What are the criteria for selecting tracheostomy tubes for bedside procedures?

Criteria for Bedside Tracheostomy Tube Procedures

Bedside tracheostomy procedures should be performed in a negative-pressure room, preferably in the ICU, with a team consisting of the least number of providers with the highest level of experience to minimize risk of infection transmission and complications. 1

Location Considerations

Preferred Setting

• Negative-pressure room in the ICU is the optimal location 1
• Alternative: Negative-pressure room in the operating room (with attention to transportation risks) 1
• If negative pressure rooms are unavailable: normal pressure room equipped with HEPA filters and strict door policy 1

Rationale for Bedside Procedures

• Minimizes risk of exposure to healthcare workers during patient transport 1
• Reduces risk of ventilator circuit disconnection during transport 1
• Avoids contamination of hospital corridors and other areas 1
• Logistical challenges of transfer to operating rooms are increased during infectious disease outbreaks 1

Patient Selection Criteria

Anatomical Considerations

• Patients without significant anatomical abnormalities 1
• Absence of significant pretracheal vessels (can be identified by ultrasound) 1
• Normal neck anatomy without excessive obesity or neck extension limitations 1

Clinical Stability

• Hemodynamically stable patients 1
• Adequate oxygenation with minimal ventilatory requirements 1
• Ability to tolerate brief periods of apnea during critical steps of the procedure 1

Procedural Technique Selection

Percutaneous Dilatational Tracheostomy (PDT)

• Advantages for bedside procedures:

  • Less bleeding (reduced need for cautery) 1
  • Generally performed at bedside in ICU 1
  • May require fewer healthcare workers 1
  • Can be performed by non-surgically trained physicians 1

• Contraindications for bedside PDT:

  • Significant pretracheal vessels identified by ultrasound 1
  • Complex anatomy not amenable to PDT 1
  • High risk of accidental premature extubation 1

Open Surgical Tracheostomy (OST)

• Considerations for bedside OST:
  • No need for bronchoscopy (potentially reducing aerosolization) 1
  • May require more healthcare workers in the room 1
  • Requires more logistical planning for bedside procedure 1
  • Entry into trachea may be quicker without need for dilation 1

Safety Requirements

Personnel

• Team with the least number of providers with highest level of experience 1
• Experienced operator performing the procedure 1
• Adequate assistance for positioning and equipment handling 1

Equipment

• Complete tracheostomy kit at bedside 2
• Functional suctioning system 2
• Oxygen source 2
• Manual resuscitation bag 2
• Enhanced personal protective equipment (PPE) for all team members 1
• Appropriate lighting and positioning equipment 1

Infection Control

• Enhanced PPE for all team members 1
• Portable HEPA filtration systems if negative pressure not available 1
• Systems for donning and doffing PPE 1
• Provision of additional equipment from a "clean" location 1

Risk Mitigation Strategies

Aerosolization Reduction

• Complete neuromuscular blockade 1
• Packing the oropharynx 1
• Performing apnea during high-risk steps 1
• Reducing or avoiding suction and diathermy 1
• Using gauze or sponge at stoma site 1
• Maintaining closed ventilator circuit when possible 1

Procedural Planning

• Multidisciplinary planning before procedure 1
• Detailed rehearsal of procedure 1
• Checklist of equipment and medications 1
• Clear communication protocols while wearing PPE 1

Pitfalls and Caveats

• Avoid using carts in the room to minimize contamination 1
• Be aware that PPE may limit communication (hearing) among team members 1
• Consider ultrasound guidance to reduce need for bronchoscopy during PDT 1
• The choice between PDT and OST should be based on institutional expertise and defined protocols 1
• Recognize that the ideal negative-pressure single-occupancy rooms suitable for tracheostomy are not available in most facilities 1

By following these criteria and recommendations, healthcare providers can safely perform bedside tracheostomy procedures while minimizing risks to both patients and staff.