What are the guidelines for performing and managing a tracheostomy?

Guidelines for Performing and Managing a Tracheostomy

Multidisciplinary guidelines recommend standardized approaches to tracheostomy management with clear protocols for both routine care and emergency situations to minimize morbidity and mortality. 1

Indications for Tracheostomy

• Tracheostomy should be considered for patients requiring prolonged mechanical ventilation (especially when expected for >10-14 days), for actual or anticipated airway obstruction, for management of secretions in patients with inadequate laryngeal reflexes, and for patients with chronic respiratory failure 2
• Early tracheostomy (within 7 days of intubation) may improve outcomes in specific patient populations, particularly head-injured and critically ill medical patients 3

Pre-Procedure Planning

• A comprehensive multidisciplinary approach involving anesthesiologists, surgical specialists, and perioperative nurses is essential for safe tracheostomy management 4
• Patient-specific factors that should be documented include:
  • Airway assessment (including previous laryngoscopy grade) 1
  • Anticipated difficulty of upper airway management 1
  • Coexisting medical conditions that may impact the procedure 5

Surgical Techniques

• Two main approaches are available:
  • Open Surgical Tracheostomy (OST): Involves direct visualization and surgical creation of the tracheal stoma 2
  • Percutaneous Dilational Tracheostomy (PDT): Uses Seldinger technique with progressive dilation; should be performed under bronchoscopic guidance for increased safety 2, 5
• The choice between techniques should be based on operator experience and available resources, with operators only performing procedures with which they are familiar and competent 2
• For pediatric patients, a vertical tracheotomy is preferred rather than a cartilage window to avoid creating stenosis 6

Procedural Considerations

• Proper positioning with neck slightly extended using a shoulder roll is recommended 6
• Stay sutures should be placed on either side of the tracheostomy to aid in traction and facilitate tube replacement if accidental decannulation occurs 6, 1
• Maturation sutures can be used to secure the edge of the tracheal wall to the anterior neck skin, particularly important in pediatric cases 1, 6
• Ultrasound guidance can be helpful in identifying neck structures in patients with difficult anatomy 5

Bedside Equipment and Emergency Preparedness

• All clinical areas caring for tracheostomy patients must be properly equipped with both routine and emergency airway equipment 1
• Essential bedside equipment includes:
  • Humidification equipment and suction with appropriate catheters 1
  • Spare tracheostomy tubes (same size and one size smaller) 1
  • Clean container for spare inner cannula 1
  • Tracheostomy dressings and tapes 1
  • Personal protective equipment 1
• Emergency equipment must include:
  • Basic airway equipment (oxygen masks, self-inflating bags, oral/nasal airways) 1
  • Advanced airway equipment (laryngeal mask airways, laryngoscopes with appropriate tubes) 1

Bedhead Signs and Documentation

• Standardized bedhead signs should be used to provide essential information about the tracheostomy 1
• For new tracheostomies, documentation should include:
  • Type of tube and size 1
  • Date of insertion 1
  • Presence of stay sutures or maturation sutures 1
  • Whether the tracheostomy was surgically or percutaneously created 1
• For established tracheostomies, documentation should include:
  • Upper airway patency assessment 1
  • Previous airway management details (laryngoscopy grade, successful devices) 1
  • Emergency contact information 1

Emergency Management Algorithms

• Two distinct algorithms should be used based on whether the patient has:
  • A potentially patent upper airway (tracheostomy patient) - "green algorithm" 1
  • No upper airway (laryngectomy patient) 1
• Key principles in emergency management include:
  • Oxygenation takes priority over securing a definitive airway 1
  • Early call for appropriate assistance 1
  • Clear division of responsibilities between primary responders (basic assessment and emergency oxygenation) and secondary responders (advanced airway management) 1

Common Complications and Management

• Major life-threatening complications include:
  • Tube displacement or decannulation 7
  • Tube obstruction 7
  • Hemorrhage 7
• Long-term complications include:
  • Tracheal stenosis 8
  • Tracheomalacia 2
  • Tracheoesophageal fistula 7
  • Infection 7

Special Considerations

• Percutaneous tracheostomy can be safely performed in patients previously considered high-risk (obesity, coagulopathy, limited neck extension) with proper technique and experience 5
• For COVID-19 patients, procedures should be performed in negative pressure rooms with enhanced PPE by the most experienced providers to minimize aerosolization risk 2

Training and Education

• Multidisciplinary training and education are essential for safe tracheostomy management 1
• Local adoption and training should address special circumstances encountered in individual clinical areas 1
• Regular simulation of emergency scenarios improves team performance during actual emergencies 1