may be better tolerated and allow a reduction of sedation. As a consequence it facilitates physical therapy, nursing care, and transfer of the ventilated patient out from the ICU setting.
Weaning from mechanical ventilation is also expedited due to the decreased work of breathing from a reduction of airway resistance and dead space.
Other benefits include patient comfort such as the initiation of oral intake, communication, and mobility, and possibly fewer respiratory infections.
Table 6.1 Risks and benefits of tracheostomy.
| Benefits | Risks |
|---|---|
| Secure airway Expedite weaning or transfer from ICU Facilitate nursing care Communication Patient comfort and eating Mobility/physical therapy | Pneumothorax Tracheo‐innominate artery fistula |
Early versus late tracheostomy
Early tracheostomy is variably defined, and generally performed within 4 days of intubation.
Earlier tracheostomy is considered if the likelihood of intubation is recognized to be prolonged beyond 2 weeks.
Patient discomfort secondary to translaryngeal intubation and multiple failed extubation attempts may also support earlier tracheostomy.
The benefits for earlier intervention are not clear. In some studies, such as in patients with traumatic brain injury or subarachnoid hemorrhage, reductions in length of stay (LOS) and pulmonary infections have been seen. However, in these neurosurgical populations, patients are often considered for earlier tracheostomy due to mental status issues and fear of weaning. A review and meta‐analysis also indicated early tracheostomy placement reduced the duration of mechanical ventilation and hospital stay.
There is no definitive mortality benefit for early tracheostomy.
In general, the decision for tracheostomy should begin with an evaluation of the patient within a week of intubation as to the likelihood of extubation in the upcoming week. The first week’s course is often predictive of ventilator dependency.
Open surgical tracheostomy versus bedside PDT
Bedside approaches are performed either as open, cut‐down procedures or via PDT using the Seldinger method. The Seldinger method is essentially a blind procedure done at the bedside.
The primary advantages to the bedside approach are the more efficient use of OR time and the consequent cost savings, which include those of patient transportation and general anesthesia.
Further advantages of PDT include smaller incisions, decreasing the likelihood for poor wound healing, scarring, and peristomal bleeding, and reduced local site infections. The procedure can also be more timely.
LOS in the ICU as well as time to placement of the tracheostomy is significantly shortened with PDT, suggesting further cost savings when using bedside procedures.
Most importantly, major complications and mortality are similar between PDT and open surgical tracheostomy. This is regardless of whether the bedside procedure is PDT or open.
Risk factors
Consent for procedure includes the risks of: pneumothorax (PTX), tracheo‐innominate artery fistula, airway damage and stenosis, bleeding, infection, and death.
Mortality of this procedure is less than 1%, while major morbidity is 5–10%.
Bleeding with PDT is minimal. Prior ultrasonography of the trachea assesses for any smaller crossover veins, which are uncommon but may cause bleeding.
PTX is a serious complication that can be fatal if not immediately recognized and treated. It presents with difficulty in ventilation, hypotension, and/or oxygen desaturation due to tension PTX, and often within minutes of the tracheotomy. Chest tube kits should be readily available during these procedures.
Innominate artery fistula can either be a relatively early or late event, and is a surgical emergency. A surgeon should immediately assess any bleeding from the tracheostomy site since any manipulation of the tube may undo the (possibly life‐saving) tamponade effect on the fistula.
Tracheal stenosis and tracheomalacia can be late complications at the tracheostomy site.
Selection of candidates for bedside PDT
Patient’s history and clinical status
Indication for tracheostomy: failed weaning/extubation, relief of airway obstruction or secretions.
Review surgical history for prior neck surgery, tracheostomy, or radiotherapy to the anterior trachea/neck.
Hemodynamic stability, stable cardiac condition.
Lack of bleeding, intact coagulation profile (preferably INR <1.5 and platelet count >50 000).
Absent severe sepsis.
In making the decision for PDT, it is important to keep in mind that this is an otherwise elective procedure so care must be taken to avoid potential complications.
Examination of candidates
The ideal patient for PDT has a well‐defined anatomy – a long thin neck, with palpable tracheal spaces that can be hyperextended safely. The first criterion safeguards the anatomy for this essentially blind procedure: namely that the tracheotomy is done between the third and fourth tracheal cartilage. The splaying of the cartilage rings is key in the proper positioning of the patient for PDT. In general, patients with recent neck injuries, morbidly obese necks, and previous tracheostomy or neck irradiation are contraindicated for bedside PDT. Anterior infection or burns of the neck, as well as goiter or masses, are also contraindications. Such patients are better relegated to an open surgical procedure.
If cervical spinal injury is present, PDT is contraindicated, and if in question, neurosurgical or neurological clearance for hyperextension would be necessary. Patients whose neck cannot be hyperextended such as patients with cervical osteoarthritis are also better treated in the OR. Note: PDT is not meant for acute emergency tracheotomies where the more cephalad cricothyroid membrane is the anatomy of choice for the tracheotomy.
The physical exam concentrates on identifying adenopathy, burns, infection, masses, scars (previous surgery or old tracheostomy scar), trauma, and thyromegaly (goiter). Review the skin surface for small veins to avoid lacerating during the procedure. If available, US examination can assist in identifying any aberrant vasculature or other anomalies that may defer PDT to an operative procedure.
Assess the extent of neck hyperextension. Is the neck short and thick? Is extension not possible due to cervical arthritic changes? Inability to
