What are the quantifiable selection criteria for open bedside tracheostomy?

Quantifiable Selection Criteria for Open Bedside Tracheostomy

The key quantifiable selection criteria for open bedside tracheostomy include timing of at least 10-14 days after mechanical ventilation initiation, hemodynamic stability, adequate oxygenation (FiO2 ≤50%), and PEEP ≤10 cm H2O. 1

Patient Selection Criteria

1. Duration of Mechanical Ventilation:

   • Patients requiring prolonged mechanical ventilation ≥10-14 days 1, 2
   • Consider tracheostomy within 7-10 days of intubation when prolonged ventilation is anticipated 3

2. Oxygenation Parameters:

   • FiO2 ≤50% 1, 4
   • PEEP ≤10 cm H2O 1, 4

3. Hemodynamic Stability:

   • Stable vital signs without vasopressor requirements or with minimal support 1
   • No active bleeding or coagulopathy 5

4. Anatomical Considerations:

   • Normal neck anatomy without significant anatomical abnormalities 1
   • Absence of significant pretracheal vessels (confirmed by ultrasound) 6
   • No excessive obesity or neck extension limitations 1

5. Clinical Improvement Indicators:

   • Patient showing signs of clinical improvement from primary respiratory condition 6
   • Prone positioning no longer anticipated to be required 6
   • Failed or high risk of failing primary tracheal extubation 1

Procedural Setting Requirements

1. Room Specifications:

   • Negative-pressure room in the ICU (preferred) 1
   • If unavailable, normal pressure room with HEPA filters 6, 1

2. Equipment Availability:

   • Complete tracheostomy kit 1
   • Functional suctioning system 1
   • Waveform capnography 1
   • Fibreoptic scope for visualization 1

3. Personnel Requirements:

   • Team with highest level of experience 6, 1
   • Minimum number of providers necessary (typically 3-4) 6

Contraindications

1. Absolute Contraindications:

   • Significant pretracheal vessels identified by ultrasound 6, 1
   • Severe hypoxia requiring high oxygen (FiO2 >50%) 1, 5
   • Uncorrected coagulopathy 5

2. Relative Contraindications:

   • PEEP >10 cm H2O 4
   • Hemodynamic instability requiring high-dose vasopressors 1
   • Significant anatomical abnormalities 1

Benefits of Bedside Tracheostomy

1. Patient-Related Benefits:

   • Reduced sedation requirements 6
   • Improved patient comfort 6, 3
   • Facilitated weaning from mechanical ventilation 1

2. System-Related Benefits:

   • Avoids transport risks 1, 4
   • Reduced costs compared to operating room procedures 5
   • Shorter ICU and hospital stays 2
   • Procedural time typically <30 minutes 5

Complication Rates to Consider

1. Overall Complication Rate: 1.4-4.3% 4, 7
2. Early Complications:
   • Bleeding requiring intervention: 0.2-1.6% 4, 7
   • Tube misplacement requiring revision: 0.4% 4
   • Procedure failure: 0.1% 4
3. Late Complications:
   • Persistent stoma: 0.4% 4
   • Subglottic stenosis: 0.2% 4
   • Laryngotracheal stenosis: 0.36% 7

Practical Implementation

When implementing these criteria in practice, use a systematic approach:

1. Initial Assessment (Day 3-7 of mechanical ventilation):

   • Evaluate likelihood of prolonged ventilation need
   • Review anatomical suitability using physical exam and ultrasound
   • Assess hemodynamic stability and oxygenation parameters

2. Daily Reassessment (After Day 7):

   • Monitor for clinical improvement
   • Evaluate weaning potential
   • Reassess oxygenation requirements (FiO2, PEEP)

3. Final Decision Point (Day 10-14):

   • Confirm all quantifiable criteria are met
   • Ensure appropriate team and setting availability
   • Proceed with bedside tracheostomy if criteria satisfied

By applying these quantifiable selection criteria, clinicians can systematically identify appropriate candidates for open bedside tracheostomy while minimizing risks and optimizing outcomes.