h of tracheal intubation, were associated with a reduced length of ICU stay, fewer ventilator days and lower mortality.13 Reduced sedation requirements and increased patient mobility were potential explanations for these improved outcomes. Another reason may be that physicians reserve this procedure for patients more likely to survive ICU. However, these studies are underpowered and have design weaknesses. A systematic review recently compared ‘early’ versus ‘late’ tracheostomy and failed to show any significant difference in either mortality or risk of developing nosocomial pneumonia.14
A recently published trial comparing early (within 4 days) and late (after 14 days) tracheostomy failed to show a difference in mortality, duration of mechanical ventilation, length of intensive care stay or major infectious complications.18 A multicentre UK trial (www.tracman.org.uk) has been completed and presented but not yet published which shows no benefit from earlier tracheostomy.
A barrier to ‘early’ tracheostomy appears to be the inability of clinicians to predict accurately the need for prolonged mechanical ventilation.19,20 There is a necessity for developing a reliable scoring system that would predict the duration of mechanical ventilation. No such scoring system exists, although a number of parameters including paO2/pAO2 ratio, positive end-expiratory pressure value and chest radiographic appearance of pulmonary infiltrates have shown a correlation with duration of mechanical ventilation.21
If an early strategy for tracheostomy is pursued, it is anticipated that this procedure would inevitably be performed on some patients who would otherwise have been successfully extubated. Those centres geared towards early tracheostomy may also lose a degree of expertise in effective patient weaning from mechanical ventilation and strategies employed to prevent re-intubation.
There are cohorts of patients with end-stage neuromuscular or cardiorespiratory disease who may be better served by removal of the translaryngeal tube and palliative care rather than performing a tracheostomy. A tracheostomy in terminally ill patients may only serve to prolong dying, with all the problems related to ethical principles of futility and resource allocation. On the contrary, if these patients ask for a prolongation of life, tracheostomy should be considered, as it might increase the patient's comfort.
In certain patient populations, early tracheostomy appears to be particularly beneficial – including those with severe trauma,22 burns to the face, neck and airway, those with a neurological injury who are unable to protect their airway because of bulbar dysfunction and reduced level of consciousness, and those with neuromuscular weakness (such as myasthenia gravis or Guillain–Barré syndrome).
Tracheostomy can be performed by conventional open surgical techniques in the operating theatre or at the bedside. The increased popularity of percutaneous tracheostomy has made surgical tracheostomy the back-up technique in many centres. Typical indications include failed or predictably difficult percutaneous tracheostomy, abnormal anatomy and emergency situations. Irrespective of the technique used, tracheostomy carries inherent risks of bleeding, airway obstruction, hypoxia, hypercarbia, pneumothorax and other life-threatening complications. In an already critically ill patient, there is little margin for error and all procedures should be performed or directly supervised by competent operators.
Open techniques are usually performed by ENT or head and neck surgeons. Typically, a transverse skin incision is made between the lower border of the cricoid cartilage and suprasternal notch. The strap muscles are retracted laterally to expose the underlying thyroid isthmus and the trachea. The thyroid isthmus is either retracted cephalad or divided, exposing the tracheal rings. An incision is made between the second and third tracheal rings and the tracheostomy tube is placed under direct vision. If performed at the bedside, this procedure is more difficult because of suboptimal operating conditions such as lighting and operating on a wide bed; nevertheless, very good results can be achieved by senior physicians at the bedside.
Percutaneous dilational tracheostomy
Percutaneous dilational tracheostomy had been found to be well tolerated in terms of immediate and late complications. Many percutaneous techniques have been developed over the last decade that use either multiple or single dilators to form a tracheal stoma. The anterior tracheal wall can be dilated inside out or from outside in after endoscopically guided midline placement of an introducer needle and a guide wire.23 A tracheostomy tube is then inserted through the stoma with the help of a loading dilator. The single-dilator technique is by far the most popular for the reasons cited below.5 The obvious reasons include fewer manipulations in the airway, lower risk of bleeding/aerosolization of secretions and quicker stoma dilatation with a lower risk of hypoxia/hypercarbia.
The classical Ciaglia technique has provided the most experience. The inward force produced during dilatation of the tracheal stoma using multiple dilators and tracheostomy tube placement has been reported to be associated with posterior tracheal wall tears and tracheal ring fractures.24
In an attempt to avoid or minimize tracheal damage, single-step dilators, made up of softer materials with hydrophilic surfaces, have been introduced (Blue Rhino kit, Cook Medical, Bloomington, Indiana, USA; Ultraperc kit, Portex; Smiths Medical International Ltd (EMEA), Ashford, Kent, UK; and the Percutan kit, Tracoe Medical GmbH, Frankfurt/Main, Germany). The single-dilator technique claims the following advantages over the multiple-dilator technique:
- The single dilator has a hydrophilic coating which, when wet, reduces friction and thus allows smooth dilatation of the tracheal stoma. The stomal dilatation appears to be quicker and less traumatic.
- The faster technique reduces the time during which dilators and bronchoscope obstruct the airway, reducing the risk of hypercarbia and hypoxia.
- The single-step dilator is flexible, tapering to a soft malleable tip, which will bend to the required angle to follow the direction of the guide wire down the trachea.
- It avoids aerosolization of blood and secretions as dilators are changed. The continuous tamponade effect reduces bleeding during the procedure.
There are a number of other kits commercially available including Fantoni's translaryngeal technique,25 the guide wire forceps dilator technique,26 Percutwist single threaded dilator27 and the recently introduced balloon dilation technique (Blue Dolphin, Cook).28 Several clinical trials have compared these techniques, without any method being shown to be superior.29 Operator experience and patient selection are crucial determinants of procedural complications. For the reasons stated above, the single-dilator technique is currently the most popular in the UK.5 Recently, efforts have also been made to make easier the passage of the tracheostomy tube over a loading dilator without leaving a gap between the tracheostomy tube tip and the loading dilator.
Emergency percutaneous dilational tracheostomy
Until recently, percutaneous dilational tracheostomy has been considered an elective procedure. Increasingly, however, it has been used in emergency situations where orotracheal intubation has failed.30,31 However, in life-threatening situations, this procedure should be undertaken only by physicians with extensive experience in percutaneous dilational tracheostomy. In ‘cannot intubate, cannot ventilate’ scenarios, cricothyroidectomy remains the standard of care until a definitive airway is established. Further studies will be required to confirm whether this method is preferable to surgical tracheostomy. We have recently used the Blue Rhino method for emergency tracheostomy with good results. But, theoretically, this technique may prove unsuitable for patients with obstructing tumours, as what level the tumour extends downwards may be uncertain.
With the reduction in numbers of surgical tracheostomies in the UK,5 there is an issue with training of surgeons and their competence in this technique. This could have an impact on their ability to perform the procedure, especially in an emergency setting.
Contraindications to percutaneous tracheostomy
There are absolute and relative contraindications to PDT dependent on operator and centre experience. Many will coexist and change over time.
Relative contraindications include:
- significant coagulopathy;
- active infection over the anterior neck;
- unstable cervical spine fracture;
- morbid obesity (BMI > 35 kg/m2);
- gross anatomical distortion of the neck;
- previous neck surgery or tracheostomy;
- previous radiotherapy to the neck;
- extensive burns to the neck;
- requirement of high PEEP (>15 cmH2O) or FiO2 > 0.6;
- haemodynamic instability;
- raised intracranial pressure;
- patient unlikely to survive for more than 48 h.
Absolute contraindications include the need for an emergency airway in the presence of a tracheal tumour and children less than 12 years because of the risk of damage to the softer cartilaginous airway.
The number of relative contra-indications to percutaneous dilational tracheostomy (PDT) reduces with increasing experience of the operator, the use of fibre optic bronchoscopy5 and ultrasound imaging of the neck.32 There are specific kits designed for the morbidly obese with long dilators and tubes (Uniperc kit, Smith Medicals).
Ultrasound scanning of the neck and endoscopy
Two trained operators are required for percutaneous tracheostomy: one to perform the procedure and another to manage the airway. Ideally, the procedure should be performed during normal working hours to ensure supervision and support from senior staff members and other specialists, if required.
Ultrasound scanning of the neck prior to percutaneous tracheostomy allows visualization of the anterior neck structures, particularly blood vessels and the depth and angulation of the trachea.32 Useful information about adjacent structures helps with the risk–benefit analysis of surgical versus percutaneous tracheostomy. Imaging can also guide needles and dilators away from at-risk structures.
Endoscopy, using a fibre optic scope passed through the tracheal tube, should be used to guide the correct placement of the introducer needle, guide wire and tracheostomy tube.23 Direct visualization reduces posterior tracheal wall damage and tube misplacement. Many authors have advocated endoscopy during percutaneous tracheostomy, citing a decreased rate of operative complications.33,34 However, the presence of a fibre optic scope may hinder ventilation, increasing the risk of hypoxia and hypercarbia with an associated rise in intracranial pressure in susceptible patients.35 It should be appreciated that bleeding, distortion of structures and obstruction of the visual field with larger dilators may prevent endoscopic visualization of damage until after it has occurred. An alternative approach includes the use of a rigid, small-diameter scope, such as a Bonfil's laryngoscope, which interferes less with ventilation and avoids potential expensive damage to the flexible scope by needle puncture.36
Tracheostomy is not without risk. Complications can be classified into immediate, early and late (Table 1). Bleeding, hypoxia, pneumothorax, trauma to the trachea and surrounding structures and technical failure are common immediate complications. Most complications are reported only as case reports and their frequency appears to be inversely proportional to the experience of the operator.
Major complications are rare but can be devastating owing to the large size of the dilators and difficulties in controlling bleeding or other damage with percutaneous techniques. Limited soft-tissue dissection in percutaneous techniques results in less tissue damage and lowers the risk of bleeding and wound infection compared with surgical tracheostomy. There is always a risk of tracheal damage including rupture and displacement of the tracheal rings, tear of the posterior tracheal wall and formation of a tracheo-oesophageal fistula. All of these may be associated with bleeding and the formation of false passages as well as major air leaks. Modifications in the equipment (single dilator) and improvements in the technique of insertion (routine use of endoscopic guidance) appear to reduce the incidence of immediate perioperative complications.36 The use of ultrasound scanning to examine the vasculature of the neck in relation to the stoma site may further reduce the incidence of complications.32 A correct choice in size and length of a tracheostomy tube is essential to prevent early tube-related complications.37
A number of meta-analyses have compared surgical vs. percutaneous tracheostomy in terms of wound infection, bleeding and overall mortality, as well as major perioperative complications.38,39 The incidence of clinically important wound infection and bleeding is about 5–6%.40 The majority of the meta-analyses suggest that percutaneous tracheostomy reduces the overall incidence of clinically relevant bleeding, wound infection41 and procedural mortality and there is a trend towards shorter duration of translaryngeal intubation prior to performing the procedure.38 Percutaneous tracheostomy also gives a better cosmetic result following decannulation.41,42 Studies have demonstrated a procedural mortality rate approaching zero and morbidity rates around 6–7% with no fatalities attributable to complications, although two procedural fatalities have recently been reported involving intractable bleeding.43,44
Although long-term complications appear uncommon, incomplete follow-up and lack of consistent definitions make conclusions difficult. Uncontrolled studies, however, have found that clinically relevant tracheal stenosis was uncommon after percutaneous tracheostomy.45,46 Tracheal stenosis can occur at either side of the stoma, at the level of the cuff, or at the tip of the tube. The main cause of the stenosis appears to be mucosal ischaemia. Most stenoses tend to be asymptomatic unless they reduce the tracheal lumen by more than 50%. The incidence of clinically significant stenosis has been variably reported in studies, ranging from 2.5 to 10%.47,48 Tracheal stenosis caused by PDT may be significantly closer to the vocal cords than that caused by surgical tracheostomy, making tracheal resection and end-to-end anastomosis very difficult.49 This provides a strong argument for ensuring appropriate levels of stoma formation by passing the introducer needle between the second and third tracheal rings or one space lower under direct endoscopic visualization. However, needle insertion below the fourth tracheal ring poses a risk of tube erosion into adjacent blood vessels. Suprastomal tracheal ring fracture is a common finding in percutaneous techniques, reported in up to 87% of cases. This may encourage local tissue granulation and possibly formation of stenosis and tracheomalacia.50 However, the incidence of subglottic tracheal stenosis following suprastomal ring fractures is not known.
Tracheo-innominate artery fistula is an uncommon but life-threatening complication.51 It is usually fatal unless treatment is instituted immediately. Many reasons have been suggested, including pressure necrosis from a high cuff pressure, tracheal wall trauma and perforation from a malpositioned (or too short) tube tip, low tracheal incision and prolonged tracheostomy. Posttracheostomy bleeding occurring from 3 days to 6 weeks after insertion should be considered to be from a tracheo-innominate artery fistula unless proven otherwise.
Tracheostomy tubes should be removed as soon as possible to regain the normal physiological functions of active coughing, upper airway warming, humidification and filtering of air. Decannulation should be considered when patients demonstrate a satisfactory respiratory drive, a good cough and the ability to protect their own airway. Patients who show no signs of tiring on continuous positive airway pressure or a T-piece with low flow oxygen therapy are candidates for decannulation. Coughing secretions up into the tracheostomy tube is a good sign, whereas generalized weakness and inability to hold the head up are predictors of unsuccessful decannulation. An impaired conscious level also reduces the chances of success. There is a common tendency of leaving tubes in too long while clinicians await the perfect time to decannulate and of time-consuming referrals to speech therapy or physiotherapy. If left too long, it can stimulate mucus production. It should be appreciated that an effective cough relies on the build up of positive pressure within the trachea against a closed glottis and then sudden release to generate a cough. This cannot be achieved with a large-bore cannula open within the trachea. You may be doing your patient a disservice by leaving the tube in situ. It has recently been reported that performance of post-ICU tracheostomy follow-up by an intensivist-led team resulted in timely decannulation of tracheostomies, reducing the hospital length of stay.52
Following decannulation, most tracheostomy stomas are allowed to granulate without suturing. They achieve a functional seal within 2–3 days. These partially healed wounds can be quickly re-opened with artery forceps in the first few days after closure, if necessary. Occasional patients will require ENT referral for tethered scars or a sinus. At long-term follow-up, clinicians should be aware of the rare but significant complication of tracheal stenosis giving rise to respiratory symptoms of stridor, persistent cough and voice changes.
Elective tracheostomies are more commonly performed by the percutaneous route in critically ill patients. Percutaneous tracheostomy reduces the overall incidence of clinically relevant bleeding and wound infection. Single-stage dilatation of the stoma is increasingly performed under endoscopic guidance prior to tracheostomy tube placement. As the optimal timing of tracheostomy remains unclear, physicians at the bedside should consider on a daily basis which patients are likely to benefit from a tracheostomy rather than routinely performing it ‘early or late’. Patients discharged from the ICU with a tracheostomy should be followed up on a daily basis by an intensivist-led team untill decannulation.
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