What are the best practice guidelines for selecting patients and performing open bedside tracheostomy (trach)?

Best Practice Guidelines for Open Bedside Tracheostomy

Open bedside tracheostomy should be performed in a negative-pressure room in the ICU by the most experienced team with the fewest necessary personnel, using enhanced PPE and techniques that minimize aerosolization. 1

Patient Selection Criteria

Indications

• Patients requiring prolonged mechanical ventilation (typically >10-14 days) 1, 2
• Patients showing signs of clinical improvement from their primary respiratory condition 1
• Patients who have failed or are at high risk of failing primary tracheal extubation 1
• Patients with significant laryngeal edema or ulceration 1

Contraindications

• Hemodynamic instability 3
• Patients requiring prone positioning (tracheostomy should be delayed until prone positioning is no longer needed) 1
• Patients with significant anatomical abnormalities that would complicate bedside procedure 3, 4
• Patients with excessive obesity or limited neck extension that would make bedside procedure unsafe 3
• Presence of significant pretracheal vessels (identified by ultrasound) 3, 4

Timing

• Delay tracheostomy until at least day 10 of mechanical ventilation 1, 5
• Perform only when patients are showing signs of clinical recovery 1

Procedural Requirements

Environment

• Negative-pressure room, preferably in the ICU 1, 3
• If negative pressure unavailable, use normal pressure room with HEPA filters and strict door policy 1, 3

Equipment

• Complete tracheostomy kit
• Functional suctioning system
• Oxygen source
• Manual resuscitation bag
• Waveform capnography (immediately available) 1, 3
• Fibreoptic scope (immediately available) 1, 3
• Spare tracheostomy tubes (same size and one size smaller) 1
• Personal protective equipment (enhanced PPE) 1

Personnel

• Experienced operator with highest level of expertise 1
• Minimal number of healthcare providers to reduce exposure risk 1
• Clear communication protocols established while wearing PPE 3

Procedural Technique

Pre-procedure

1. Multidisciplinary planning and rehearsal 1, 3
2. Detailed checklist of equipment and medications 3
3. Pre-procedural apnea test to assess physiological stability 1
4. Consider ultrasound to identify anatomy and vascular structures 3, 4

During Procedure

1. Ensure complete neuromuscular blockade throughout procedure 1, 3
2. Minimize aerosolization:
   • Pack the oropharynx 3
   • Perform apnea during high-risk steps 3
   • Reduce or avoid suction and diathermy 3
   • Maintain closed ventilator circuit when possible 3
3. Use gauze or sponge at stoma site to reduce bleeding 3

Post-procedure

1. Adapt care to minimize airway interventions and aerosol-generating procedures 1
2. Review humidification needs 1
3. Specify frequency of suction 1
4. Perform daily inner tube care 1
5. Discontinue positive pressure ventilation whenever possible during disconnection from ventilator circuit 1

Advantages of Bedside Tracheostomy

• Avoids risks associated with patient transport 1, 6
• Reduces costs compared to operating room procedures 6
• Facilitates weaning from prolonged ventilation 1, 2
• Provides a more controlled situation for weaning compared to high-risk primary extubation 1
• Reduces sedation requirements 1
• Improves patient comfort 2
• Facilitates transfer to lower acuity care areas 1

Technique Selection

• Both open surgical tracheostomy (OST) and percutaneous dilatational tracheostomy (PDT) can be performed at the bedside 1, 3
• During COVID-19 pandemic, open surgical procedures are preferred but percutaneous procedures are not contraindicated 1
• When open surgical tracheostomy is chosen, it should preferably be performed at the bedside in the ICU 1

Safety Considerations

• Tracheostomy is an aerosol-generating procedure and poses infection risk to healthcare workers 1
• Enhanced PPE must be used to mitigate risk of healthcare worker infection 1
• Complications can be minimized with proper technique and experienced operators 7, 6
• Waveform capnography should be used at the beginning of assessment 1

By following these guidelines, institutions can establish a standardized approach to bedside tracheostomy that maximizes patient safety and minimizes risks to healthcare workers.