Tracheostomy

Advantages of tracheostomy

European surveys investigating the use of tracheostomy in critically ill patients reveal heterogeneity regarding techniques, timing, operator experience, and settings. Tracheostomy offers many clinical benefits for patients with respiratory failure or individuals requiring prolonged MV or airway protection because of neurologic dysfunction. Compared with OTI, it provides safer airway protection and increases patient mobility by decreasing the risk of accidental extubation because of more effective securing of the tracheal cannula: patients with tracheostomy have a 1% incidence of accidental decannulation, compared with a rate of 8%–21% of accidental orotracheal tube dislocation. Moreover, because the internal cannula is not affected by head and neck movement, the occurrence of lesions resulting from tracheal mucosal abrasion and laryngeal damage is low.

Additionally, easier airway suctioning and secretions management improve pulmonary secretion management and oral hygiene; therefore tracheostomy allows better patient comfort that might facilitate communication with family members and nurses. Patients can be mobilized earlier and more easily, with faster return to oral feeding, shorter nasogastric tube dwell time, ^, and reduced risk of tracheoesophageal fistula occurrence.

Use of a tracheostomy tube can aid in weaning from MV, because the direct approach to the trachea (with an internal diameter greater than in the translaryngeal approach) and reduced length all reduce airflow resistance; it also allows faster resumption of autonomous respiration, with less use of sedative agents, fewer days on the ventilator, shorter length of stay in the ICU, and reduced use of resources. ^{, ,} Although PT continues to gain acceptance as the method of choice, no single technique has been shown to be superior to another in any clinical situation. Furthermore, PT has a steep learning curve and requires mastery of procedural skills and extensive expertise.

Percutaneous dilational tracheostomy vs. Surgical tracheostomy

Tracheostomy techniques are evolving and improving. Two basic methods are available: PT and ST. The choice of whether to use one or the other depends on available resources, operator experience, and degree of patient complexity.

ST presents a similar risk of operative complications (minor or major hemorrhage, tracheo-innominate fistula, subglottic stenosis, oxygen desaturation, subcutaneous emphysema, pneumothorax, accidental decannulation, and airway loss) compared with PT.

Several meta-analyses (Delaney and colleagues on 1212 patients, Higgins and Punthakee on 1000 patients enrolled in 15 prospective randomized controlled trials [RCTs], and more recently, Putensen and colleagues who tested 14 RCTs on different PT techniques versus ST in 973 patients) reported a significant reduction in wound infection and stoma inflammation in PT; the latter is also performed faster even if associated with increased technical difficulties, although the benefits were found in studies using the multiple dilators technique (MDT), which is now replaced by the single-step dilation tracheostomy (SSDT) technique.

Based on the analysis of different European surveys about the use of tracheostomy in critically ill patients, a wide heterogeneity regarding techniques, timing, operator, and structures used to perform the procedure can be observed.

Surgical techniques

ST in European ICUs is less common than PT; meanwhile, elsewhere it is equally distributed.

ST is prevalent in surgical ICUs: surgeons performed 61% of STs in Germany and 44% of all tracheostomies in the Netherlands. In an Italian survey, a dedicated team involving more than one intensivist and a nurse performed 62.6% of all tracheostomies.

Most STs were performed in operating rooms. In Germany, 28% of STs were performed in the ICU, whereas in the Netherlands the percentage was lower. In 42% of French ICUs, surgeons always performed tracheostomies (in France, ST remains largely preferred).

Although PT has become a common procedure in patients undergoing elective tracheostomy, in the case of long-term MV, ST remains the method of choice in selected critically ill patients presenting with distortion of neck anatomy, prior neck surgery, cervical irradiation, maxillofacial or neck trauma, morbid obesity, difficult airway, or marked coagulopathy (e.g., patients undergoing heparin treatment during extracorporeal membrane oxygenation support). ST can be also safer when anatomic landmarks are difficult to palpate, the patient presents with a malignancy at the site of insertion, or if emergency tracheostomy placement is required.

Usually physicians are more likely to perform ST to explore the airway anatomy in the operative setting and then proceed to the PT where the airway is less well visualized (some PT procedures such as the Griggs technique can be easily converted to ST in cases of difficult anatomic landmarks).

Otolaryngologists or general surgeons perform ST in the operating room in selected challenging cases involving patients presenting with complex anatomy (short neck, morbid obesity, neck stiffness, local malignancy, tracheal deviation) or coagulopathy, in addition to patients with neck, esophageal, and cardiovascular surgeries.

ST procedures can be performed under general anesthesia with propofol, fentanyl, and muscle relaxant administration. The surgical treatment of the tracheal window can be either mini-invasive similar to PT (with an open access without sutures) or invasive, realizing a true stoma and removing the anterior part of the tracheal wall with a ring flap sutured to the skin; the tracheostomy tube must be inserted between the first and third tracheal rings and fixed with two sutures: in this case, the surgical treatment involves a full dissection of the pretracheal tissues and insertion of the tracheostomy tube into the trachea under direct vision.

Because morbidity has been observed related to the transport of critically ill patients, to further reduce the rate of inadvertent mishaps, alternative techniques and surgical procedures such as ST should be considered and performed by anesthesiologists or surgeons at the bedside in the ICU. Even if it can be more difficult because of suboptimal conditions of lighting, suction, sterility, and cautery, bedside tracheostomy avoids transferring the patient to the operating room, making it ideal for selected cases.

ST presents a similar risk of complications or death compared with PT, except stoma infections. The proportion of patients receiving PT or ST varies across different settings: ST is largely performed in ICUs managed by surgeons, PT is preferred in ICUs managed by intensivists, and both techniques are adopted in medical/surgical ICUs.