An educational material describing the Indications for Tracheostomy-Complications of Tracheostomy-Timing of Tracheostomy-Tracheostomy Technique-Tracheostomy Decannulation and types of Tracheostomy Tubes

2. • Overview of Tracheostomy
• Dr. MOHAMMAD VAZIRI-Thoracic Surgeon
• Iran University of Medical Sciences
• Member of The
• New York Academy of Sciences
• European Society of Thoracic Surgeons
• International Association for the Study of Lung Cancer
• European Society of Medical Oncology
• Clinical Research Associate – McMaster University

3. • OUTLINE
• Indications for Tracheostomy
• Complications of Tracheostomy
• Timing of Tracheostomy
• Tracheostomy Technique
• Tracheostomy Decannulation
• Tracheostomy Tubes
• Changing the Tracheostomy Tube
• Speaking Valve

4. • Indications for Tracheostomy
• The most common indications for tracheostomy are
(1) Acute respiratory failure and need for prolonged mechanical ventilation
(2) Traumatic or catastrophic neurologic insult requiring airway, or mechanical
ventilation or both.
• Upper airway obstruction is a less common indication for tracheostomy.
• 10% of mechanically ventilated patients undergo tracheostomy

5. Indications for Tracheostomy

6. Complications of Tracheostomy

7. Complications of Tracheostomy

8. • Timing of Tracheostomy
• The question of early versus late tracheostomy is complex and requires a 2-
part solution:
(1) we must predict which patients will require prolonged ventilation, and
(2) we must make a decision about when the tracheostomy should be
performed.

9. • The definition of early tracheostomy differs between studies.
• Of the papers surveyed from the past 10 y, early was generally defined as
within 3–10 d of mechanical ventilation, whereas late was variously defined as
any time outside the early period, within 7–14 d, 14–28 d, or 28 d after
initiation of mechanical ventilation.
• Earlier timing of tracheostomy correlated with shorter time on mechanical
ventilation and shorter ICU and hospital stay, but was not associated with
hospital mortality.

10. • Optimal Timing of Tracheostomy Based on Recent Randomized
Controlled Trials
• 2 recent randomized trials (Italian multi-center trialand TracMan United
Kingdom multi-center trial) have consistent findings that earlier tracheostomy
was not associated with improved survival and that clinicians cannot
accurately predict which patients will require prolonged mechanical
ventilation.
• Based on the evidence to date, it is reasonable to wait at least 10 days to be
certain that a patient has an ongoing need for mechanical ventilation

11. • Limitations of Tracheostomy Timing Studies
• Small number of trauma and surgical patients
• Different outcome measures: all-cause mortality versus VAP versus
ICU/ventilator-free days
• No standardization of tracheostomy technique (open or percutaneous in
TracMan, Griggs vs PercuTwist in Italian multi-center trial)
• No large United States RCT to date

12. • Patients Who Would Benefit From Early Tracheostomy
• Trauma and neurologic damage from stroke, head injury, and spinal cord
injury (SCI) represent a subset of patients for whom the benefits of early
tracheostomy have been specifically investigated.
• For these studies, 7–8 d was a relatively consistent cutoff

13. • Similar to trauma patients, retrospective studies report that early tracheostomy
(within 7–8 d) in traumatic brain injury (TBI) patients is associated with some
improved outcomes compared with delayed tracheostomy, but no large
prospective randomized trials have yet validated these findings.

14. • Tracheostomy Technique
. Patient selection is a significant factor during the consideration of whether to
perform percutaneous or surgical tracheostomy
• In most adult ICU patients requiring elective tracheostomy and without
contraindications to percutaneous tracheostomy, it has been suggested that
percutaneous dilatational tracheostomy (PDT) should be considered the
procedure of choice.

15. • Indications and Contraindications to PDT
• Three critically important preoperative criteria for PDT are:
• Ability to hyperextend the neck
• Presence of at least 1-cm distance between the inferior cricoid cartilage and
the suprasternal notch, ensuring that the patient will be able to be re-intubated
in case of accidental extubation.
• Patient tolerance of transient hypercarbia and hypoxemia

16. • Relative contraindications to PDT are:
• Emergency airway access
• Difficult anatomy
• Morbid obesity with short neck
• Limited neck movement
• Cervical spine injury, suspected or otherwise
• Aberrant blood vessels
• Thyroid or tracheal pathology

17. • Relative contraindications to PDT are:
• Coagulopathy, clotting disorder
Prothrombin time or activated partial thromboplastin time 1.5 time reference range
Thrombocytopenia, platelet count 50,000 cells/L
• Significant gas exchange problems, eg PEEP 10 cm H2O or FIO2 0.6
• Evidence of infection in the soft tissues of the neck at the insertion site
• Need for proximal or distal extension tracheostomy tube placement

20. • The preponderance of evidence confirms that percutaneous tracheostomy is as
safe as surgical tracheostomy and is associated with decreased procedural
time and cost

21. • Asystematic review comparing different PDT techniques in critically ill adult
patients examined data from 1,130 subjects in 13 randomized trials.
• Multiple dilators, single-step dilatation, guide wire dilating forceps, rotational
dilation, retrograde tracheostomy, and balloon dilation techniques were all
performed bedside in the ICU.
• The different techniques and devices appeared largely equivalent

24. Comparison of 2 single tapered dilator percutaneous tracheostomy sets. A: Ciaglia Blue
Rhino. B: Portex ULTRAperc (White Rhino).

25. A) Placing the finder needle. (B) Identifying the finder needle in the trachea via bronchoscopy.
(C) Inserting guidewire via needle with subsequent removal of needle.

26. Insertion of 12-F dilator with a straight path downward over the guidewire.

27. (A) The conical dilator is fed onto the guidewire so that wire can be seen on both sides. (B)
Using an overhand motion, the conical dilator is advanced into the trachea. (C) The
bronchoscopic image as conical dilator is advanced into the trachea.

29. • (A) The appropriately sized tracheostomy tube, with an obturator (blue) to keep it stiff, is
fed onto the cannula–guidewire complex.
• (B) This tube is then advanced en masse into the trachea.
• (C) This is the bronchoscopic view of the tracheostomy with cuff not yet inflated. The
obturator, cannula, and guidewire have been removed while the tracheostomy is stabilized
with the nondominant hand.
• (D) The cuff is inflated and bronchoscope is inserted via the tracheostomy to confirm
position in the trachea. The endotracheal tube will then be removed.

30. Ciaglia Blue Dolphin percutaneous technique.

31. • Ciaglia Blue Dolphin percutaneous technique.
• This is a safe and effective percutaneous tracheostomy technique that uses
radial outward dilation to minimize bleeding and injury to tracheal rings.
• A: Balloon inflation with normal saline to a maximum pressure of 11 atm
using an inflation pump. The balloon protrudes 1–1.5 cm above the skin
surface.
• B: Ciaglia Blue Dolphin components: (1) introducer needle, (2) guide wire,
(3) 14 French dilator, (4) balloon-tipped catheter loading dilator assembly, (5)
Cook inflation device.

32. PercuTwist technique for percutaneous tracheostomy. A: PercuTwist dilator. B: CrystalClear
cannula. C: PercuQuick cannula. D: PercuTwist set.

33. Tapered tracheostomy tubes for use with percutaneous dilatational tracheostomy to avoid poor fit with tapered
dilators. A: Portex Per-Fit (courtesy Smiths Medical). B: VersaTube (courtesy Cook Medical). C: Shiley PERC
(courtesy

34. Percutaneous dilatational tracheostomy limitations: need for proximal or distal extension
tracheostomy. A: Proximal extension for full or thick neck. B: Distal extension for long
tracheal anatomy, tracheal stenosis, or tracheomalacia.

35. • Need for Proximal or Distal Extension Tracheostomy.
• Proximal extension tracheostomy may be required with thick neck anatomy
and in obese patients
• Distal extension tracheostomy may be required in patients with long tracheal
anatomy, tracheal obstruction (to get the tip distal to the obstruction), or
tracheomalacia

36. • High-Risk Patients and Percutaneous Dilatational Tracheostomy
• The largest study examining this issue reported a single-center prospective
analysis of 1,000 PDT procedures (2001–2009) in ICU subjects with
increased bleeding risk or obesity.
• They identified that increased international normalized ratio was the most
important risk factor for bleeding followed by thrombocytopenia
• Interestingly, platelet dysfunction associated with continuous renal
replacement therapy was not associated with increased bleeding risk
• The rate of complications in subjects with high body mass index was not
increased.

37. • Tracheostomy Decannulation
• Answer the following to determine readiness of patient
• Have the indications for the tracheostomy placement resolved or significantly
improved?
• Is the patient tolerating a decannulation cap on an appropriately sized
uncuffed tracheostomy tube without stridor?
• Does fiberoptic laryngoscopy confirm airway patency to the level of the
glottis and immediate subglottis?

38. • Tracheostomy Decannulation
• Answer the following to determine readiness of patient
• Does the patient have an adequate level of consciousness and
laryngopharyngeal function to protect the lower airway from aspiration?
• Does the patient have an effective cough while the tracheostomy tube is
capped?
• Have all procedures that require general endotracheal anesthesia been
completed?

39. • If yes to all, proceed with the following decannulation process:
• Remove the tracheostomy tube
• Clean the site
• Cover the site with a dry gauze dressing
• Instruct the patient to apply pressure over the dressing with fingers when talking or
coughing
• Change dressing daily and as needed if moist with secretions until the site has
healed
• Monitor for decannulation failure

40. • Additional Recent Advances in Tracheostomy
• Real-Time Ultrasound
• There are currently no randomized trials to establish the safety or efficacy of
preprocedural and/or real-time ultrasound guidance during PDT compared
with the current standard of care.

41. Real-time ultrasound should be considered in
Obese patients in whom surface landmarks are difficult to discern
• Patients with altered cervical anatomy
• Difficult tracheostomy procedures such as repeat tracheostomy.

42. • There are some potential advantages to the real-time ultrasound PDT
technique, including
• (1) Decreased hypercarbia and associated increased intracranial pressure in
neurologic and TBI patients due to no bronchoscope in the airway
• (2) Avoidance of vascular structures in the anterior neck, particularly the
midline thyroid veins
• (3) Direct visualization of the site of entry into the trachea and determination
of which tracheal ring, which is particularly useful in patients with difficult
surface anatomy, morbid obesity, and previous tracheostomy.

43. • In conclusion, there is no benefit to early tracheostomy in most ICU patients
with acute respiratory failure, and waiting until 10 days of intubation and
mechanical ventilation is recommended
• Special patient populations may benefit from early tracheostomy, including
• (1) high likelihood of prolonged mechanical ventilation (ARDS, COPD,
failed primary extubation)
• (2) SCI and chronic neurologic disorders
• (3) TBI patients

44. • Recent large randomized trials have confirmed that clinicians and intensivists
are poor in predicting who will need prolonged intubation
• The optimal technique for tracheostomy is PDT with bronchoscopic guidance
• Choice of technique must take into account both individual and institutional
experience, body habitus, risk factors for bleeding, and pathophysiology

45. • It has been demonstrated that tracheostomy teams and a tracheostomy hospital
service are associated with standardized protocols and improved outcomes.
• The UK National Tracheostomy Safety Project has standardized resources

47. • Tracheostomy Tubes
• The inner diameter, outer diameter, and any other distinguishing
characteristics (percutaneous, extra length, fenestrated) are marked on the
flange of the tube as a guide to the clinician.

48. Components of a standard tracheostomy tube.

49. • Anatomy of the Tracheostomy Tube
• Tracheostomy Tube Material
• Metal tubes are constructed of silver or stainless steel.
• They are not used commonly due to expense, rigid construction, and lack of a
cuff and a 15-mm connector to attach a ventilator.
• Metal is durable, inhibits bacteria growth, does not react with tissues, resists
biofilm formation, is easy to clean, and can be sterilized with heat or steam.
• .

50. • Anatomy of the Tracheostomy Tube
• Tracheostomy Tube Material
• The most commonly used tracheostomy tubes are made from polyvinyl
chloride (PVC), silicone, or polyurethane.
• PVC softens at body temperature, conforming to patient anatomy and
centering the tube in the trachea.
• Silicone is naturally soft and unaffected by temperature, resists colonization
and biofilm buildup, and can be sterilized.

51. • Tracheostomy Tube Dimensions
• The dimensions of tracheostomy tubes are given by their inner diameter, outer
diameter, length, and curvature.
• The sizes of some tubes are given by Jackson size, which was developed for
metal tubes and refers to the length and taper of the outer diameter. These
tubes have a gradual taper from the proximal to the distal tip.
• The Jackson sizing system is still used for most Shiley dual-cannula
tracheostomy tubes , but the International Organization for Standardization
(ISO) method of sizing as determined by the inner diameter of the outer
cannula at its smallest dimension is used for most other tubes.
• .

52. • Tracheostomy Tube Dimensions
• For dual-cannula tubes, the diameter of the inner cannula is the functional
inner diameter. The outer diameter is the largest diameter of the outer cannula.
• Tracheostomy tubes that might at first seem similar may in fact be quite
different in their dimensions .
• When selecting a tracheostomy tube, the inner diameter, outer diameter, and
length must be considered

53. • If the outer diameter is too large, the leak with the cuff deflated will be
decreased, and this will affect the ability to use the upper airway with cuff
deflation for speech.
• A 10-mm outer diameter tube is usually appropriate for adult women, and an
11-mm outer diameter tube is usually appropriate for adult men

54. • Tracheostomy tubes are angled or curved
• Because the trachea is essentially straight, the curved tube may not conform
to the shape of the trachea, potentially allowing for compression of the
membranous part of the trachea, while the tip may traumatize the anterior
portion.
• The angled tube may be better centered in the trachea and exert less pressure
along the tracheal wall.

55. Shiley single-cannula tube (left) and Shiley percutaneous tube (right). Both are size 8 tubes,
but note the differences in size and style between them.

57. • Extra Length Tracheostomy Tubes
• If the tracheostomy tube is too short, the distal end can obstruct against the
posterior tracheal wall
• Extra length tubes are constructed with extra proximal length (horizontal extra
length) or with extra distal length (vertical extra length).
• Extra proximal length facilitates tracheostomy tube placement in patients with
a large neck (eg, obese patients).
• Extra distal length facilitates placement in patients with tracheomalacia or
tracheal anomalies.

58. A: Endoscopic view showing a correctly positioned tracheostomy tube. B and C:
malpositioned tracheostomy tubes

59. • The most common malposition resulted in the posterior tracheal wall
occluding the distal tip of the tube.
• There should be a high index of suspicion for tracheostomy tube malposition
when patients demonstrate unanticipated difficulty in being liberated from
mechanical ventilation following tracheostomy.
• Several tube designs have a spiral wire-reinforced flexible design.
• These tubes are not compatible with lasers, electrosurgical devices, or
magnetic resonance imaging.

60. • Dual-Cannula Tracheostomy Tubes
• The use of an inner cannula allows it to be cleaned or replaced at regular
intervals without removing the tracheostomy tube from its stoma.
• The inner cannula can be removed to restore a patent airway if the tube
occludes, which may be an advantage for long-term use outside an acute care
facility.
• If a fenestrated tracheostomy tube is used, the inner cannula occludes the
fenestrations unless there are also fenestrations on the inner cannula.
• One potential issue with the use of an inner cannula is that it reduces the inner
diameter

61. • Fenestrated Tracheostomy Tubes
• The addition of an opening in the posterior portion of the tube above the cuff.
• The patient can inhale and exhale through the fenestration and around the tube. This
allows for assessment of the patient’s ability to breathe through the normal
oral/nasal route (preparing the patient for decannulation)
• The cuff must be completely deflated by evacuating all of the air before the tube is
capped. The decannulation cap is then put in place to allow the patient to breathe
through the fenestrations and around the tube
• The fenestrations may cause the formation of granulation tissue, resulting in airway
compromise.
• Proper position of the fenestrations in the airway should be inspected regularly.

62. Fenestrated tracheostomy tube.

63. • Subglottic Suction Port
• Tracheostomy tubes that provide a suction port above the cuff are available.
• One such design is the Blom tracheostomy tube .
• The subglottic suctioning cannula is located on the exterior surface of the
cannula as a separate lumen, which can be connected to intermittent or
continuous suction, and is intended for the evacuation of secretions situated
above the tracheostomy tube cuff.

64. Tracheostomy Tube Cuffs
. Uncuffed
• Tubes allow airway clearance but provide no protection from aspiration.
Cuffed tracheostomy tubes allow secretion clearance and offer some
protection from aspiration, and positive-pressure ventilation can be more
effectively applied when the cuff is inflated.
• Specific types of cuffs used on tracheostomy tubes include high-volume low-
pressure cuffs, tight-to-shaft cuffs (low-volume high-pressure), and foam
cuffs.
• Tracheal capillary perfusion pressure is normally 25–35 mm Hg. Because the
pressure transmitted from the cuff to the tracheal wall is usually less than the
pressure in the cuff, it is generally agreed that 30 cm H2O (22 mm Hg) is the
maximal acceptable intracuff pressure.

65. • it is recommended that cuff pressure be maintained at 20–30 cm H2O (15–22
mm Hg) to minimize the risks for both tracheal wall injury and aspiration.
• Intracuff pressure should be monitored and recorded regularly (eg, once per
shift)
• A common cause of high cuff pressure is that the tube is too small, resulting
in overfilling of the cuff to achieve a seal in the trachea.
• Another common cause of high cuff pressure is malposition of the tube (eg,
cuff inflated in the stoma).
• Other causes of high cuff pressure include overfilling of the cuff, tracheal
dilation, and use of a low-volume high-pressure cuff.

66. • The tight-to-shaft cuff minimizes air-flow obstruction around the outside of
the tube when the cuff is deflated. It is a low-volume high-pressure cuff
intended for patients requiring intermittent cuff inflation.
• When the cuff is deflated, speech and upper airway use are facilitated. The
cuff is constructed of silicone. It should be inflated with sterile water because
otherwise the cuff will automatically deflate over time due to gas permeability.
• A foam cuff consists of a large-diameter high-residual volume cuff composed
of polyurethane foam covered by a silicone sheath. The foam cuff was
designed to address the issues of high lateral tracheal wall pressures that lead
to complications such as tracheal necrosis and stenosis.

67. • Stomal Maintenance Devices
• Several approaches can be used for stomal maintenance in patients who cannot
be decannulated.
• One of the easiest approaches is to use a small cuffless tracheostomy tube (eg,
size 4 cuffless).
• Another approach is to use a tracheostomy button

69. • This device consists of a hollow outer cannula and a solid inner cannula. It fits
from the skin to just inside the anterior wall of the trachea.
• With the solid inner cannula in place, the patient breathes through the upper
airway. When the inner cannula is removed, the patient can breathe through
the button, and a suction catheter can be passed through the button to aid
airway clearance.
• Since a tracheostomy button does not extend into the trachea and does not
have a cuff, its use is limited when there is a risk of aspiration or during
positive-pressure ventilation.
• Other devices used for stomal maintenance include the Montgomery Safe-T-
Tube and the Montgomery long-term cannula

70. Montgomery Safe-T-Tube (left) and long-term cannula (right).

71. • Changing the Tracheostomy Tube
• The tracheostomy tube may be changed to another one for a number of
reasons:
to reduce the size of the tube, to change the length of the tube if it is
malpositioned, because it is obstructed with secretions, because it is broken (eg,
cuff leak), to change the type of tube, or as a routine change with a chronic
tracheostomy.
• It is advisable to have 2 people present.
• Prior to removing the old tube, all components of the new tracheostomy tube
should be checked for integrity

72. • The patient is placed either supine or semirecumbent, with the neck extended.
Removal of a tube through a tight stoma with a bulky cuff can be facilitated
using lidocaine jelly or water-soluble lubricant inserted around the stoma/tube
interface.
• The tube exchanger is passed through the tube into the trachea. The tube is
then withdrawn while keeping the tube changer in place, and the new tube is
passed over the tube changer into the trachea.
• Changing the tracheostomy tube in the patient’s home is not recommended

73. • Shiley recommends changing their PVC tracheostomy tubes every 29 d.
• The Portex Blue Line package insert recommends 30 d as the maximal
recommended period of use. The Portex Bivona tube package insert
recommends it be used for up to 29 d.
• Many manufacturers recommend that a tube with an inner cannula should not
be used for 30 d.
• Several studies have reported material breakdown of tracheostomy tubes over
time.

74. Algorithm to manage failure to replace a tracheostomy tube during a routine change.

75. • Decannulation
• Decannulation be considered in patients once mechanical ventilation is no
longer needed, upper airway obstruction is resolved, airway secretions are
controlled, and swallowing has been evaluated.
• Level of consciousness, ability to tolerate tracheostomy tube capping, cough
effectiveness, and secretions as the most important factors in the decision to
decannulate.

77. • Accidental Decannulation
• Accidental decannulation occurring in a patient with a mature stoma and with
normal neck anatomy should be a benign event because the tracheostomy tube
can usually be easily reinserted
• Factors associated with accidental decannulation include mental status
changes, increased secretions, and shift change.

79. • Ward Versus ICU
• There has been some concern raised about the safety of patients with a
tracheostomy who are managed outside the ICU.
• In a prospective observational survey from 31 ICUs in Spain, Fernandez et al
reported that, after adjustment for the propensity score and Sabadell score, the
presence of a tracheostomy cannula was not associated with any survival
disadvantage.

80. • Speaking With a Tracheostomy Tube
• Spontaneously Breathing Patients
• With the cuff deflated (or with a cuffless tube), patients (or their caregivers)
can place a finger over the proximal opening of the tracheostomy tube to direct
air through the upper airway and thus produce speech.
• In the spontaneously breathing patient, a speaking valve directs the exhaled
gas through the upper airway, which may allow the patient to speak.

82. Equipment used to measure tracheal pressure when a speaking valve is applied.

83. • Speaking Valve Contraindications
• Unconscious or comatose patients (relative)
• Inflated tracheostomy tube cuff or foam-cuffed tracheostomy tube(absolute)
• Thick and copious secretions (relative)
• Severe upper airway obstruction (absolute)
• Endotracheal tube rather than tracheostomy tube (absolute)

84. • The patient’s risk for aspiration should be evaluated before the speaking valve
is placed
• If the tracheal pressure is 5 cmH2O during passive exhalation (without
speech) with the speaking valve in place, this may indicate excessive
expiratory resistance.
• If the tracheal pressure is high, consideration should be given to downsizing
the tube.

85. • The ability of the patient to tolerate the speaking valve can be briefly assessed
by finger occlusion of the tracheostomy tube after cuff deflation.
• Oxygen can be administered while the speaking valve is in place using a
tracheostomy collar or an oxygen adapter on the speaking valve.
• Care must be taken to ensure that the cuff is deflated before the speaking valve
is attached.

86. Blom speech cannula. Inspiratory pressure opens the flap valve and closes (expands) the bubble valve,
sealing the fenestration so that all of the tidal volume goes to the lungs. As inspiration ends, the flap
valve closes. Expiratory pressure collapses the bubble valve, which unblocks the fenestration and
directs all of the exhaled air to the upper airway to allow phonation.