TRACHEOSTOMY IN ICU:

WHO SHOULD DO IT ?
THE SURGEON OR THE
ANESTHESIOLOGIST ?
Dr. Ion MICLEA PhD, MD
Dr. Robu Cornel
Prof.Univ.Dr. Serban BUBENEK PhD, MD
Institutul de Urgenta pentru Boli Cardiovasculare “Prof.Dr.C.C.Iliescu”
 Terminology

 1649
 The word “tracheostomy”
 Derived from Greek
 from words “tracheia arteria” – ”rough artery”
 and “stoma” – “mouth”
 History
• 1500 B.C.
• First reference
• Hindu book of medicine “Rig Veda”
• 330 B.C.
• Calistene described Alexander the Great “punctured the trachea of a soldier with the
point of his sword to relieve choking”
• 1546
• Antonio Musa Brasavolo
• First successful tracheotomy
• 1860
• Evans Conway
• Reported “only a 68% mortality”
• 1909
• Dr. Chevalier Jackson
• Established safe guidelines
• Basics still used today
• 1953
• Seldinger technique
• 1957
• Sheldon et al.
• First described Percutaneous Tracheostomy
 History
• 1985
• Ciaglia et al.
• Described the percutaneous dilatational technique
• 1989
• Paul et al.
• First description of Bronchoscope-assisted percutaneous
tracheostomy
• Present days
• More than 600 publications on “percutaneous tracheostomy” since
1985
• Dilatational technique - Gold standard (Ciaglia)
• Percutaneous tracheostomy gaining acceptance
Cheng E, Fee WE Jr.. Ann Otol Rhinol Laryngol. Sep 2000;109(9):803-7
 Indications of tracheostomy
• Need for prolonged mechanical ventilation in cases
of
 Pneumonia refractory to treatement
 Severe chronic obstructive pulmonary disease
 Acute respiratory distress syndrome
 Severe brain injury
 Multiple organ system dysfunction

The Council on Critical Care of the American College of Chest

Physicians recommends tracheostomy in patients who are expected to
require mechanical ventilation for longer than 7 days. (1999)
 Indications of tracheostomy
 Airway obstruction due to following
 Inflammatory disease
 Congenital anomaly (laryngeal hypoplasia, vascular web)
 Foreign body that cannot be dislodged with Heimlich and
basic cardiac life support maneuvers
 Supraglottic or glottic pathologic conditions (neoplasm,
bilateral vocal cord paralysis)
 Laryngeal trauma or stenosis
 Facial fractures that may lead to upper airway obstruction
 Edema (trauma, burns, infection, anaphylaxis)

Scott E Brietzke MD, Michael S Kong MD, Annual Meeting of the American Academy of
Otolaryngology - Head and Neck Surgery Foundation, 2008
 Indications of tracheostomy
 Need for improved pulmonary toilet
 Inadequate caugh due to chronic pain or weakness
 Aspiration and the inability to handle secretions

 Prophylaxis (preparation for extensive head

and neck procedures and the convalescent
period)
 Severe sleep apnea not amendable to
continuous positive airway pressure devices
 Benefits of tracheostomy
 Facilitates
 Weaning from positive pressure ventilation and sedation
 Removal of secretion by aspiration
 Long-term airway management

 Prevents aspiration from the pharynx or

gastrointestinal tract
 Separates the oropharyngeal flora from the
pulmonary flora

F. Blot, C. Melot, CHEST, 2005, 1347-1352

 Contraindications of tracheostomy
 Absolute contraindications
 Patientsage younger than 8 years
 Necessity of emergency airway access because of acute
airway compromise !?
 Gross distortion of the neck anatomy due to
 Hematoma
 Tumor
 Thyromegaly
 High innominate artery
C. Russell, B. Matta, Cambridge University, 2004
 Contraindications of tracheostomy
 Relative contraindications
 Patient obesity with short neck that obscures neck landmarks
 Medically uncorectable bleeding diatheses
 Prothrombin time or activated partial thromboplastin time
more than 1,5 times the reference range
 Platelet count less than 50.000/µl
 Bleeding time longer than 10 minutes
 Need for positive end-expiratory pressure of more than 20
cm of water
 Evidence of infection in the soft tissues of the neck at the
prospective surgical site
C. Russell, B. Matta, Cambridge University, 2004
 Advantages of percutaneous
tracheostomy over surgical tracheostomy
 A relatively simple technique suitable for trained staff in the
critical care setting
 It does not require an operating theatre
 Infection rates for percutaneous tracheostomy range from 0 to
3,3%, whereas those for open tracheostomy have been reported
to be as high as 36%
 Stenosis rates for percutaneous tracheostomy range from 0 to
9%
 Small and neat stoma of dilatational tracheostomy generally
results in a more cosmetic scar
Freeman BD, Isabella K, Cobb JP, et al. A prospective, randomized study comparing percutaneous with surgical
tracheostomy in critically ill patients. Crit Care Med. May 2001;29(5):926-30
Advantages of surgical tracheostomy
over percutaneous tracheostomy
 Emergency tracheostomy (controversial) ?
 Difficult to palpate the anatomical landmarks
 Very obese patients
 Short or bull neck
 Enlarged thyroid
 Nonpalpable cricoid cartilage
 Gross deviation of trachea
 Infection at or near the intended site for tracheostomy
 In pediatric age group (controversial)
 Previous neck surgery may distort the anatomy
 Unstable cervical spine fracture
 Required PEEP>15 cm H2O, as oxygenation may be compromised during
the procedure ?
 Malignancy at the site of tracheostomy
 Uncontrolled coagulapathy, considered as a relative contraindication
Complications of percutaneous
tracheostomy

 Similar to surgical procedure

 The incidence is lower
 Complications:
 Early complications
 Late complications

Michael W. Sicard, M.D. , Baylor Collage of Medicine, 1994

Early complications of tracheostomy
 Hypoxia during the procedure, due to failure of ventilation
 Pneumothorax, pneumomediastinum, creation of false passage, and
subcutaneous emphysema, due to the placement of the tracheostomy tube
in the paratracheal space
 Damage or injury to the posterior tracheal wall may lead to tracheo-
oesophageal fistula
 Major bleeding is unusual
 Minor bleeding can usually be controlled by pressure or occasionally suture
 Haemorrhage into the airway is potentially dangerous as it may result in a
blood clot obstructing the airway
 Needle puncture on the lateral wall of trachea may lead to stenosis
 Secondary haemorrhage may occur from infection or erosion of vessels
Late complications of
tracheostomy

 Subglottic stenosis – the incidence

of subglottic stenosis is lower in
percutaneous tracheostomy than that
in open surgical procedure
 Equipment for percutaneous
tracheostomy
 Portex kit for percutaneous tracheostomy
 Scalpel
 14 G Cannula with needle
 10cc syringe
 Guidewire with introducer
 Dilator
 Guidewire dilating forceps
 Tracheostomy tube and obturator with lumen
 Two cotton tapes
 Portex
percutaneous tracheostomy set
 Videolaryngoscopes
GlideScope®

 GlideScope non-glare color Video Monitor

 Video cable
 Reusable GVL
 Cobalt Video Baton
 GlideRite rigid stylet
Anatomy of the larynx
 GlideScope
videolaryngoscope
 Videolaryngoscopy during
percutaneous tracheostomy
 During percutaneous tracheostomy, correct
positioning of the endotracheal tube is important
 During the procedure it is possible to puncture the
cuff with the needle
 Tracheal tube cuff puncture can lead to
 Failure of ventilation
 Loss of positive end-expiratory pressure
 Posible aspiration of gastric contents, blood or secretions

M. Gillies, J. Smith and C. Langrish - British Journal of Anaesthesia 2008 101(1):129

 Videolaryngoscopy during
percutaneous tracheostomy
 Under videolaryngoscopy the
endotracheal tube can be
withdraw, until the cuff is visible
at the vocal cords
 After that, the tube is manually
held in place while the procedure
is carried out
 Videolaryngoscopy has been
demonstrated to give equivalent
or superior laryngeal visualisation
in routine and difficult airways
Vocal cords view during
videolaryngoscopy
 Advantages of this technique
 Videolaryngoscopy offers good visualisation of
the larynx even with the cervical spine fully
extended
 Tube position can be visualized continuously
 The shape of the Glidescope blade causes
minimal interference with the conduct of the
tracheostomy
 The screen can be positioned to be in view of both
operators
Richard M. Cooper, John A. Pacey Michael J. Bishop and Stuart A. McCluskey – Canadian Journal of
Anesthesia, 2005, 191-198
 Description of the technique
 The patient should be adecquately
anesthetised, to avoid movements,
and monitored using standard
techniques
 The neck is extended by placing a
fluid bag, or a sandbag, or a pillow
under the shoulders
 The area around the intended site is
cleaned with antiseptic solution
 The area is surrounded by sterile
drapes
 Description of the technique

 The anesthetist that manages

the airway of the patient
prepares the
videolaryngoscope

• He also has aspiration equipment

and different sizes of endotracheal
tubes
 Description of the technique
 The patient should be preoxygenated by
ventilation with 100% oxygen for at least 5
minutes before starting the procedure
 The anesthetist that performs the tracheostomy
is sterile equiped
 He is the one that surrounds the area with
sterile drapes
 Description of the technique
 The anesthetist that controls the
airway should:
 Suction the pharynx
 Deflate the cuff of the
endotracheal tube
 Withdraw the tube, under
videolaryngoscopy, until the
cuff is seen between the vocal
cords
 Reinflate with the cuff entirely
above the vocal cords
 Continue mechanical
ventilation of the patient
 Description of the technique
 The anesthetist that performs the
tracheostomy should:
 Locate the thyroid cartilage between
thumb and forefinger
 Identify and mark the anatomical
landmarks
 Thyroid cartilage
 Cricoid cartilage
 Tracheal rings
 Sternal notch
 Possible insertion sites
 The ideal site is between the second
and third tracheal rings, although a
space one higher or lower may be
employed
 Description of the technique
 The anesthetist that performs the
tracheostomy should:
 Introduce the needle between the
tracheal rings until the position
of the needle tip in the trachea is
confirmed (loss of resistance)
 The needle is withdrawn, the
14G cannula is left in place
 the flexible guidewire is inserted
through the cannula, and the
position is checked using the
videolaryngoscope
 The 14G cannula is withdrawn,
the guidewire is left in place
 Description of the technique
 The dilator is slid over the wire, through
the soft tissues into the trachea
 With gentle sideways movement of the
dilator, push the dilator forward to
penetrate the anterior wall, dilating both
the tissues and tracheal wall
 The dilator is now withdrawn, and the
guidewire dilating forceps is introduced
 Using two hands, open the forceps to
dilate the tracheal wall sufficiently to
accept the tracheostomy tube
 Withdraw the forceps in the open position
 The tracheostomy cannula (tube) is slid
over the guidewire into the trachea
 If correct positioned, the guidewire and
the obturator with lumen are withdrawn
 Description of the technique

 Inflate the cuff of the tracheal

tube
 Suction the trachea and
tracheostomy tube to establish a
clear airway
 Transfer the breathing system to
the tracheostomy tube
 Description of the technique

 Confirm successful tube

placement
 Secure the tracheostomy tube
with the supplied cotton tapes
 Description of the technique

 Withdraw the
endotracheal tube
after confirmation
of correct placement
of the tracheostomy
tube under
videolaryngoscopy

Juan D. Pulido, MD*, Faisal Usman, MD, James D. Cury, MD, Abubakr A. Bajwa, MD, Kathryn Koch, MD and Luis Laos, MD -
University of Florida, Jacksonville, FL – 2009, CHEST
 Our experience
ICU in cardiac surgery
2001- 2017 = 287 percutaneous tracheostomies
 2001-2009 – a number of 118 percutaneous tracheostomies were
performed, with three incidents:
 1-false passage
 1-damage of the posterior tracheal wall with tracheo-oesophageal fistula
 1-tracheal stenosis ( treated with Montgomery canula for 1 year)

 Nov.2009- March .2017- a number of 169 percutaneous tracheostomies

were performed under videolaryngoscopic guidance ( GLIDESCOPE®)
Results APTT
Results INR
When were performed the PDTV ?

15.07 (±8.41) days

EARLIER is BETTER !
 Results
 No incidents resulting from the technique were
observed

 No failure of the ventilation/ loss of the airway

access

 No bleeding at the insertion site

 No infection at the insertion site

 Comments
 Mean days until tracheostomy
15.07 (±8.41) days
 After reintubation
 Long sedation due to neurological disfunction after deep
hypotermic cardiocirculatory arrest
 Intra aortic baloon pump maintained for 7 days in
cardiogenic shock
 Severe sepsis/septic shock occuring after SIRS+low/
inadequate cardiac output
 Surgical complications at distance from initial intervention
 Stroke

 Surviving rate 48 %
 Conclusions
Video assisted laryngoscopy - traheostomia
•Safe and comfortable manoever for the second operator

•Confidence for the first operator

•No risk of “short time crisis”

•No ventilation - air leak
•Need for ET change
•!!!!!! ICU patient- possible difficult (re)intubation

•Tube position can be visualized continuously

•minimal interference with the conduct of the tracheostomy

•eliminates the need for bronchoscopic guidance

•Low complications risk

 Endconclusion
End

In the absence of absolute contraindications

THE ANESTHESIOLOGIST SHOULD PERFORM

ALL TRACHEOSTOMIES IN THE ICU
UNDER VIDEOLARONGOSCOPY.
THANK YOU !