1. TRACHEOSTOMY CARE AND EMERGENCIES

2. Indications for tracheostomy  Airway  Severe Facial Trauma,  Head and neck cancers / tumours  Acute Angioedema and Inflammation of the head and neck.  Ventilation  Respiratory wean / tracheal toilet – ICU setting (performed in 8-24% of ICU patients)  Need for long-term mechanical ventilation – often neurological indication  Obstructive Sleep Apnoea seen in patients intolerant of Continuous Positive Airway Pressure (CPAP) therapy.  Emergencies  Failed orotracheal or nasotracheal intubation, either tracheotomy or cricothyroidotomy may be performed.

3. ICU Tracheostomies  ITU indications:  Prevents laryngeal / upper airway damage from prolonged translaryngeal intubation.  Access to the lower airway for suctioning  Stable airway for long-term weaning  Vs ETT reduces resistive and elastic work of breathing  Easier mouth care  Earlier entral feeding and mobilisation  Improved comfort and reduced sedative usage  Complications:  Bleeding, infection, stenosis, death  Need to identify patients early:  Avoid tracheostomy in patients who can be weaned quickly  Perform tracheostomy early in patients who will need long-term mechanical ventilation / slow weaning

4. Tracheostomy Tube Types  Single or double lumen  Double lumen – removable inner tube for cleaning – considered safer  Uncuffed  Air can flow through the tracheostomy or the oropharynx  Cuffed  Allows for IPPV  Prevents aspiration  Fenestrated tubes  Allows increased airflow through the upper airway giving the patient the ability to speak and cough  Can be blocked by using and un-fenestrated inner tube to allow IPPV and prevent aspiration.

7. Anaesthesia for a surgical tracheostomy  Pre-op  Consider using ICU vent and TIVA  STOP NG feed  Correct coagulopathy  Peri-op  Head ring, neck extension and head elevation  Tape tube and keep pilot balloon available  Aspirate NGT and oropharynx  Preoxygenate prior to tube change ! RISK OF AIRWAY FIRE!  Prior to incision of trachea either withdraw or advance tube to avoid damage to cuff.  Surgeon will direct withdrawal of ETT under direct vision to allow insertion of tracheostomy, don’t complete withdraw until surgeon confirms position within trachea  Attach circuit to tracheostomy and confirm position / ability to ventilate.

8. Surgical vs Percutaneous  Bedside Percutaneous Tracheostomy first performed by Ciaglia in 1985.  Absolute contraindications: need for an emergency airway in a pt with a tracheal tumour, children <12yrs – soft tracheal cartilage – increased risk of injury.  Relative contraindications: coagulopathy, active infection over neck, unstable C- spine, morbid obesity, anatomical distortion, previous neck Sx / Rx, trauma or burns to neck, high PEEP or FiO2, elevated ICP.  Proposed advantages: relatively simple procedure, easier to perform, shorter procedure time, eliminates time, cost and morbidity associated with transfer to theatre.  RCT’s comparing surgical and percutaneous tracheostomies:  Advantage for percutaneous in terms of: wound infection, bleeding, mortality and scarring  Equivocal in terms of: false passage and subglottic stenosis.  Disadvantage in terms of: decannulation / obstruction.  Comparison of the various percutaneous techniques has demonstrated that a single-step dilator technique is the most reliable in terms of safety and success rate.  Other questions:  Bronchoscope  USS of neck  LMA vs ETT

10. TracMan  RCT in the UK between 2004 and 2011 published in 2013  Compares early and late tracheostomy for patients predicted to require >7 days of mechanical ventilation within the first 4 days of ITU admission.  909 pts randomised, 455 for early tracheostomy (within 4 days of ITU admission), 454 for late tracheostomy (more than 10 days post ITU admission)  Main Findings:  No difference in mortality at 30 days, ICU discharge, hospital discharge, 1yr and 2yrs.  No difference in duration of mechanical ventilation  No difference in length of ICU stay (for ICU survivors)  In the late group only 45% of patients had a tracheostomy – in the majority of patients not receiving a tracheostomy this was because it was no longer required at 10 days.  There was a modest reduction in sedative use in the early group but the majority of patients continued to receive sedatives after procedure.  Poor ability of clinicians to predict need for long-term ventilation.

13. 1. The ventilator liberation process: update on technique, timing, and termination of tracheostomy. Respiratory Care October 1, 2012 vol. 57 no. 10 1626-1634 2. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-2129 3. Tracheostomy management Contin Educ Anaesth Crit Care Pain (2008) 8 (1): 31-35.