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title: Percutaneous Tracheostomy author: "Callum Taylor" output: html_document: css: styles.css tags: notebook: 🌑-FFICM

Percutaneous Tracheostomy

Benefits of Tracheostomy:

  • Patient Comfort
  • Reduced Sedation Requirement
  • Decrease in Dead Space 1

Benefits of Percutaneous Tracheostomy:

  • Can be done more easily on ICU, avoiding transfer problems
  • Can be done by intensive care physicians 1

Benefits of Surgical Tracheostomy:

  • Can be done more easily on people with more difficult airways 1

Risks of Tracheostomy

  • Both have similar complication rates. Percutaneous has a bit less infection. 1
  • It's the transfer to theatre that may increase the risk of complications. 1

Landmarks

3

Technique

  • Patients need assessment for airway prior to insertion
  • The insertion uses a seldinger technique.
  • You need 3 people (Bronch, Trach, Assistant)
  • You need capnography.
  • One person pulls back the tracheal tube by the endoscopist under direct vision with either the laryngoscope or the bronchoscope until it's at the laryngeal inlet.
  • The other person prepares the skin with chlorhexidine/iodine. The area is draped. Local is infiltrated (local with adrenaline
  • Identify the cricoid cartilage and the sternal notch
  • Make a vertical 2cm incision between these points.
  • Blunt dissection of subcut/deeper tissues down to trachea,
  • Feel up to tracheal rings
  • Visualise needle point with bronchoscope
  • Needle/cannula into trachea at second or third tracheal rings
  • Use bronchoscope to visualise needle/cannula and optimal positioning.
  • You want it between tracheal rings in midline.
  • You want to watch post trach wall during dilatation.
  • You then wire cannula
  • Take needle out
  • Place dilator on wire
  • On portex, some traction on inner stylet for dilator
  • Then second dilator (again with backwards traction)
  • With the horn shaped dilator, roll it in following curve rather than a direct push
  • Afterwards you can scope down the tracheostomy to check good positioning between tube and carina.2

Timing

  • Early would be 2-5 days
  • Late would be 8-10 days 1
  • Earlier tracheostomy (as in <10 days) may have greater survival, better weaning, and earlier ventilator free. But other studies say no evidence on mortality.
  • TracMan - 909 patients, no difference in abx use, VAP rates, ICU length of stay, moderate reduction in sedatives, no change in mortality. 1

Complications

Somewhere between 2-20% rate.

Immediate:

  • Major bleeding
  • Pneumothorax
  • Post Tracheal Wall Damage
  • Tracheal ring fracture -> Tracheal Stenosis
  • False Passage
  • NAP 4 found one failure causing brain damage. 1

Early

  • Displaced/Obstructed
  • Dypnoea, hypoxia, rapid deterioration 1

Late

  • Tracheal Stenosis, originating from cuff pressures
  • Can require tracheal reconstruction surgery. 1

Sources

  1. Percutaneous tracheostomy. Revalidation For Anaesthetists. Bisanth Batuwitage. Stephen Webber. Alastair Glossop. 2014. ↩↩↩↩↩↩↩↩↩↩

  2. Neil Brain. 2021/08/31 ↩

  3. Deranged Physiology ↩