Chapter 12: Respiratory care, CPR and blood transfusion
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Source: Adapted from Bonvento et al. ([28]), Cheung and Napolitano ([44]), Hyzy and McSparron ([115]), NTSP ([206]).
Source: Adapted from Ceachir et al. ([39]).
Evidence‐based approaches
Types of tracheostomy
A temporary tracheostomy may be performed surgically in theatre or percutaneously in a critical care environment. The tracheostomy may be formed because the patient is unable to maintain their own airway and/or clear their own secretions, because they are expected to require ventilator support for longer than 7–10 days, or because they are expected to be a slow respiratory wean from the mechanical ventilator (Cosgrove and Carrie [52]). It may also be formed during certain head and neck surgeries to allow access to the upper airways. The tracheostomy tube will be removed as soon as the patient has recovered and can safely maintain their own airway again.
A permanent tracheostomy is required when it is unlikely that the patient will be able to maintain their own airway or manage their own secretions because of an underlying disease or condition that is likely to be progressive or irreversible. Examples of such conditions include certain cancers of the head and neck, a neuromuscular disorder, a cerebral vascular accident or following a traumatic head injury (Cheung and Napolitano [44]). In these examples, other than the creation of the tracheostomy stoma, the patient's anatomy is not surgically altered and the upper airway remains connected to the trachea.
Following complete surgical removal of the larynx (total laryngectomy), the trachea is sutured in position to form a permanent stoma, known as a laryngectomy stoma. Because the patient's anatomy has been permanently altered, there is no longer any connection between the upper airways and the trachea, and the patient will breathe through the laryngectomy stoma for the remainder of their life (Ceachir et al. [39]).
Percutaneous tracheostomy
The percutaneous method most commonly used is known as percutaneous dilatational tracheostomy (PDT). It enables the pre‐tracheal tissues to be incised under local anaesthesia. A sheath is inserted into the trachea between the cricoid and the first tracheal ring, or between the first and second rings. A series of conical dilators are slipped over a guidewire, progressively dilating the trachea until the stoma is dilated enough to allow insertion of a tracheostomy tube (Cheung and Napolitano [44]).
Percutaneous tracheostomies are more cost‐effective and are associated with fewer complications than surgical tracheostomies and so are becoming increasingly popular (Cheung and Napolitano [44]). They also have the additional benefits of rapid stoma closure and healing following decannulation (tracheostomy tube removal), with patients being left with a smaller and less visible scar (Batuwitage et al. [15]). They are frequently performed in the critical care setting as an early intervention after initiation of mechanical ventilation (Cosgrove and Carrie [52]).
Surgical tracheostomy
Surgical tracheostomy is ideally performed in the operating theatre under a general anaesthetic. The procedure is usually elective (planned) and performed during head and neck surgery, or during surgery for other conditions where the patient is expected to have a prolonged period of mechanical ventilation post‐operatively (e.g. gastro‐oesophagectomy). A surgical tracheostomy can also be performed in a critical care environment under local anaesthetic during a life‐threatening airway emergency as a non‐elective procedure (unplanned).
The tracheostomy is usually sited over the second and third, or third and fourth tracheal cartilages. Depending on the type of incision made, temporary stay sutures may be placed to ensure the trachea can easily be recannulated if the tracheostomy tube is accidentally dislodged before an adequate tract has formed. Traction of the sutures helps to keep the trachea open and prevents soft tissues from obscuring the stoma, facilitating recannulation (Lee et al. [131]).
Rationale
Indications
Tracheostomies and laryngectomies are carried out to maintain a patent airway and facilitate effective ventilation. Indications for both are listed in Tables 12.13 and 12.14 respectively.
Table 12.13 Indications for a tracheostomy
| Indication | Detail |
|---|---|
| Airway maintenance or protection | Acute upper airway obstruction (e.g. by a foreign object or oedema of the soft tissues) may make emergency short‐term tracheostomy essential. More lasting damage to the upper airway (e.g. from chemical or inhalation burns) may require long‐term tracheostomy. |
| Laryngeal pathology or prolonged upper airway obstruction (e.g. head and neck surgery) | Some maxillofacial and head and neck procedures make it necessary to secure the patient's airway without obstructing the mouth and pharynx. |
| Tracheal toilet | A patient who has a poor cough and cannot clear their secretions may require a tracheostomy. |
| Prolonged intubation (>7–10 days) | Prolonged endotracheal intubation carries a high risk of damage to the soft tissues of the mouth, pharynx and trachea. It reduces the patient's ability to communicate and increases the work of breathing by extending the dead space. Tracheostomy reduces or removes the risk of tissue damage, facilitates lip reading and reduces the work of breathing by shortening the dead space, so promoting the process of weaning from mechanical ventilation. |
| Delayed return of glottic reflexes | Patients with reduced function in cranial nerves V, VII, IX, X or XII, with damage to the brain stem or a reduced consciousness level, may be unable to maintain a patent airway or protect their airway from aspiration of food, drink and saliva. Short‐ or long‐term tracheostomy may be indicated. |
Table 12.14 Indications for a laryngectomy
| Indication | Detail |
|---|---|
| Malignancy | Laryngectomy can be a curative treatment for laryngeal cancer or malignancy of adjacent structures. |
| Non‐functioning larynx | A functional laryngectomy may be performed if the larynx is no longer functioning and where aspiration is severe and life threatening. This may occur following previous treatments for head and neck cancers. |
| Post‐trauma laryngeal stenosis | Laryngectomy may be performed for severe laryngeal trauma or stenosis when other surgical techniques have not been effective. |
Contraindications
Relative contraindications for tracheostomy include:
- severe localized skin infection
- uncorrected coagulopathies
- tracheomalacia
- an inability to extend the neck due to an underlying condition (e.g. cervical fusion or cervical spine instability).
