SCCM Resource Library-Percutaneous Tracheostomy: State-of-the-Art Update

Video Transcription

Good morning, everyone. Welcome to this session on percutaneous tracheostomy. My name is Wes Shepard. I'm a professor of pulmonary and critical care at Virginia  Commonwealth University and spend a lot of my time in practice in interventional pulmonology. And today, the session will have a focus on three main areas.  First of all, Dr. Chris Radchenko, who is an assistant professor in pulmonary critical care at the University of Cincinnati, will speak on patient selection, timing,  and a little bit about the history of the procedure. I will cover major and common complications and their management. And then lastly, Dr. Linda Morris,  who's a professor and director of nursing research and an APN at the Shirley Ryan Ability Lab Rehab Hospital, and also associate professor of PM&R and anesthesiology  at the Northwestern Feinberg School of Medicine. We'll probably hold questions till the end of all three talks. But thank you guys for hanging in there till the last morning.  You never know what size audience you're going to get at the end of the meeting. But real quick audience survey, just so we have an idea. And I'll probably miss somebody.  Just raise your hand. Pulmonary critical care, all right, thoracic surgery, APPs, physician assistance, respiratory therapy, nursing, other critical care. All right.  How many of you are currently involved in some way in the practice of percutaneous tracheostomy? Great. All right. Excellent. So we'll start with Dr. Radchenko.  Thank you.  OK, excellent. Good morning, everyone. As Dr. Shepard had mentioned, my name's Christopher Chanko. I'm from University of Cincinnati, one of the interventional pulmonologists there.  It's a pleasure being here. Thank you to this society for allowing us to present this presentation. I do not have any conflicts of interest. And so over the next 20 minutes, I'm  going to take us through summarizing the historical landmarks and evolution in surgical tracheotomy and percutaneous tracheostomy. We're going to evaluate timing considerations  for placement of percutaneous tracheostomy. And we'll discuss key features in patient selection for those that we're considering performing percutaneous tracheostomy.  So from a historical standpoint, the trachea has been accessed through incisions through the anterior neck, historians believe dating back to ancient Egyptian times,  even back to 3600 BC. In ancient Greece, it was told that Alexander the Great had saved a choking soldier by creating a cervical neck incision with the tip of his sword.  But Asclepias was credited as the first person to perform tracheostomy in 100 BC. Seven centuries later, we started seeing earliest written account of tracheotomy.  So fast forwarding through to the European Renaissance, there hadn't been much progress made with regards to tracheotomy. This procedure was considered dangerous, very low success  rate. Over the course of approximately 350 years, there was really only 28 known reports of tracheotomy performed. Antonio Brasavola performed the first recorded  successful tracheostomy, and he had reported his findings in 1546. In the late 19th century, we started seeing intricate, customized tracheostomy sets  with ivory, sterling silver, inner and outer cannula. And debate had been ongoing into the 20th century with surgeons debating technical aspects of the procedure itself.  Many techniques, surgical instruments, and tracheal tubes were devised. Dr. Chevalier Jackson had described the most common and currently used surgical technique  earlier in the century. But towards the later 20th century, the 1950s and 60s is when we started seeing the idea of percutaneous tracheostomy placement.  But it really hadn't gained popularity until 1985 after the chalea, a needle guide wire with serial dilators technique, was described.  And then over the course of years since that time, we started seeing further refinement and different techniques devised as well, which you can see there. So that was history.  So talking about timing considerations for placing percutaneous dilational tracheostomy or doing tracheostomy is a challenge. So I wish I had a single answer that  would be all-encompassing for all ICU patients. But unfortunately, that doesn't exist. There's no optimal time with significant practice variation  among physicians on when to place a trach. So part of the challenge is that there's heterogeneity in the definition for early versus late tracheostomy.  Some will describe 2 to 14 days as early, 10 to 28 days as late. But there had been ongoing debate even to this day. But for the last 40 years, there had really  been ongoing debate for early versus late placement of tracheostomy. But truly, the decision needs to be individualized according to the clinical presentation, the disease  process, requirement of prolonged mechanical ventilation, and patient preference.  So how are we doing as a critical care society? So a study by Estevan and colleagues, they had looked at practice patterns across over 400 ICUs,  over 4,000 patients across the world. And they were finding that practice trends generally were towards placement of tracheostomy after a median of 11 days of being  on mechanical ventilation. And so the earlier studies that were done, they were looking at placing tracheostomy early. And what they were seeing was that there actually  was improvement in short-term outcomes. They were seeing reduction in VAP rates. They were seeing that there was increased ventilator-free days, sedation-free days.  And actually, various studies were showing that there was an improvement in mortality. So this ended up leading to development of more rigorous studies.  And so the study I'm showing here is Taragny and colleagues. This was a study that was published in JAMA. They had randomized patients to undergo early tracheostomy  at 7 days versus late at 14 days. And what they had seen that their primary outcome was for ventilator-associated pneumonia.  And they did not see that there was a significant difference, although there was a trend. But they were seeing that there was a higher likelihood  of weaning from the ventilator, a higher likelihood of discharging from the ICU within 28 days if you were assigned to the early tracheostomy group.  They did not find that there was a change in outcomes at one year, however. This led further on to the tracheo-management study, which was a multi-center randomized control  trial of over 1,000 patients assigned to either early tracheostomy within four days versus late tracheostomy 10 days after being on mechanical ventilation.  And what they found was that there was actually no impact on 30-day or two-year mortality. There was no impact on ICU length of stay. There was no difference in antibiotics.  So they tried to tease out VAP rates by using antibiotic-free days. And there was no difference between both groups. What they did find was that there was reduced sedative use  in the early group. But interestingly, 53% of patients, over half of the patients that were assigned to the late tracheostomy group didn't actually receive  tracheostomy because they had subsequently improved and they had been liberated from mechanical ventilation before the time of being assigned to tracheostomy.  Again, just kind of showing that we don't have the best tools in predicting who's going to require prolonged mechanical ventilation versus not. So to help better look at the data,  there was several meta-analyses that were performed. I'm showing two of them. So the first meta-analysis was by Hosokawa and colleagues.  And what they had done was they stratified early versus late with a 10-day cutoff, early being before 10 days, late being after 10 days.  And what they had seen is that there were better outcomes with early tracheostomy with regards to ventilator-free days as well as sedation or sedation-free days.  But what they had also found was that there was higher rates of tracheostomy placement suggesting, or in the early group that was suggesting  that perhaps the outcome was being affected by patients that were getting early tracheostomy that may not have necessarily needed that. And had they left them,  they would have been subsequently liberated from mechanical ventilation. And then the other meta-analysis that I'm showing was by Sacmani and colleagues.  And in their meta-analysis, they had failed to demonstrate any reduction in mortality, duration of mechanical ventilation, ICU length of stay,  or VAP among patients mechanically ventilated for under 10 days. And what they did find, again, was that there was a reduction in sedation requirements, but they had also found  that early tracheostomy led to more procedures. So with that, for timing of tracheostomy, it's difficult to standardize the decision. And the decision truly needs  to be individualized for each patient. Typically, we don't perform tracheostomy before 10 days unless prolonged mechanical ventilation can easily be determined.  We use an anticipatory approach where you would look at the patient, looking at what is the likelihood that they'll require prolonged mechanical ventilation.  You give consideration for the underlying disease process, such as a stroke or a cervical spine injury, and also consider costs, airway security, as well as LTAC options.  So finally, let's go through patient selection. So this is an interesting area that has changed, and it seems like every time we have discussions  on contraindications, relative contraindications, that they're always changing. So to start, who are the ideal patients for percutaneous dilational tracheostomy?  And so the ideal patient would be someone with a long, thick, thin neck, able to undergo full neck extension, who has good palpable anatomy,  two to three centimeters above the suprasternal notch, who is not on significant amounts of PEEP, like beyond extremes, 10, 12, 17 centimeters  of water pressure, who is hemodynamically stable, no coagulation abnormalities, and has a history of being inubated without difficulty.  But unfortunately, that is not reality for the majority of the patients that we take care of. So for this slide here, I wanted to show you this.  So at one point in time, probably dating back 20 years, 10 years ago even, many of these conditions that are listed under relative contraindications were considered absolute  contraindications. But as the technique has been further refined, people have gained further experience with it. What we're finding is  that the absolute contraindications I'd listed were an overlying site infection and truly an uncorrectable coagulopathy, although that may be able to be argued.  For relative contraindications, obesity is one of them that we commonly get consulted on, and you see many patients in the ICU who do have obesity.  Coagulopathy, patients that are on high amounts of pressure on the ventilator or have high oxygen requirements. Those that have limited cervical motion,  increased intracranial pressures, redo tracheotomy among others. And so I was going to touch on some of the key features here.  So with obesity itself, so obesity can create a challenge for many reasons, not only for percutaneous tracheostomy, but also for surgical tracheostomy.  And so whenever we're called to evaluate a patient who has obesity, truly a bedside exam is going to be more important than what the patient's BMI is.  And so if you go to the bedside and you can palpate anatomy accurately, this is going to be more important than the true BMI number when you're evaluating these patients.  But here, as you can see here, is that with obesity, although the procedure has been done, what we're seeing highlighted in red is that there are increased rates of complications.  In the by hand study, there was up to 40% minor complication rates. And then for major complications, it can increase up to, you know, 10, 12%, somewhere in that realm.  So with obesity, it's increasingly common that we're seeing this in the ICU. Surgical tracheotomy can also be very difficult. So studies use diverse techniques  with varying degrees of BMI. There are some studies where they had over 100 BMI where they're replacing tracheostomy. Neck anatomy is certainly more important than BMI.  Keep patients in an upright position. You'll be able to tell when you flatten them if they're going to desaturate or if they'll tolerate the procedure from that perspective.  And oftentimes, you have to place extra long tracheostomy tubes, which are compatible with several of the different sets for PDT.  With coagulopathy, what about coagulopathy? So there are many studies on percutaneous tracheostomy with coagulopathy.  This is a summary of many of the studies here. And basically from this is that the procedure can be done on patients with coagulopathy, and it can be done safely with correction  of coagulation abnormality. But what we were seeing here is that there is an increased trend for complication rates  the more abnormal people's coagulation parameters are. This Beider-Linden study here itself was showing that patients that were thrombocytopenic  with a platelet count less than 50,000 or a PTT with greater than 50 seconds, they were seeing that not necessarily for acute bleed.  Acute bleed was a problem with the initial incision site and the target of where you're going, but more so with chronic bleeding.  And what you can see is that odds ratios were five times for a thrombocytopenia less than 50. And again, 3.7 for a PTT greater than 50 as well.  But combined, you're getting odds ratios  of up to 10 when you have both of those parameters that are abnormal. And the largest study we have, the Roseland study, also kind of reiterated that these patients  that do have abnormal coagulation cascades are at increased risk of bleeding.  Has PDT been done on patients on clopidogrel? And it has, although I will tell you that the data is very sparse, it's very limited. And so a study here that I'm showing  had been done on 20 patients who were on clopidogrel and there was no major bleeding. There was minor bleeding in one of the 20 patients.  So our summary for coagulopathy is that studies use various techniques. We would recommend that you correct coagulopathy as necessary with a platelet threshold greater than 50,000.  Use lidocaine with epinephrine for local anesthesia before your incision. It's likely safe in most coagulopathic patients, but again, there's minimal data on clopidogrel  and some of the newer antiplatelet agents.  This is one slide that I wanted to pay particular attention to. So with high PEEP, oftentimes we get consulted for patients that are on high amounts of PEEP on the ventilator.  And so are these patients safe to perform percutaneous tracheostomy on? And so there was a study by Beiderlinden and colleagues  where they had looked at patients that were on high PEEP and here it was greater than 10 millibar, which is very, very close, 0.98 centimeters of water pressure.  And what they had looked at was 88 patients with a mean PEEP of 16.6, which is quite high, versus 115 patients with a mean PEEP of 7.6. They had used various techniques  for percutaneous tracheostomy. And what they had seen was that oxygenation and various oxygenation indices that they were looking at were no different between the two groups  at one hour post-procedure and 24 hours post-procedure. So although it can safely be performed, we would recommend that patients be optimized  and employ a risk mitigation strategy as best as possible when doing percutaneous tracheostomy on patients on high amounts of PEEP.  So a couple others that I was gonna say before I close here was with limited cervical motion. So we do get consulted on patients  that have unstable C signs and limited cervical motion. It has been done. Some of the studies that had been conducted for patients that had non-cleared C spines,  there's a study here by Mayberry and colleagues. They were successful in 96% of the cases. And the complication rates were similar to those that were non-cleared.  And this looked like it was very similar between these other studies here that I've listed. Again, with a couple of minor complications,  but no significant long-term major complications.  Increased intracranial pressure is one that we have concern for. And so the concern is that any type of airway procedure, and certainly tracheostomy may increase  in intracranial pressures. And so this study by Malanki and colleagues found that although there was a slight increase in ICP during the procedure,  this was not statistically significant.  A further study on this actually randomized 30 patients to surgical trach versus percutaneous trach versus translaryngeal trach.  And what they had found was that the intracranial pressures increased in all of these groups. ICP or intracranial hypertension was more common in percutaneous tracheostomy.  But cerebral perfusion pressure did drop more frequently with surgical tracheostomy. During cannula placement, there was increase in PaCO2 in all groups.  And then finally, TIP trial. So this was a trial that was done on patients that had severe cerebral disease.  So mostly stroke, hemorrhagic strokes, CVAs, traumatic brain injury. They had looked at 38 patients where they were monitoring ICPs and mean arterial pressures.  They were giving Manitol for ICPs greater than 30. And what they were finding was that the median ICP had rose from nine to 18 millimeters of mercury. There was transient events  greater than 30 millimeters of mercury. And this was seen along with CPP dropping,  but mainly during positioning of the procedure. So our summary on limited cervical motion and intracranial elevation and intracranial pressure  is that the anatomy, again, is very important. Neck should remain in a neutral position. Remove the C collar, but maintain stabilization of the neck laterally.  Be aware of your anterior-posterior pressure when doing your dilations. And keep the head of the bed greater than 30 degrees. In patients with critical cerebral disease,  ICP and cerebral perfusion pressure monitoring should be performed.  And then finally, once upon a time, redo tracheostomy. This was considered an absolute contraindication. But actually, some studies, again, not robust data,  but studies are showing that it certainly can be done. And from experience, oftentimes it is much easier to do a percutaneous tracheostomy on a prior tracheostomy case.  But again, just don't assume that the previous scar or tract is always in the correct location. And then finally, a piece on emergency tracheostomy.  So this has been done by very experienced surgeons.  But what we will say is that although it's been done, the literature is very limited. And it's certainly not the first-line airway rescue technique that we would recommend.  And with that, I'll leave you with this slide, again, looking at the relative and absolute contraindications. And I will go ahead and pass along to Dr. Shaffer.  Thank you, Chris, for that great summary.  So we'll transition into discussions on complications and management.  Unfortunately, if you do enough percutaneous tracheostomy or tracheostomy in general, you will face this topic at some point.  These are my disclosures. None of them are directly related to the topic at hand today. And so we'll basically just run through  some of the most common and most significant complications encountered with the procedure, and then some approaches to their management. So I think the best way to organize  percutaneous tracheostomy complications  are as listed in this table. So there are many things that can happen on an intra-procedural timeframe, and we'll touch on many of these. And then early post-procedural  in the first week or two following the procedure, and then, of course, late post-procedural complications. Now, obviously, not everything on this list  is specific to percutaneous tracheostomy. Many of these things can also occur in surgical tracheostomy as well, but we're gonna focus on those related to the percutaneous technique.  So let's start with a case. 68-year-old with prolonged mechanical ventilation following a myocardial infarction. Been intubated for 15 days,  slowly resolving heart failure and pneumonia. Of course, they're on Plavix and aspirin for the coronary stents they had placed at the time of admission.  You can see the ventilator support, volume ventilation, FIO2 60%, A to P, platelets 136, INRs 1.6. They're on continuous renal replacement therapy, and you have been consulted  to perform a percutaneous tracheotomy.  Not an uncommon scenario.  So just one note, we do not have audience response, so we're gonna use low-fidelity audience response, which is either your left hand or your right hand  if you guys don't mind participating in the low-fidelity technique. So as the consultant, which of the following do you recommend? Continue mechanical ventilation  for several more days and reassess. Proceed with a PERC trach on aspirin and Plavix. Proceed with a PERC trach on aspirin and Plavix after transfusing with platelets or FFP.  Or recommend a surgical consult for surgical tracheotomy to be performed on aspirin and Plavix. How many would choose A?  So a couple would wait. How about B?  So many of you would actually perform it on aspirin and Plavix. C?  And D?  All right, so pretty, the responses are pretty well distributed amongst those areas. So I highlighted all of these. There's not really an absolute right answer here, obviously,  but the scenario is one we see fairly commonly. So we'll touch on some of those issues. Which of the following regarding coagulopathy and percutaneous tracheotomy is correct?  A, major severe bleeding occurs  in 10 to 15% of cases. B, randomized clinical trials show no difference in PERC trach performed on Plavix versus controls. C, a low fibrinogen level or a SAP score greater than 40  are independent predictors of significant bleeding with PERC trach.  Or D, renal replacement therapy does not predict the risk of bleeding. So who thinks A is correct?  All right, B.  Okay, C.  And D.  All right, again, we have somewhat of a distribution. So in this case, a low fibrinogen and a SAP score actually have been shown to show some prediction in terms of bleeding  following the procedure. Chris showed you this slide. I put it up again, again, only to emphasize the tremendous heterogeneity  in the PERC trach literature when it comes to coagulopathy, most of which is related to INR and thrombocytopenia. There's very little published in the realm of antiplatelet therapy.  So just to highlight a couple of those papers, and Chris did show you this first paper with 246 patients, a small number of which 20 were either on Plavix  or had been off of Plavix three days or less. It was a retrospective chart review with a control group, no major bleeding with no significant difference in minor bleeding.  The middle study was a larger study, 1,000 patients, a more homogenous technique. They were all single dilator, single tapered dilator percutaneous tracheostomy.  90% of them had either none or considered mild bleeding. 8.4% had moderate bleeding.  They reported one severe bleeding episode that actually required surgical intervention. But if you look at those that had moderate or major bleeding in that group, severe group,  they had a higher SAP score, lower fibrinogen, higher prevalence of continuous renal replacement therapy, lower platelet counts performed by a resident,  no offense if there's any health staff residents in the audience, higher incidence of coagulopathy, and logistic regression analysis showed independent  predictors, again, low fibrinogen, SAP score, less experienced operator, and difficult procedure. The third paper looked interestingly at bivalirudin and heparin,  some of which the drips were continued. They didn't give a good clear reason why the drips had to be continued during the procedure. They also had concomitant thrombocytopenia,  much smaller group of patients. Only one patient described major bleeding in that group. Okay, so you decided, we went with the majority of you,  and you decided to proceed with the procedure on aspirin and Plavix. Following the dilation with the single tapered dilator,  you notice brisk pooling of a large amount of dark blood. What is your next step to manage this patient? Hold pressure and call for surgical backup.  Quickly proceed and place the tube.  Order a STAT platelet transfusion and give DDAVP, or try to apply silver nitrate or some form of cautery to the edge of the incision.  So, how many of you would choose A, B, C, and D? All right, I think we had a fairly dominant consensus on B. So, quickly proceed with placement of the tracheostomy tube.  So, in cases of brisk, what appears to be dark venous bleeding pooling after dilation with the tapered dilator or the punch dilator, this is usually a venous bleeding source,  most likely from superficial veins. So, the best approach in these cases is usually proceed and tamponade the bleeding with actual placement of the trach tube.  That is effective in almost all cases. You can hold pressure, but you may be doing that for a long time. Obviously, ordering transfusions are not going  to be achievable in a timely manner in these cases in order to stop the bleeding. So, in cases that seem to be brisk venous bleeding,  tamponading with the actual trach tube is usually a very effective next step. Which of the following regarding PERC trach intra-procedural bleeding is correct?  Randomized clinical trials using ultrasound have demonstrated a reduced incidence in bleeding. The most common cause of death during percutaneous tracheostomy is bleeding  related complications. Moderate to major intra-procedural bleeding most commonly is due to the thyroid gland. And bronchoscopic guidance reduces the incidence of major bleeding.  Who would say A is correct?  B? C? Yeah, everyone's afraid of the thyroid. D? All right. So, actually, in this case, the most common cause of death we see reported in the literature  from percutaneous tracheostomy are bleeding related complications. Now, fortunately, having said that, death during percutaneous trach is actually quite uncommon, quite rare.  If you look at some of the larger case series and more serious listed complications in the literature, it's estimated that a death occurs in about one out of every 600 procedures.  So, if you do enough of these, you may encounter this unfortunate complication. And about a third of those are related to intra-procedural hemorrhage.  A little less than a third are related to airway complications, airway tearing. Now, in that series, only about half the patients were utilizing bronchoscopic guidance,  which we'll talk a little bit more about. There are a number of ultrasound-related papers to guidance of percutaneous tracheostomy,  both in assessing the vasculature prior to placement as well as real-time placement of the needle. Those are sort of two different indications for ultrasound in the procedure.  But none of them have shown a definitive difference in outcomes.  Thyroid isthmus puncture, this used to be described as a complication. We know from just normal anatomy and also from autopsy studies and cadaver studies that this occurs commonly,  probably up to a third of patients. So, you could argue it's not really a complication. Yes, the thyroid is a very vascular organ, but fortunately, even in the cases  of thyroid isthmus puncture, they typically do not have significant bleeding.  If, let me back up, you can see obviously lateral to the trach are the major vessels of the neck. So, one of the risk factors for major vessel puncture, arteries, veins of the neck,  more rarely aorta, would be a deep lateral puncture. So, you miss the trachea altogether and the needle goes very lateral. So, that's always a concern  to watch out for vascular injury.  These are patients that could potentially require urgent surgical repair. But again, this is a very, very uncommon injury to have that severe of a vessel injury.  All right, so, you moved ahead, you placed your trache tube in our patient and it was successful. You've now tamponaded the brisk venous bleeding  that he had and you left the ICU to go to lunch. But of course, you got called back because 30 minutes later, the patient developed subcutaneous emphysema  in the neck and upper chest. So, based on the technique that was used in the picture that I'm showing you, what mechanism of air leak are you concerned about?  So, in other words, what's wrong with this picture? Do you think it was a needle puncture when you entered the trachea into the posterior membrane, into the pleural space?  Maybe you over dilated the stoma tract or air is leaking out through the anterior tracheal wall around your tube or a guide catheter override phenomenon.  Let's see, one hand for D. Anyone agree with A?  B?  C?  And D?  Got a few Ds. So, this is actually what I'm showing you. So, all of these things are potential mechanisms for air leak, pneumothorax, subcutaneous emphysema.  But what I'm showing you here is guide catheter override. So, you see here the tip of a blue rhino or single taper dilator. And the picture I showed you, there's something missing,  which is the guide catheter. So, the guide catheter or stiffening catheter is the white catheter that provides some additional stabilization to the guide wire.  And there's a notch on it. And you can see that that notch lines up with the tip of the single taper dilator. Occasionally, with a lot of force, or if you're not paying attention,  your single taper dilator can override that stiffening catheter onto the wire. And this is a very stiff tip, and it can easily bend or overcome the strength of the wire  and damage the posterior membrane. So, this is something we actually harp on with our fellows as we're teaching.  Fortunately, that's something that's also pretty uncommon. And in general, when you see subcutaneous emphysema or pneumothorax, this is very uncommon complication  from percutaneous tracheostomy. Again, all the mechanisms we just talked about  are potential ways in which that could happen. If you have a simple needle puncture of the posterior membrane as you're trying to advance through the tracheal wall  and position yourself, that typically is pretty inconsequential. You can simply remove the needle. Even if it goes into the esophagus, it's unlikely to cause any major trouble.  That can be avoided with bronchoscopic guidance, obviously, but you would simply just reposition your needle and restick. Rare cases, posterior membrane tear  are much, much more serious complications and may require surgical repair. You can see here in this schematic, this is a brachiocephalic vein, trachea,  and in someone, particular patient, perhaps with bolus emphysema, high-riding apex of the lung, you can see the potential anatomic relationship  where a puncture through the posterior membrane or lateral wall might actually enter the pleural space.  So going back to guide catheter override, as I was describing, this was actually described way back in the 90s in the earlier days of percutaneous tracheostomy.  So again, just showing you without the stiffening catheter how the dilator can be strong enough to overcome the wire. Here's a picture of a posterior membrane tear  that was basically unzipped from a procedure that did not go well.  Okay, the next day, you're called back to the bedside for continuous soaking of the tracheostomy dressing with large clots. There's minimal blood on endotracheal suctioning,  which is the following as the next most appropriate action. A surgical consult for neck stoma exploration. Remove the trach tube and re-intubate with an endotracheal tube.  Examine the skin edges with application of some type of topical anticoagulant or cautery, or you vow to never perform a pertrache in a patient on aspirin and Plavix.  So after our poor gentleman's sequence here, you probably will choose D. In the interest of time, I'm gonna just move ahead here. So we're talking about bleeding from the skin edge.  This is commonly seen in the first couple days, and the key distinctions are you're not getting much blood back on suctioning. Everything's external. We're more concerned if we hear  that the ICU nurses are suctioning a lot of blood from the airway. So the skin edges can be exposed. You can apply a variety of topical anticoagulant  or coagulation tools, silver nitrate, cautery, surgical, you know, gel foam, all kinds of things you can pack and try to deal with that.  But that's usually a pretty simple problem to deal with.  Just a couple other intraprocedural complications. Loss of airway, a dreaded complication of pertrache. You have to retract the endotracheal tube up  pretty high into the subglottic space. So it's important to have someone stabilizing the tube. Bronchoscopic guidance allows you the added safety mechanism  that if the airway tube was removed, you have a potential option of easily reintroducing the tube there as well. But important to have all the supplies available  at the bedside in case that were to happen. Lateral puncture, easy to fix. You simply reposition your needle and re-stick in a more medial location.  Tracheal ring fracture, not necessarily a complication. Pretty well known to occur as somewhat of a normal part of pertrache and up to a fourth or a third of patients  we see this endoscopically, bronchoscopically during the procedure. It was seen pretty clearly on post-mortem studies, cadaver studies, may happen more  in people with calcified rings. If you're placing your needle and you get a lot of resistance initially going through the trachea, you may be trying to push through a tracheal ring  and can simply readjust. Hypoxia, hypercapnia, again, these are things that we try to mitigate with appropriate oxygenation. If the patient's hypercapnic, obese,  difficult to ventilate, you can minimize the amount of time the bronchoscope is in the airway.  And I think the take-home point is the bronchoscope does not have to be in the airway the entire time.  The bronchoscope, the critical visualization portions are positioning the ET tube and then the second critical visualization portion is the needle puncture,  making sure the guide wire is intraluminal. From that point on, the bronchoscope can come out. You don't have to watch the punch dilator go in.  You don't have to watch the blue rhino if you've already confirmed your guide wire and everything is intraluminal in those patients that are difficult to ventilate or oxygenate.  Injury to the bronchoscope or ET tube, again, kind of common sense. You have to avoid high punctures and make sure your tube is pulled back appropriately.  Chest x-ray is not necessary following PERC-TRACH. That's been fairly well studied unless it was a complicated procedure, you had deep sticks or other clinical things  you're concerned about.  And the last main thing to focus on, accidental decannulation. And this is an area of safety that Dr. Morris is gonna focus more on. In the first seven days, it's an immature tract.  It's very different than a surgical trach tract. So we recommend not replacing the tube unless there's an expert set of hands there at the bedside,  re-intubate the patient and arrange for some alternative means for replacing the tube.  These are some of the guidelines that exist from a couple societies, although there are not a lot of great up-to-date guidelines. Again, if it's longer than seven to 14 days,  you can probably safely replace the tube, but it's something that has to be done with caution.  And then lastly, the dreaded bleeding comp. We talked about every form of bleeding our patient encountered. Tracheal nominant fistula, extremely rare, well under 1%.  The most common risk factor is a low-lying trach tube. This can occur at the tip of the tube, at the level of the cuff, from erosion,  compression through the tracheal wall into the inominant, sometimes pinned between bony structures as well. It's most commonly fatal.  About half of them will have some type of sentinel or herald bleed, which may or may not be recognized. Most commonly occurs in the first three weeks of the following placement.  If you are able to recognize it,  the patient should be intubated from above with an ET tube to bypass the bleeding area, over-inflate the cuff, and then place a finger into the pre-tracheal space through the stoma  to attempt to tamponade the bleeding vessel.  Interesting picture, this is on the spectrum of tracheal injury from a PERC trach. These are denuded mucosa with tracheal rings that were exposed. So this patient would be a patient  who typically would end up with tracheal stenosis, which is obviously a complication of PERC trachs or surgical trachs. PERC trach, tracheal stenosis tends to be a little higher,  perhaps because of less accurate placement, but that is an older study. So again, these are the key aspects with a focus on bleeding. Recognize that much of the early bleeding  can occur at the skin edge. Bronchoscopy is essential and can ameliorate a lot of these complications. Guide catheter override. We preach anatomic accuracy.  And remember, the procedure can be aborted at any point. So if you're in trouble and you're uncertain, you can always stop and call for help. Thank you.  I'm going to talk about the importance of a tracheostomy safety team. And by way of disclosures, we do have a book out, Tracheostomy is the Complete Guide.  It's actually currently out of print and we are hoping to get the second edition out early this year. And I do do some legal consulting as well, some of which involves trachs.  Our learning objectives for today are, or at least my objectives, are to talk about  a tracheostomy care bundle as a quality improvement strategy and describe components of a comprehensive teaching program for staff, patients, and caregivers.  I just want to talk for a moment about where I work. After spending pretty much all of my career, except for the last four years, in acute and  critical care, I am now at an acute inpatient rehab facility. And I frequently get asked, oh, is that a SNF? Is that an LTAC? No, it's actually quite different.  We moved into this beautiful new building in March of 2017. We are formerly the Rehab Institute of Chicago, if you're familiar with that name.  We're now called the Shirley Ryan Ability Lab. When we moved, we transformed the concept and our name.  We have a building size of over a million square feet, clinical and research space, lots of new capabilities, human simulator training lab, which we are starting to do  for our patients and family members too. We have, this is our aquatic center. This is one of the two-story ability labs. This is where our patients do their therapy.  And you can see that there's a patient who is in a harness, who is in an anti-gravity lift track, which actually goes around the perimeter of the lab.  And we partnered with the Chicago Fly House that does work for Cirque du Soleil to create a four-point suspension system, which you can't really see at the top of the stairs there.  Also, one thing to note is that the bottom few stairs mimic public buildings, the stairs you'd find in public buildings. And the top of the remaining stairs mimic those at home.  One thing about inpatient rehab facilities are that patients have to be able to participate in three hours of intensive rehab per day.  And if they're not able to participate at that level, that's when they need to go to a SNF or an LTAC. That's the big difference.  So what is the reason for a multidisciplinary tracheostomy team? Mainly it's in terms of outcomes. We find that it accomplishes many different outcomes.  One is decreased length of stay, decreased incidence of tube blockages, decreased calls for respiratory distress, increased use of speaking valves, decreased time to downsizing,  and decannulation. So there's lots of benefits to a multidisciplinary trache team. One thing that I found when I was in acute care and tried to establish a multidisciplinary  trache team is that there was a lot of pushback from different areas. You know, well, we have to staff for that. We have to, you know, everybody is kind of siloed care.  Now it's really kind of a pleasure to work in an environment in a rehab setting where that's the philosophy is multidisciplinary care. So first let's talk about the trache bundle.  The idea actually came from a group at St. Mary's in London who created a tracheostomy bundle of a simple set of interventions that made big differences in care.  We looked at that bundle and we revised it to include, to actually make it more comprehensive and also make it more pertinent to a rehab population.  But our tracheostomy bundle consists of supplies as well as care practices. And so the supplies you can see are, we want to have a trache tube of the same size in  the room and a trache tube one size smaller in stock. This is different than when I was in acute care and I was at Northwestern for 12 years before I came to Shirley Ryan.  And in the acute care hospital, we want everything at the bedside right there. In a rehab setting, the reimbursement is different.  So we have to be a little bit more concerned about cost. But we do have our supplies very close by, especially in our new building.  We also want intercannulas when they're applicable at the bedside, suction catheters, cleaning kits, et cetera, et cetera.  And we want not only all supplies for daily care, but also those for emergency care, everything at the bedside so you can manage any kind of an emergency there.  We also want, so we have the ambu bag and the face mask there as well, oral care kits and a charged portable suction device.  So for our patients that are going to rehab for three hours of a day away from their room, so they need a portable suction machine and a go kit with the extra trach, et cetera,  to go with them wherever they go. Here is our trach supply cabinet. And this, I happen to know that this patient came from Northwestern because when I was  there, I created a trach kit, which is that pink bath basin that you see there. So I'm glad that they're still doing that. And so there's a special place for all of the supplies.  And here's the care practices. We want to make sure that we ensure adequate humidity. We clean or change the inner cannula at least once a shift, but we check it frequently.  We clean the stoma at least once a shift. Change the dressing every shift and apply one drain sponge.  So many times I see two drain sponges underneath, mainly because they're packaged as two.  But the more drain sponges you put underneath there, that's increasing the risk of decannulation. Moving the tube further away from the stoma.  We want to check and document the cuff status and check the security of the trach ties every two hours and adjust if needed.  Also checking the patency of the trach, making sure that that tube is patent. That's one thing. Just because the trach is in the neck does not mean the tip of it is in the trachea.  And so we want to ensure that people check that patency. Check the functionality of the suction system. Change the suction canister. And then oral care.  We're pretty passionate about doing oral care as well. We put it all together into a one-page trach checklist. And by the way, I'm going to be showing you several resources.  I'm very happy to send you any of these resources. I'm going to list my email address at the last slide.  And I'll be happy to send you the trach checklist or any of the other things. We also, as part of our multidisciplinary trach team, we thought that, okay, we've got  this trach bundle. Now we want to make it easy for the nurse and the therapist and whoever to document all of these things that they're doing.  So we put together a documentation system within Cerner to make sure that it's very easy for the staff to document, okay, I've got all my supplies at the bedside.  And by the way, when I'm doing the legal consulting, that's one of the things that I look for is the documentation.  And it's very reassuring to see that, you know, this place has the system put together so that they do know what the important things are and they do document it.  This is only a partial list of all the things that are on there. So to summarize, this section is, I like to use the acronym SHIPS.  So that we've got, we want to check the stoma frequently. We want to ensure adequate humidity. We want to check that inner cannula. We want to check tube patency regularly.  And supplies, we want to make sure that we have all the supplies in place whenever we need them.  So let's move on then to a comprehensive education program, which we created for staff as well as patients and families.  First of all, we need to identify our training groups, which is essentially all the professionals.  Nursing, PT, OT, speech, the physicians and residents, as also the care techs, the patient care techs, the PT aides, those kinds of things, as well as the patients and families.  So what we did was we created different modules. These are online learning modules supplemented with competencies. The nurses get the most.  They get up to 2.75 contact hours of continuing education credit for this. Module one focuses on daily care, suctioning, dressing changes, inner cannula, showering.  That kind of thing. Module two is emergency management. Module three is the different types of trachs. There's lots of different types of trachs that staff need to be aware of.  What's the downsizing process? What's the expected progression? How do we monitor a patient with a cap or a valve or an HME? And also talking about trachs versus laryngectomies.  And finally, module four is a checklist for the patient and family education. PCT curriculum. Our PCTs are very involved in patient care as well.  So they need to be educated as well as how to help with ambu bagging while the nurses, for example, suctioning or showering, for example. What are the shower precautions?  How do we protect the trach while the patient's in the shower? The trach and the ventilator. And that was a big thing.  When I went from critical care to a rehab setting, I got to see how they shower. Put a patient with a trach and a vent in the shower. It's an art. It really is.  And then they need to know, what are the red flags? What do they need to do if they notice, for example, a patient with an open trach can all of a sudden have a loud voice?  Or what do they need to do if they notice some of these things?  What do they need to do to send the patient to therapy? How do they need to? They need to make sure that all of the equipment and supplies are there on the wheelchair when  the patient goes to therapy. And they're very involved in the oral care as well. Respiratory therapist curriculum. They spend a lot of time. There are primary airway people.  They spend a lot of time doing the downsizing, doing the trach changes, making sure that the new people are competent in doing the trach changes.  The modules talk a lot about emergency management. They have a lot more. They can do more things than the nurses can in terms of emergencies.  They do a lot of the patient and family education as well, supplemented with the nurses, talking about trachs versus laryngectomies and also red flags as well.  The allied health curriculum, they get also about emergency management. We do train our therapists to do suctioning as well and using the amboos and recognizing red flags.  The speech people get a little bit more with the downsizing and getting patients involved in phonation.  And our OT people, we talk a little bit more about shower precautions with them. For the residents and attendings, they prefer more live lectures rather than the online  learning modules. So I do some training with them annually on talking about the trach checklist, talking  about emergency management and red flags, talking about the downsizing and decannulation process, and also what kinds of tubes are available for different conditions.  One of the things I put together was a tracheostomy tube guide. This is one page from that. And again, I'm happy to share the guide with you.  What each page is a different tracheostomy tube. And it talks about what kind of material is involved, how do you clean it, where do you  find it, how do you order it, what it's used for, and what are some of the precautions that you need to be aware of with this particular tube. And then patient and family education.  We do teaching and actually several different sessions with patients and families to make sure, especially before they go home, so that they're safe going home and that they can  be checked off on all of these different things. When to call the physician, how to manage an emergency, how to change their own trach,  and manage an emergency before 911, before the paramedics get there. And we're just now starting to do some of this training in our high fidelity simulator lab as well.  Here's the first page from the patient and family skills checklist. So that we have them, we demonstrate for them, we have them do a return demonstration,  and then have the clinician sign off, and then add any comments if there's any comments to add.  They might need more on this, or we need to look at the technique and manage the technique, those kinds of things.  Here's another take home trache care at home booklet that I put together. And it goes through trach care, it goes through emergency management, it goes through cleaning  the trach, trach changes, all these different things in easy to understand language. And then the end pages, you know, who's your DME company, who's the doctor, who's the nurse  to call back for questions. Then we also do tracheostomy rounds. And this is an important thing.  We at our hospital, we have our trach safety group is called the Tracheostomy Champions. And they are a multidisciplinary group, PT, speech, OT, physicians are all involved from  each unit. And we come together every month for meetings. Our purpose for tracheostomy safety group, of course, is our trach rounds, I should say,  is during rounds, we do a patient assessment, we do an environmental assessment, making sure that the patient has the equipment and supplies available at the bedside.  We listen to what people have to say, PT might have some input, speech, you know, is concerned about phonation, we'll talk about that.  And also at the same time, we're also doing not only education for the staff, who may not be familiar with, you know, what's going on with this patient, but we also educate  the patient and the family as well. And of course, their frequent question is, when can I get the tube out? You know, that's the big question. So we talk about that.  So our tracheostomy champions, as I said, from nursing, from allied health, we also have a patient care tech on the team as well, respiratory, of course.  And they're all working together for patient safety. We do have a monthly meeting, the trach champions meet monthly. We do weekly trach rounds.  And we do, after trach rounds, and I'll show you, we do education and reporting too. So after we do the trach rounds, I do a, oops, this is a little bit out of sequence here,  but I'll come back to it in a second. Here's an example report that I put together for the managers.  It's important not only for what I find, it's important to report it so that the manager has some responsibility in follow up if there are problems.  For example, in one patient, I found the neck flange digging into the skin, there was a pressure area forming, there was no extra trachs at the bedside, trach ties were loose,  all kinds of things. So it's important for the manager to follow up to know that, okay, we need to pay attention to what's going on here and have some responsibility for follow up.  Let's go back now. One thing that I wanted to, when I was in the ICU too, and that is, people are not familiar.  A lot of times the surgeons would call me after they would put the trach in and they'd call me to, you know, manage the rest of the care, which was great.  But it didn't really get people involved in knowing what the next step was. So I put together this very simple checklist for a trach progression checklist.  First of all, trach progression can begin in the ICU. The first step is getting the patient off the ventilator, if that's possible.  When I was at Northwestern, I kept a database, and it was approximately 3,000 patients. And I found that once the trach went in, about 60% of the patients were able to get off of  the ventilator within a couple of days. So for those patients who were able to get off the ventilator, then the first step should  be is trying deflating the cuff, and if the patient is able to tolerate cuff deflation. And then once the patient's able to tolerate cuff deflation after off the ventilator,  then we want to start progressing their trach. If they can tolerate cuff deflation, then we can think about changing their trach to  either a cuffless tube or a TTS tube, which will allow capping trials. We never, ever want to cap a standard cuff trach.  But once the cuff can start to be deflated, we can change the trach, get them talking, and they start to feel more normal. They start to feel more involved.  They start to be more involved in their care, and that's kind of a natural progression. So we can start that.  And if the patient does not tolerate, or for example, they're weaned to just they're off the vent during the day, but they need to go back on at night, that's where the TTS  tube comes in really very handy. Because it is a cuff tube, and you can use it to ventilate the patient, but then during  the day, it deflates, and the cuff disappears essentially, which makes it essentially the only cuff trach that is safe to cap.  So once the patient is able to tolerate prolonged capping, then we think about their ability to get the tube out. And that is, do they have adequate cough strength?  Is their vital capacity at least a liter? For most patients, it's 15 milliliters per kilogram of body weight. And can they manage their own secretions?  And once we look at all of those things, and they no longer need the trach, then we can get the trach out. They're ready for decannulation.  But that's where most of the other patients then will need acute rehab. Because a lot of them, at least if they've had a prolonged stay in the ICU, that's where  they fail is they just don't have the cough strength, and they can't manage their secretions.  And so that's where we work with a lot of trach patients in a rehab setting. So to summarize, we looked at the trach bundle consisting of trach supplies, trach care practices.  We talked about a comprehensive teaching program for staff, patients, and families. We talked about the tracheostomy champions as leaders of the trach safety program, how  important trach rounds are, and reporting as well. I did want to bring to your attention a couple of resources if you're interested in trach safety.  In the UK, there's a national project going on called the National Tracheostomy Safety Project, the NTSP. In fact, they do have an app that you can download on your phone.  You can get lots of resources at your fingertips. And if you're interested in laryngectomies, Dr. Itzhak Brook is a laryngectomy himself and has a lot of videos.  He has his own blog. He's kind of made it his passion to teach health care providers as well as patients and families about managing laryngectomies.  You also might want to inform your patients about several online support groups. One is Yahoo Neck Breathers. There are several online support groups through Facebook.  And trachresource.com, that's our website. Another excellent resource is the Global Tracheostomy Collaborative, the GTC.  This is an international group of specialists all with a passion for tracheostomy care. Their motto is better care everywhere.  The membership is free for patients and for health care members. There is a charge for hospitals. And the purpose is to benchmark.  Hospitals submit data and compare themselves with like hospitals across the world. And they do offer free webinars. The next one is coming up at the end of the month on the 26th.  The topic is Facilitation of Speech and Swallowing on a Vented Patient with a New Trache. So you can register online at globaltrache.org. And here's my contact information.  And you're welcome to, we have time, we don't really have time for questions, I'm sorry. But we can take a few questions. Thank you. Thank you. Time for a couple of questions.  Hi, Chet. Yeah, I'm Chet Morrison from Saginaw, Michigan. And mindful of the time, I have a question, a warning, and a disagreement, okay?  The question is, what's your experience when you get consults for tracheostomies on patients in ECMO?  And I've seen a couple of guides that say tracheostomies should be done when they're on ECMO, except they're very ill, obviously, and anticoagulated. So if you could talk to that.  The warning is, sometimes when you have tracheal dislodgements, the attempts before you get there to try and make things better can cause further complications.  And I've actually seen bilateral pneumothoraces caused by over-vigorous ventilation. And I know it wasn't a posterior rupture, because it was a surgically-placed trach.  And yet, the patient required chest tubes, so I would say that, you know, make sure you also have that. Because otherwise, the panic sets in when people start to decompensate.  And they can cause pneumothoraces just in attempts to manipulate the trach and ventilation. And finally, the disagreement is that you mentioned when bronchoscopic visualization,  about when the catheter and the wire is placed interluminal, then, you know, you don't have to see things like the punch guide going in.  I would say that bronchoscopic visualization of that first initial dilator is very important. Because otherwise, occasionally, the wire can bend, and you can get it in the plane  anterior to the trachea. There's a nice plane anterior to the trachea. It's what our cardiothoracic colleagues use when they're doing mediastinoscopies.  It's a nice plane, but you don't want the tracheostomy tube in there, obviously. It doesn't work. So I would just plead that, you know, at least see the first dilator in.  And then I agree. Then the procedure goes very nice and smooth because you've got a little trach. The stiffener goes right in, the dilator, it's all good. Thank you very much. Sure.  Just a quick comment, the ECMO question. There's actually a recent paper, I think, from last year showing a larger series with  significant increased complications in PERC trachs done on ECMO. I think it always begs the question of, at that point, you know, what's the harm in waiting,  you know, if someone is intubated for 12 days and an ECMO patient, is there really harm in, you know, in waiting another five to seven days from a translaryngeal intubation risk,  you know, a laryngeal injury? Probably not. But I think it's a matter of individual patient selection, choosing when that patient is most stable to undergo that procedure.  I think in those cases, waiting longer is probably not going to cause any great harm. You know you're not going to get that patient out of the ICU sooner with an earlier trach.  Thanks for your comment on the visualization. And I would agree. We do try to do continuous bronchoscopic visualization.  I think the point I was making was in cases where the patient's very hard to oxygenate or they're very hypercapnic, you do have that option in more difficult cases to remove the  scope at various portions of the procedure if necessary. But I agree. We try to maintain continuous visualization as much as possible.  Yeah, yeah, great, thank you.

Video Summary

The session on percutaneous tracheostomy focused on three main areas: patient selection and timing, management of complications, and the importance of a multidisciplinary tracheostomy care team. Dr. Chris Radchenko discussed the historical landmarks and evolution of surgical and percutaneous tracheostomy. He also talked about the timing considerations for placing percutaneous tracheostomy, highlighting that there is no optimal time and the decision needs to be individualized based on the clinical presentation and patient preference. Dr. Wes Shepard then discussed major complications and their management. He emphasized the importance of bronchoscopic guidance during the procedure to reduce the risk of bleeding and other complications. He also discussed the need for a comprehensive tracheostomy care bundle, which includes supplies at the bedside and specific care practices for daily care. Dr. Linda Morris spoke about the importance of a multidisciplinary tracheostomy care team. She highlighted the benefits of a team approach, including decreased length of stay, decreased complications, and increased use of speaking valves. She discussed the use of a tracheostomy bundle as a quality improvement strategy and emphasized the need for a comprehensive teaching program for staff, patients, and caregivers. Overall, the session provided valuable insights on patient selection, management of complications, and the importance of a multidisciplinary approach to tracheostomy care.

Asset Subtitle

Procedures, Pulmonary, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Describe the indications and techniques for performing percutaneous tracheostomy
Recognize relative contraindications and review the literature supporting extended indications for percutaneous tracheostomy
Identify complications specific to percutaneous tracheostomy and discuss their management

History, Timing, and Patient Selection

Christopher C. Radchenko

Complications and Management

Ray W. Shepherd

The Necessity of a Multidisciplinary Tracheostomy Management Team

Linda L. Morris

Meta Tag

Content Type Presentation

Knowledge Area Procedures

Knowledge Area Pulmonary

Knowledge Level Advanced

Learning Pathway Cardiothoracic Critical Care

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Tracheostomy

Tag Cardiothoracic Critical Care

Year 2020

Keywords

percutaneous tracheostomy

patient selection

timing

complications management

multidisciplinary tracheostomy care team

historical landmarks

evolution

surgical tracheostomy

bronchoscopic guidance

comprehensive tracheostomy care bundle

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.