Head-of-Bed Signs and UK Trach Safety Project

http://tracheostomy.org.uk//Templates/Algorithms.html

When to Trach

Consider when > than 14 days of intubation are planned.

Risks include:

Tracheoinnominate Artery Fistula (TIA)-causes severe airway bleeding which can be fatal. Consider hyperinflating the cuff to tamponade bleeding as temporizing measure. In differential of any bleeding >48 hours after placement.
Tracheoesophageal Fistula (TEA)-may require methylene blue in esophagus to diagnose if not seen on endoscopy. Consider barium swallow. Esophagus will have air in it on x-rays.
Tracheal Stenosis

Portex trach tube is far superior to the Shiley trach tube which comes in the Cook kit, and, at least to me, the superiority of Portex’s trach tube outweighs the superiority of the Cook/Shiley Blue Rhino PDT kit. The solution may be that Portex is already marketing a ‘White Rhino’ kit in Europe, and we’re hoping to see it here soon, so that will allow us the best of both worlds.

Severe reactive airway disease: use pretreatment

Coagulopathy

Keep extra clamp to pull out dilator

Early may be better (Crit Care Med 2004 Vol 32 #8 1689-1693)

Change tubes over 4.5 pediatric endotracheal tube

Technique for Crash Trach (Injury 2008;39:375)

Percutaneous Tracheostomy

We tried the Ciaglia and the Fantoni techniques and we prefer the Ciaglia/ Blue Rhino set.

Changing a Perc Trach

1. Check the size currently in situ and ensure that you have the correct size and one size smaller, just in case. 2. Mentally walk through the procedure, like say oxygenate, deflate the cuff, remove and suction…….. 3. Demonstrate to all what a magnificent operation has taken place, that one can see with a light into the trachea and that the patient can easily breath through the hole.

there is no need for positive pressure then there is no need for a cuff, and I try to change tubes to uncuffed before the patient leaves ICU. It is pretty clear that cuffs do NOT prevent aspiration – we know that one factor in VAP is continuous microaspiration past the cuff, and we deliberately keep cuff pressure less than mucosal capillary pressures so a good vomit will go past the cuff anyway. Cuffs do interfere with swallowing, however because of pressure on the cricopharyngeus. I find that if I don’t aggressively change to uncuffed tubes before the patients goes to the ward the patient gets caught in a vicious cycle of ‘leave the cuff up to prevent aspiration ….. look he has failed his swallow test you had better leave the cuff up to protect his airway ….” and nobody every gets around to taking the rotten tube out.

Just below thryoid for incision. Can enter sub-cricoid

Cut trach tie 1/3 and 2/3 then put slit 1 cm down to pull end through

can put saline into angio to see if it sprays when pt ventilated

put finger in hole, use it to guide the needle

Details on technique by the man, Ciaglia (Chest 1996;110(3):762)

Perc Trach without Bronch (Chest 2004;126(3):869)

The use of the bronchoscope is felt by some to be mandatory but many including myself, Sedar, and some of the Intensivists in the Silvester series prefer to perform the procedure with the bronchoscope on standby only to be used if needed. We have developed a technique using a bronchoscopy adapter on the endotracheal tube through which we place a 5 mm Cooktube changer which extends 10 cm beyond the tip of the endotracheal tube allowing easy rescue of the air way if needed. The tube changer is small enough not to impair ventilation (important for ICP control) during the procedure or interfere with accessing the trachea and placing the tracheostomy. PT is now really a misnomer since most operators use a modified technique creating a 1.52 cm horizontal incision a fingers breadth below the cricoid cartilage. Blunt dissection is carried out to the anterior tracheal wall with a hemostat and gloved finger. Our preference is to leave the cuff on the endotracheal tube inflated as it is drawn back 8 cm from its original position.

We place the needle for canulation on the trachea while it is splinted by the cuff of the endotracheal tube. When the cuff passes under the gloved finger held on the trachea beside the needle, the needle is inserted and air is aspirated and the guide wire is passed, etc.

(Curr Opin in Crit Care 2005;11:326)

We buy the small Blue Rhino kit without the Shiley Trach tube, and use the Portex Trach tube separately. I do not like the Shiley tube – if you don’t position it properly on the loading dilator, there is a gap between the tube and the dilator. I have had this rip on the tracheal ring, making it impossible to advance and having to get a new tube. It just does not slide in nearly as easily as the Portex. So, by unbundling, we are able to get the best of both worlds. It does cause us to have to scurry around sometimes to make sure that all the things we need are present, but it is much more preferable than having to use a sub-standard Trach tube. What bothers me is that I have many times talked to both the Cook and Shiley people about it – they each point a finger and blame the other company, then point the finger at me and tell me that we are doing something wrong because “nobody else complains about the trach tube!!”. If the Blue Rhino were not so superior, I would stop using it also, based on their attitude!

Open Tracheostomy

Prep out to both shoulders up to chin and down to nipple line

Mark Thyroid, Cricoid and Sternal Notch

Incise from above notch to just below cricoid ~2.5 cm

Grab with pickups in tissue

Use coag setting on bovie to cut through fascia

Insert wheatleys

Go down to strap muscles using a small kelly or right angles to spread for the bovie

Switch to debakeys

Find isthmus of thyroid

Place straight clamp with jaws facing up. Put two kellys in jaws with concave facing in

cut with bovie or mets

Tie off with vicryl

Feel for depth of innominate

Deflate cuff

Make square cut, can mark with bovie

Johnson uses horizontal slit with two 45 degree extensions into ring

Insert dilator

Put obstructing cannula into trach

Grab cricoid with hook

Pull tube back

Put trach in horizontally and rotate

Close skin with two nylons

then suture trach through the plastic, not through the hole

Pull a drain gauze through

Get trach tray or suture Kit

Prep

Place table over patient’s waist and cover with drape

Hyperextend neck

Mark Cricoid and sternal notch. Entry point is usally two finger breadths above notch

Inject with lido c epi before setting up the kit to increase hemostasis

Incision

Spread with two mosquitoes all the way down to the trach

Feel for between 1st and 2nd ring

Deflate cuff and pull back to 18, you should feel the loss of resistance

Reinflate cuff

Put needle against trach

Put finger in hole to feel

Insert needle and withdraw until air bubbles

Hold cath and pull out needle

Reinsert syringe and verify placement

Advance wire, remove needle, dilate three times with small dilator

Put on white with dilator

From this point forward, always have knob in between your fingers

Dilate three times

Put on trach with inner cannula

Pull out wire, white, and dilator. May need kelly

Hold Trach

Put in inner cannula

Attach vent, look for return of expiratory

Inflate Cuff

After sutured, then pull ET tube

put iv bag between shoulder blades

put head in head ring

consider laryngoscopy

reinflate cuff after pulling back

Laryngoscope. 2005 Oct;115(10 Pt 2):1-30. Related Articles, Links Endoscopic percutaneous dilatational tracheotomy: a prospective evaluation of 500 consecutive cases. Kost KM. Department of Otolaryngology, McGill University, Montreal, Quebec, Canada. kmkost@yahoo.com OBJECTIVES/HYPOTHESIS: An evaluation of 500 adult, intubated, intensive care unit patients undergoing endoscopic percutaneous tracheotomy using the multiple and single dilator techniques was conducted to assess the feasibility and safety of the procedure as it compares with surgical tracheotomy. Endoscopy was used in all cases and evaluated as an added safety measure in reducing complications. STUDY DESIGN: A prospective evaluation of endoscopic percutaneous dilatational tracheotomy in 500 consecutive adult, intubated intensive care unit patients. METHODS: Between 1990 and 2003, endoscopically guided percutaneous dilatational tracheotomy (PDT) was performed in 500 consecutive adult, intubated patients in the intensive care units (ICU) of three tertiary care adult hospitals. The first 191 patients underwent PDT using the Ciaglia Percutaneous Tracheostomy Introducer Kit (Cook Critical Care Inc., Bloomington, Indiana) and in the remaining 309 patients the Ciaglia Blue Rhino Single Dilator Kit (Cook Critical Care Inc., Bloomington, Indiana) was used. The procedure was contraindicated in the following situations: 1) children, 2) unprotected airway, 3) emergencies, 4) presence of a midline neck mass, 5) inability to palpate the cricoid cartilage, and 6) uncorrectable coagulopathy. The following parameters were recorded preoperatively: age, sex, diagnosis, American Society of Anesthesia (ASA) class, body mass index (BMI), and number of days intubated. Recorded hematologic parameters included hemoglobin (Hgb), platelets, prothrombin time (PT), partial thromboplastin time (PTT), and the international normalized ratio (INR) since it became available in 1998. All patients were ventilated on 100% oxygen and vital signs were continuously monitored. Tracheotomy was carried out under continuous endoscopic guidance using a series of graduated dilators in the first 191 cases, and a single, tapered dilator in the remaining 309 patients. The preoperative data on each patient, along with the type of dilator used, the size of the tube, the intraoperative and postoperative complications, and blood loss information were recorded prospectively and maintained in a computer spreadsheet. Univariate analyses were used in each group separately for each type of dilator to assess the risks of a complication within subgroups defined by each parameter/characteristic, and the statistical significance assessed with a chi test, or Fisher exact test. RESULTS: The total complication rate was 9.2% (13.6% in the multiple dilator group, and 6.5% in the single dilator group), with more than half of these considered minor. Overall, the two most common complications were oxygen desaturation in 14 cases and bleeding in 12 cases. The absence of serious complications such as pneumothorax and pneumomediastinum are attributable to the use of bronchoscopy. There was no significant association between the rate of complications and age, gender, ASA, weeks intubated, tracheostomy tube size, Hgb levels, platelets, PT, PTT, or INR. There was a statistically significant relationship between experience and the likelihood of complications in the multiple dilator group (P < .0001), with a higher rate of complications in the first 30 patients (40%) compared with 8.7% in the remaining 161 patients. This relationship did not exist for the first 30 patients in the single dilator group. Patients with a BMI of 30 or higher experienced a significantly greater (P < .05) number of complications (15%), compared with an 8% complication rate in patients with a BMI of less than 30. This risk was even more significant for patients with a BMI of 30 or greater who were also in ASA class 4 (11/56 or 20%) (P < .02). CONCLUSIONS: Endoscopic PDT is associated with a low complication rate and is at least as safe as surgical tracheotomy in the ICU setting. Bronchoscopy significantly decreases the incidence of complications and should be used routinely. While embraced by critical care physicians, endoscopic PDT has been infrequently performed by otolaryngologists. As the airway experts, otolaryngologists are in the best position to learn and teach the procedure as it should be done. Publication Types: 2006/2/14, Marek Nalos <mareknalos@mediclub.cz>: > Chest. 2004 Aug;126(2):547-51. Related Articles, Links Percutaneous tracheostomy is safe in patients with severe thrombocytopenia. Kluge S, Meyer A, Kuhnelt P, Baumann HJ, Kreymann G. Department of Medicine, University Hospital Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany. skluge@uke.uni-hamburg.de STUDY OBJECTIVES: Severe thrombocytopenia has been described as a contraindication for percutaneous tracheostomy (PT). The objective of this study was to assess the safety of PT in mechanically ventilated patients with severe thrombocytopenia (defined by a platelet count of < 50 x 10(9) cells/L). DESIGN: Retrospective, single-center cohort study. SETTING: Medical ICU of the University Hospital Hamburg-Eppendorf, Germany. PATIENTS: Forty-two medical patients with acute respiratory failure and severe thrombocytopenia. INTERVENTIONS: Bedside PT under bronchoscopic guidance using the Griggs guidewire forceps technique.Measurements and main results: The mean (+/- SD) intubation time prior to undergoing PT was 6.7 +/- 3.9 days (range, 1 to 20 days). The mean platelet count was 26.4 +/- 11.6 x 10(9) cells/L (range, 1 x 10(9) to 47 x 10(9) cells/L). The median transfusion of platelets before the procedure in 40 of the 42 patients was 6 +/- 2.5 U (range, 3 to 12 U). Twenty-two patients (52%) had an additional coagulopathy (activated partial thromboplastin time [APTT], > 40 s; international normalized ratio, > 1.5). PT was safely performed in all 42 patients. Only two (5%) patients developed major postprocedural bleeding complications that required suturing. Both of these patients had an elevated APTT due to heparin therapy. CONCLUSIONS: When performed by experienced personnel, PT with bronchoscopic guidance has a low complication rate in patients with severe thrombocytopenia, provided that platelets are administered beforehand. However, in order to minimize bleeding complications heparin infusions should be temporarily interrupted during the procedure. PMID: 15302743 [PubMed – indexed for MEDLINE] Chest. 2003 May;123(5):1595-602. Related Articles, Links Comment in: Chest. 2003 May;123(5):1336-8. Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication. Polderman KH, Spijkstra JJ, de Bree R, Christiaans HM, Gelissen HP, Wester JP, Girbes AR. Departments of Intensive Care, University Medical Center, Amsterdam, the Netherlands. k.polderman@tip.nl STUDY OBJECTIVES: To assess short-term and long-term complications of bronchoscopy-guided, percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) and to report a complication of PDT that has not been described previously. DESIGN: Prospective survey. SETTING: University teaching hospital. PATIENTS: Two hundred eleven critically ill patients in our ICU. INTERVENTIONS: PDT was performed in 174 patients, under bronchoscopic guidance in most cases. ST was performed in 40 patients. RESULTS: No procedure-related fatalities occurred during PDT or ST. The incidence of significant complications (eg, procedure-related transfusion of fresh-frozen plasma, RBCs, or platelets, malpositioning or kinking of the tracheal cannula, deterioration of respiratory parameters lasting for > 36 h following the procedure, or stomal infection) in patients undergoing PDT was 4.0% overall and 3.0% when bronchoscopic guidance was used. No cases of paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis occurred in patients undergoing PDT. We attribute this low rate of complications to procedural and organizational factors such as bronchoscopic guidance, performance by or supervision of all PDTs by physicians with extensive experience in this procedure, and airway management by physicians who were well-versed in (difficult) airway management. In addition, an ear-nose-throat surgeon participated in the procedure in case conversion of the procedure to an ST should become necessary. We observed a complication that, to our knowledge, has not been reported previously. Five patients developed intermittent respiratory difficulties 2 to 21 days (mean, 8 days) after undergoing PDT. The cause turned out to be the periodic obstruction of the tracheal cannula by hematoma and the swelling of the posterior tracheal wall, which had been caused by intermittent pressure and chafing of the cannula on the tracheal wall. In between the episodes of obstruction, the cannula was open and functioning normally, which made the diagnosis difficult to establish. CONCLUSIONS: Bronchoscopy-assisted PDT is a safe and effective procedure when performed by a team of experienced physicians under controlled circumstances. The intermittent obstruction of the cannula caused by swelling and irritation of the posterior tracheal wall should be considered in patients who develop unexplained paroxysmal respiratory problems some time after undergoing PDT or ST.

How to do a Perc Trach by Charles Bruen

How to document a PERC Trach

Trach emergencies

Hyperextend the neck as first step

Incise as big as you need all the way down the midline

CUT TO AIR bleeding is a good thing, it tells you your patient is still alive

Meta Analysis of Early Trach shows reduced ICU time and Vent days (BMJ 2005 Griffiths J, Barber VS, Morgan L)

Canadian Journal of Anesthesia 54:321-322 (2007) Use of the “Aretube” to facilitate ventilation during percutaneous tracheostomy

Tracheostomy protocol (Crit Care Med 2008;36:1742)

The PWA is performed by the nursing and respiratory therapy staff and determines whether a patients level of ventilatory support is appropriate for weaning attempts (i.e., Fio2 <=0.5, positive end-expiratory pressure <=8 cm H2O, minute volume <15 L/min) and whether acute physiologic derangements (i.e., increased intracranial pressure, significant hemoptysis, active gastrointestinal hemorrhage, evolving myocardial infarction, elevated minute ventilation) might preclude successful weaning. Ventilator settings are then adjusted to provide a continuous positive airway pressure of 5 cm H2O and Fio2 = 0.4. If after 2 mins patients manifest no evidence of respiratory or hemodynamic derangement (i.e., dyspnea, use of accessory muscles, SpO2 <92%, tachypnea, tachycardia, bradycardia, hypotension), SBT is performed. Patients displaying evidence of respiratory or hemodynamic distress during this 2-min trial are categorized as PWA failures and returned to pretrial ventilatory support. During SBT, patients receive minimal ventilatory support (pressure support 58 cm H2O, positive end-expiratory pressure 5 cm H2O, Fio2 = 0.4) for 30 mins. Patients exhibiting signs of respiratory or hemodynamic distress are categorized as SBT failures and returned to pretrial ventilatory support. Patients passing the SBT are considered extubation candidates. SBT results are conveyed to the physician staff responsible for decision for extubation. Timing of extubation following successful SBT completion is at the discretion of the physician staff.

Emergency Perc Trach Case Report in a Burn Patient (Resuscitation (2006) 68, 301—305)

Use of ultrasound in the perc trach procedure

Critical Care 2011, 15:R67

perc trach ultrasound Critical Care 2011, 15:147

Deadspace

This is actually a myth (Anaesth Intensive Care. 2013 Mar;41(2):216-21. )