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Open Tracheotomy in the Intensive Care Unit

See also:
     Percutaneous Tracheotomy - Dilation
     Percutaneous Tracheotomy Case Example
     Tracheotomy - Tracheostomy

The operation of tracheotomy occupies a most anomalous position. There is no other justifiable life-saving operation whose reign of usefulness has not been extended by modern methods.

Chevalier Jackson, American Laryngological, Rhinological, and Otological Society meeting 1909

Introduction: History of Tracheotomy

Tracheotomy has a long history in medicine, first described 4,000 years ago, in the Rig Veda, a Hindu book of medicine in 2,000 B.C. (Szmuk et al, Int Care Med 2008). It was performed in ancient Egypt and Greece, prior to being rediscovered in the Renaissance by Antonio Brasavola who performed a tracheotomy on a patient with airway obstruction from tonsillar hypertrophy in 1546 (Szmuk et al, Int Care Med 2008).

The expanded use of general anesthesia in the early 1900’s included its application  to patients needing tracheotomy for airway obstruction. Chevalier Jackson contended that the practice of performing the procedure  with administration of general anesthesia was responsible for tracheotomy falling out favor due to frequent episodes of rapid respiratory collapse. Following Jackson’s presentation in 1909 of his series of 100 tracheotomies done with meticulous technique under local anesthesia, tracheotomy regained favor (Jackson, Trans Am Lary Rhin Oto, 1909).  

Primary indications for tracheotomy are relief of upper airway obstruction and to provide a mechanism for long term ventilation. Conversion from oro- or naso-tracheal intubation to tracheotomy  improves pulmonary toilet and  reduces the need for sedation and usually reduces  ventilator requirements. The number of tracheotomies performed in the U.S. has nearly doubled in the past two years, to more than 100,000 per year, in conjunction with a rise in the use of mechanical ventilation (Cheung et al, Resp Care 2014). Given the majority of tracheotomies in the U.S. are now performed due to need for prolonged mechanical ventilation, a major paradigm shift has occurred in demographics of patients treated with tracheostomy over the past two decades.

Percutaneous Dilatational Tracheotomy vs Open Tracheotomy

Ciaglia described the percutaneous dilatational tracheostomy (PDT) in 1985 (Ciaglia et al, Chest, 1985). The goal of this technique was to reduce the incision size to allow the smallest possible tracheostomy tube, avoid hemorrhage, and decrease infection rates and could be performed in the intensive care unit (ICU) without anesthesia staff present. The PDT is based on a Seldinger technique whereby the skin is incised and a needle is placed in the tracheal lumen followed by a guidewire through the needle and successively larger dilators and ultimately the tracheostomy tube itself (Ciaglia et al, Chest, 1985). This technique has since been modified slightly with use of flexible fiberoptic bronchoscopy through the endotracheal tube to confirm intraluminal placement of guide wire and dilators as well as availability of the equipment needed in kit form. PDT has now been accepteded as the standard of care in the critical care literature and is recommended in guidelines and expert panels (Trouillet et al 2018).  It has been further modified by some practitioners who now routinely use of ultrasound to evaluate the neck to ensure accurate knowledge of the patients anatomy in preparation for a PDT (detailed below).

PDT is typically performed by ICU staff or trauma surgeons, and not otolaryngologists. In fact, a recent study found that at the Cleveland Clinic  0% of tracheotomies performed by Otolaryngologists used the PDT method (Bowen et al, Am J of Oto H&N, 2017). The primary concern for PDT is that pertinent anatomy is not visualized. There have been multiple deaths from hemorrhage (typically due to exposed innominate artery) and loss of airway reported after PDT (Divisi et al Resp Med, 2015). More routine use of ultrasound in the process may assist in localization of aberrant vascular anatomy and should be considered (see below for further details). 

Two of the primary stated benefits of PDT are that the critically ill patient does not need to be transported to the operating room which has an inherent set of risks and that an anesthesia provider and operating room is not required which raises costs for the procedure. For this reason, there has been a push towards use of bedside open tracheotomy (OT). Yoo et al compared 169 randomized patients who had tracheotomy at the bedside or in the OR (Yoo et al Laryngoscope, 2011). Among those subjects who had bedside OT, there was significantly decreased time to tracheotomy (1.5 vs 3 days), significantly decreased cost ($4,575 less), and a trend towards shorter ICU stay which was not significant (Yoo et al Laryngoscope 2011). The authors found no differences in safety or complication rates.

There have been several studies comparing PDT versus OT and overall results are mixed. Putensen et al performed a systematic review and meta-analysis of 22 studies and found  PDT decreased “inflammation” of stoma and decreased time of procedure, they found that PDT was associated with increased number of “technical difficulties” (Putensen et al, Crit Car, 2014). Another more recent meta-analysis found no differences between PDT or OT in mortality or complications, but did find decreased infections and time of procedure for PDT (Johnson-Obaseki et al, Laryngoscope 2016). A third meta-analysis again found decreased rates of infection, scarring and  cost associated with PDT but  a significantly increased risk for post-procedure complications including inadvertent decannulation and airway obstruction (Higgens et al, Laryngoscope 2007). In summary these findings seem to indicate that PDT has a lower rate of infection and decreased time and cost compared to OT. However, and perhaps most importantly, in the majority of these meta-analyses, the studies compared OT in the OR versus PDT in the ICU. Clearly, costs will be higher when the procedure is performed in the OR and there will likely be selection bias for patients selected to have a procedure done in the ICU versus the OR.

There has been one randomized controlled trial that specifically controlled for selection bias. Massick et al studied 164 patients who met criteria for tracheotomy and selected100 patients who met criteria for a procedure to be performed at bedside while the other 64 had OT performed in the OR (Massick et al Laryngoscope 2001). Bedside criteria included favorable anatomy and illness severity. The 100 bedside subjects were randomized to either PDT or OT at bedside. A single team did all tracheotomies. They found that PDT was associated with significantly increased percentage of perioperative complications including hemorrhage and requirement to convert to open tracheotomy. In addition PDT was associated with increased postoperative complications including loss of airway and inability to replace tracheotomy tube which lead to a death (Massick et al Laryngoscope, 2001). The costs for bedside PDT were higher than bedside OT given that a flexible bronchoscope was required as well as a proprietary kit. Time of procedure was the same. The tracheotomies performed in the OR had significantly higher complications and costs than either bedside technique.

Ultrasound has emerged as a valuable adjunct to bedside tracheotomy. Vital structures can be identified and avoided using ultrasound. One study showed that 41% of patients had a vessel detectable on ultrasound within the typical anterior neck region targeted for percutaneous tracheotomy (Rees et al 2017). A study by Rajajee et al. compared tracheotomies performed with or without ultrasound and found that the use of ultrasound led to significantly decreased number of complications (Rajejee et al 2015). Ultrasound could be used at bedside for either patient selection or during procedure for indentification of vital structures. 

In summary, there is some data that PDT decreases infection rates but is associated with increased complications rates. Performance of tracheotomy at the bedside, either open, or percutaneous, significantly decreases costs and time of procedure compared to tracheotomy in the operating room. Open tracheotomy performed at bedside in the ICU is a method that has several benefits. In the well-selected patient, open tracheotomy at bedside has the following benefits: 1) decreased costs, 2) decreased time to operation, 3) no need to transfer critically ill patient, 4) decreased complication rates, both perioperatively and postoperatively compared to PDT. Open tracheotomy at bedside as the following disadvantages: 1) need for transportation of specialized OR equipment to bedside, 2) reported increased infection rates compared to PDT.

Protocol for Open Tracheotomy at Bedside

  1. Patient selection: 

    1. Indications for tracheotomy in general will not be discussed fully here, but include upper airway obstruction and long-term need for mechanical ventilation. Need for tracheotomy should be determined in conjunction with the patient’s family and ICU team. 

    2. Massick et al (Laryngoscope 2001) propose the following selection criteria for performance of tracheotomy at bedside:

      1. Favorable anatomy including: palpable cricoid > 3 cm above sternal notch and acceptable head extension

      2. History of uneventful translaryngeal intubation

      3. Acceptably reasonable ventilator settings including PEEP < 10 cm H20

  2. Equipment and Supplies Required: 

    1. Equipment

      1. Triad bipolar cautery with foot pedal

      2. Headlights x 2

      3. Mayo stand

      4. Suction with suction tubing

      5. Ultrasound for identification of vascular anatomy per surgeon preference

    2. Trays

      1. Tracheotomy tray

      2. Silverglide bipolar cautery tip tray

    3. Consumable supplies

      1. Mayo Stand Cover

      2. Small Sharps Box

      3. Kuettners X 2

      4. Bovie Pencil

      5. Guarded Tip

      6. Yellow Needle Tip

      7. Control Top Syringe

      8. 27g Needle

      9. 18g Needle

      10. Gowns (L and XL)

      11. Gloves (depends)

      12. Towels x 2

      13. ENT Split Drape

      14. Bipolar Cord

      15. Normal Saline

      16. 8-0 Cuffed Shiley x 2

      17. 6-0 Cuffed Shiley x 2

      18. 10ml Syringe

      19. Trach Strap

      20. Grounding Pad

      21. 1 pack (10 rayteks)

      22. 1 pack laps (5)

    4. Suture

      1. 2-0 silk ties

      2. 3-0 silk ties

      3. 2-0 silk FS x 2

      4. 3-0 silk SH x 2

  3. Staff needed

    1. ICU fellow or attending to provide sedation

    2. Respiratory therapist for ventilator assistance

    3. Surgeon(s)

    4. Surgical assistant (optional)

  4. Procedure: After appropriate sedation of patient by ICU staff, tracheotomy is performed in standard fashion, as described elsewhere

  5. Postoperative care: Per surgeon preference, performed in a standard fashion as with any open tracheotomy, as described elsewhere

References/Suggested Reading

  1. Szmuk, Peter, et al. "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age." Intensive care medicine 34.2 (2008): 222-228.
  2. Jackson, Chevalier. "Tracheotomy." The Laryngoscope 19.4 (1909): 285-290.
  3. Cheung, Nora H., and Lena M. Napolitano. "Tracheostomy: Epidemiology, Indications, Timing, Technique, and OutcomesDiscussion." Respiratory care 59.6 (2014): 895-919.
  4. Ciaglia, Pasquale, Rita Firsching, and Cynthia Syniec. "Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report." Chest 87.6 (1985): 715-719.
  5. Bowen, Andrew J., et al. "Is tracheotomy on the decline in otolaryngology? A single institutional analysis." American journal of otolaryngology (2017).
  6. Trouillet, Jean-Louis, et al. "Tracheotomy in the intensive care unit: Guidelines from a French expert panel: The French Intensive Care Society and the French Society of Anaesthesia and Intensive Care Medicine." Anaesthesia Critical Care & Pain Medicine (2018).
  7. Yoo, Donald B., et al. "Open bedside tracheotomy: Impact on patient care and patient safety." The Laryngoscope 121.3 (2011): 515-520.
  8. Putensen, Christian, et al. "Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis." Critical Care 18.6 (2014): 544.
  9. Higgins, Kevin M., and Xerxes Punthakee. "Meta‐analysis comparison of open versus percutaneous tracheostomy." The Laryngoscope 117.3 (2007): 447-454.
  10. Massick, Douglas D., et al. "Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy." The Laryngoscope111.3 (2001): 494-500.
  11. Rees, James, et al. "The ultrasound neck imaging for tracheostomy study: A study prompting ultrasound screening prior to percutaneous tracheostomy procedures to improve patient outcomes." Journal of the Intensive Care Society (2017).
  12. Rajajee, Venkatakrishna, Craig A. Williamson, and Brady T. West. "Impact of real-time ultrasound guidance on complications of percutaneous dilatational tracheostomy: a propensity score analysis." Critical Care 19.1 (2015): 198.
Monday, April 2, 2018