What are the indications, contraindications, and methods of tracheostomy, including types and potential complications?

Tracheostomy: Types, Methods, Indications, and Contraindications

Tracheostomy should be performed for patients requiring prolonged mechanical ventilation (>10-14 days), those with actual or anticipated airway obstruction, patients unable to clear respiratory secretions, and those with chronic respiratory failure requiring ventilatory support. 1

Indications for Tracheostomy

Primary Indications

• Prolonged mechanical ventilation, particularly when ventilation is expected to exceed 10-14 days 1
• Actual or anticipated upper airway obstruction, including upper airway tumors, bilateral vocal cord paralysis, subglottic stenosis, and congenital airway malformations 1, 2
• Secretion management in patients with inadequate laryngeal reflexes or requiring invasive pulmonary hygiene 1
• Chronic respiratory failure, particularly in patients with neurological disorders 1

Pediatric-Specific Indications

• Long-term ventilatory support in children 2
• Management of bronchopulmonary secretions 2
• Fixed upper airway obstruction (subglottic stenosis, bilateral vocal cord paralysis) 2
• Congenital airway malformations and associated syndromes 2
• Respiratory papillomatosis and craniofacial syndromes 2

Timing Considerations

• Tracheostomy should be delayed until at least day 10 of mechanical ventilation 1
• Should only be considered when patients are showing signs of clinical improvement 1
• For COVID-19 patients, tracheostomy should be considered 10-14 days after ICU admission when showing signs of recovery 1

Types of Tracheostomy

Based on Duration

• Temporary tracheostomy: Used for reversible conditions 2
• Permanent tracheostomy: Used for irreversible conditions, particularly in children with neurological impairment 2

Based on Technique

1. Open Surgical Tracheostomy (OST)

   • Involves identifying the cricothyroid membrane 3
   • Making an incision through skin and platysma 3
   • Advancing the endotracheal tube distal to the operative site before opening the trachea 3
   • Hyperinflating the endotracheal tube cuff 3
   • Pausing ventilation at key moments 3

2. Percutaneous Dilational Tracheostomy (PDT)

   • Less invasive alternative to surgical tracheostomy 4
   • Often performed with bronchoscopic guidance for increased safety 3
   • Associated with decreased risk of stomal inflammation, infection, and bleeding 5
   • Can be performed at bedside, reducing healthcare resource utilization 5

Contraindications and Cautions

Absolute Contraindications

• Patients who are unstable requiring high levels of ventilatory and oxygen support 1
• Patients requiring continued prone positioning 1

Relative Contraindications

• Coagulopathy and thrombocytopenia (higher risk for bleeding complications) 4
• Morbid obesity (anatomical challenges) 4
• Active local infection at the proposed tracheostomy site 3

Surgical Technique

Open Surgical Tracheostomy

1. Position patient with neck slightly extended using a shoulder roll 6
2. In pediatric cases, use a vertical tracheotomy rather than a cartilage window to avoid stenosis 2
3. Place stay sutures on either side of the planned incision 6
4. Identify the cricothyroid membrane and make an incision through skin and platysma 3
5. Advance the endotracheal tube distal to the operative site before opening the trachea 3
6. Create a tracheal window or flap 2
7. Insert appropriate tracheostomy tube 2

Percutaneous Dilational Tracheostomy

1. Consider ultrasound to identify vasculature before the procedure 3
2. Use bronchoscopy guidance to improve safety 3, 5
3. Perform with minimal personnel with highest level of experience 3
4. Ideally performed in a negative pressure room, particularly for infectious patients 3

Complications

Immediate Complications

• Hemorrhage and loss of airway 2
• Pneumothorax 2
• False passage creation 4

Short-term Complications

• Blockage or displacement of tracheostomy tube 2
• Infection at the stoma site 2
• Subcutaneous emphysema 4

Long-term Complications

• Tracheomalacia 2
• Tracheal stenosis 2
• Problems related to the stoma itself 2
• Tracheocutaneous fistula after decannulation 2

Tracheostomy Tube Selection

• Selection of proper diameter, length, and curvature is crucial to minimize complications 2
• Complications from improper sizing include suprastomal collapse, distal tracheal wall granuloma, and dysphagia from esophageal compression 2
• A tracheostomy tube one size smaller than usual should be available for emergency use 2

Emergency Management

• Bedhead signs should communicate essential airway details 2
• Essential airway equipment must be immediately available and accompany the patient 2
• Healthcare professionals caring for tracheostomy patients should receive regular training in routine and emergency management 2
• Blood in tracheal secretions may precede catastrophic hemorrhage and should trigger immediate evaluation 2

Decannulation Considerations

• Two fundamental criteria for decannulation: original need for tracheostomy no longer present and patient able to maintain safe and adequate airway 2
• Traditional technique involves sequential downsizing of the tube, often with partial or complete plugging over several days 2
• Most decannulation failures occur within 12-36 hours 2
• In most patients, the stoma closes spontaneously within hours or days; formal closure may be necessary if persistent 2

Special Considerations for COVID-19

• Tracheostomy should only be considered when the patient shows signs of recovery from COVID-19-associated pneumonitis 1
• Procedure should be performed with appropriate infection control measures to protect healthcare staff 1, 3
• Negative pressure room with enhanced PPE is recommended 3