Log in to comment and read comments that have been added. See our coronavirus content including current restrictions by country , vaccines , PPE , maintaining safe services , private practice , workplace and test and trace. Log in or register to post comments. A prolonged disorder of consciousness PDOC is a state of altered consciousness and awareness persisting for more than four weeks following a profound brain injury. Many patients will progress through the stages of coma, vegetative state and minimally conscious state as they emerge to full awareness, but some will remain in a vegetative state or minimally conscious for the rest of their lives.
Many patients with severe brain injury require a tracheostomy to protect their airway and facilitate weaning off a ventilator. Those who remain in PDOC require the tracheostomy on a long-term basis and can be complex to wean. The RCP PDOC guidelines recommend that airway management and tracheostomy care should be included in multidisciplinary goal-orientated programmes of care for all patients in a prolonged disorder of consciousness.
The Royal Hospital for Neuro-disability RHN provides a range of services including specialist assessment, treatment and disability management for adults with profound brain injuries. We have a large number of tracheostomy patients spread across our level 1 rehabilitation pathway and continuing care services. It is easy to appreciate how critical care resources may become overwhelmed following a surge in demand.
When resources become stretched, decisions regarding resource allocation become more challenging, and difficult judgments balancing tracheostomy, prolonged ventilation, rehabilitation and the potential of providing a real benefit for long-term quality of life need to be made. With the high transmissibility and risk of serious illness, the potential risks to healthcare staff need to be considered in addition to the potential benefits to the patient.
One argument surrounds the challenges of primary extubation, with higher rates of reintubation reported in patients with COVID [ 11 ]. Prolonged periods of tracheal intubation associated with the use of neuromuscular blocking agents [ 2 ] and the routine use of systemic corticosteroids [ 12 ] contribute to respiratory muscle deconditioning [ 13 ], which can make going straight from an endotracheal tube to self-supported breathing challenging.
Urgent re-intubation of a critically hypoxic patient has clear risks for the patient, but it is also important to consider the risks to attending staff. Non-invasive ventilation, face-mask continuous positive airway pressure, or high-flow nasal oxygen pose potential risks to healthcare staff through infectious aerosol generation [ 14 ], compounded by the risks associated with re-intubation [ 15 ].
It is difficult to distinguish whether laryngeal pathology is a consequence of coronavirus infection, a sequel to the associated prolonged tracheal intubation, ventilation, prone positioning, and re-intubation, or more likely a combination of these direct and indirect factors [ 16 , 17 , 18 ]. An elective tracheostomy can provide a closed respiratory circuit to facilitate weaning when used with an inflated tube cuff , allowing for a more controlled wean than an attempt at primary extubation considered at high risk of failure.
However, tracheostomy care still requires airway interventions that may be considered aerosol-generating and tracheostomy is not recommended in patients who are likely to require management in the prone position [ 19 ].
In addition to benefits for patients and staff, tracheostomy may also provide additional logistical and resource benefits for the hospital [ 20 ]. Patients with a tracheostomy typically require reduced or no sedation, reducing resource pressures on drugs, equipment and monitoring [ 21 ] and allowing for less intensive nursing care, as the patient may be able to assist in their own movement and self-care and be less dependent on multiple staff for re-positioning.
During the pandemic, with increased demand for critical care beds compounded by staff absence through illness or shielding, there has been a reliance on non-critical care nurses and other healthcare professionals to assist within the ICU. Tracheostomy patients may be easier to care for than fully sedated patients, but adequate training must be undertaken to ensure these healthcare professionals are able to manage tracheostomies and identify any potential complications [ 22 ] and a role for nursing specialties already experienced with tracheostomies head and neck surgery for example may be beneficial.
It remains essential that the potential benefits of a tracheostomy are weighed against the potential burden for patients and risks to staff and local critical care resources. Tracheostomy should only be considered in patients recovering from critical illness who have a good chance of making a meaningful recovery.
Tracheostomies can pose a risk for the patient and the staff both in terms of insertion and subsequent management and, thus, the first priority when considering optimal timing for tracheostomy is whether the procedure will benefit the patient. Exposing the patient and staff to procedural risks when the patent is unlikely to survive does not benefit anybody. However, predicting which patients might benefit is difficult, both within and outside of the pandemic period.
Considering that tracheostomy is indicated in those patients who have difficulty breathing and coughing independently, it is no surprise that mortality rates are high during critical illness and following ICU or hospital discharge [ 8 ].
Tracheostomies should only be undertaken in patients who are clinically improving. Patients requiring or likely to require prone positioning for respiratory failure should not be considered for tracheostomy due to the increased risk of tube displacement, occlusion, or impaired ability to identify tracheostomy-related complications in the prone position [ 23 ].
As with all complex decisions, a multidisciplinary approach is recommended [ 22 ]. Optimal timing for tracheostomy remains controversial in non-COVID patients [ 24 ] and becomes more complicated in patients with COVID due to the perceived risk of aerosol generation.
Virological evidence suggests that the viral load falls from a peak associated with the onset of symptoms, although the window of detection is prolonged in critical illness [ 19 ] Fig. Considering that the insertion procedure is aerosol generating, therefore posing risks to operators and attending staff, delaying tracheostomy is likely to benefit staff by reducing the risk of transmission [ 25 , 26 ]. This must be balanced against the potential benefits to the patient of early tracheostomy, such as reducing laryngeal injury and laryngeal dysfunction associated with prolonged tracheal intubation, reducing the cumulative burden of sedative agents, and promoting pulmonary hygiene through better secretion clearance [ 27 , 28 , 29 ].
Earlier tracheostomy also allows for outcomes that patients find particularly important, such as an earlier return to eating, drinking, talking, and engaging in proactive rehabilitation [ 30 , 31 , 32 ]. Typical clinical course, viral polymerase chain reaction PCR , and antiviral antibody detection and infectivity of severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 infection. The transparent red box shows the suggested window for tracheostomy, on ICU days 10—21, which corresponds with 16—30 days from symptom onset.
The solid bars and curves represent the proportion of all cases. Time zero is symptom onset the x-axis is not to scale. Adapted from [ 19 ] with permission. Patient factors blue , staff factors paler blue and critical care resource factors brown.
Early in the evolution of the pandemic, healthcare workers were rightly concerned about the risks of transmission during the tracheostomy insertion procedure, which has the potential to generate infectious aerosols.
The majority of protocols considered the implied infectivity of the critically ill patient, and as the predicted viral load and antibody response became more precisely characterized as the pandemic unfolded, most recommended a minimum of 14 days of mechanical ventilation prior to tracheostomy, balancing the risks of patient benefit with risks to staff Fig. As staff became more confident with personal protective equipment PPE and in managing patients with severe COVID, reports emerged indicating a role for early tracheostomy in some patients, with potential mortality benefits [ 5 ].
The question of whether the patient is physiologically stable enough to tolerate the tracheostomy insertion is very relevant, as the time to discover that the patient will desaturate rapidly when ventilation is suspended is not when the neck has just been opened. Physiological deterioration can be anticipated to some degree in all tracheostomy procedures due to inadequate ventilation, transient suspension of ventilation and the lung de-recruitment associated with exchanging the trans-laryngeal tube for a new tracheostomy.
However, the deranged respiratory physiology associated with severe COVID may cause an exaggerated deterioration if the patient has not recovered sufficient physiological reserve to tolerate the procedure. Rapid desaturation predicts a similar response during tracheostomy, indicating risk to the patient and also to staff who may be required to undertake unplanned or additional airway interventions.
Tracheostomy should be deferred in these circumstances. Importantly, the ability to conduct or tolerate an apnea trial should not replace multidisciplinary clinical judgement regarding the risks and benefits of undertaking tracheostomy in a given patient at a particular time [ 34 ].
The first consideration is location. Performing the procedure in the ICU minimizes patient movement, avoids the logistical considerations of assembling an operating room team, but brings technical obstacles such as the large ICU bed and deficiencies in trained assistance, the environment, and with equipment Table 1.
Ideally, aerosol-generating procedures in potentially infectious patients should occur in negative pressure isolation rooms. These are not universally available, but conditions are probably most closely replicated in the operating room suite [ 35 ]. Second, the choice of insertion technique is essentially between an open surgical or a percutaneous approach. Hybrid approaches have been described and there are variations in all techniques described in the literature and facilitated by a wide range of equipment.
However, percutaneous techniques have progressed substantially in the last 20 years and many single centers have reported successful percutaneous approaches during the current pandemic, with apparently low rates of infectivity among attending staff [ 38 , 39 , 40 ]. The relative risks and benefits of percutaneous or surgical approaches have been debated in the literature for many years.
Perceived benefits to the percutaneous technique are: familiarity to critical care staff; reduced air leak from the smaller stoma; fewer wound infections; and reduced bleeding complications.
However, percutaneous approaches involve: more airway manipulation than a surgical procedure; withdrawal of the tracheal tube risking extubation and aerosol generation; and, when combined with endoscopic visualization, may result in inadequate ventilation, significant upper airway gas leak and aerosol generation during the procedure.
Perceived advantages to an open surgical technique relevant to COVID are that it allows for a more controlled procedure, performed under direct vision. When combined with an expert anesthesiologist manipulating the tracheal tube in an ideal operating room environment, a surgical procedure may be safer.
Difficult neck anatomy, obesity or overlying thyroid gland or vessels are established indications for a surgical approach. What is less clear is how to manage patients who are receiving anticoagulants, receiving antiplatelet medication, or who are at an increased risk of bleeding—all of which are common dilemmas during the coronavirus pandemic.
A percutaneous approach involves less dissection, a smaller stoma and thus a tamponading effect from the newly inserted tube, which may reduce post-procedural bleeding. A surgical approach offers more direct access to control specific bleeding sources, although the use of diathermy may be implicated in aerosolizing viral particles and diathermy should be kept to a minimum [ 19 ]. Fourth, modifications and considerations have been proposed to help reduce the risk of aerosol generation during tracheostomy insertion.
Most advocate suspending ventilation at key steps in the insertion process: manipulation of the tracheal tube within the upper airway; opening the trachea; any dilatation of the stoma; and during insertion of the new tracheostomy tube [ 41 ].
This period of apnea, however brief, risks significant de-recruitment and hypoxia, and a period of pre-oxygenation can help mitigate this. Clear communication between all team members is essential. Communication may be impeded by PPE and planning, rehearsal, and simulated practice are recommended [ 19 ].
It is also recommended that the patient should be paralyzed, thus preventing coughing and unwanted movement and reducing peak airway pressures [ 19 , 41 ]. Finally, the logistics of managing multiple critically ill patients in our hospitals may influence the choice of technique simply through the availability of trained staff to undertake the procedure, with many centers reporting a significant rise in the number of surgical procedures undertaken during the pandemic [ 23 , 39 , 40 , 41 , 42 ].
Because of the aerosol-generating nature of this procedure, it is imperative that appropriate PPE is always worn by whoever undertakes the tracheostomy insertion, and only essential staff are present in the immediate environment [ 36 ]. What is clear is that more research is needed to understand the optimal technique for a particular set of circumstances and while we await clearer answers, practitioners are advised to do what works best in their institution, with their local resources, practice and expertise used optimally following multidisciplinary discussion between all stakeholders.
For patients with COVID who have a tracheostomy, the aims of care are to minimize airway interventions and potential aerosol generation, whilst maintaining standards of safe care and ensuring that patients are proactively rehabilitated. All interventions should involve thorough planning to reduce risks to both patients and staff, and care should be performed by staff experienced with tracheostomy care [ 22 ].
All of these strategies require regular review for each patient. If, for example, secretions become thicker, additional therapies such as mucolytic drugs, nebulizers, or switching to active humidification may be required [ 19 ].
Most tracheostomy tubes have three standard components: an outer cannula, an obturator, and an inner cannula. Inspect all equipment for proper function, including the replacement tube cuff for leaks and the obturator for ease of insertion and removal. Coat the replacement tracheostomy tube with a water-based lubricant. It is important to ensure that consent is appropriately obtained from the patient prior to the procedure. The bed should be adjusted to an adequate height without any obstruction in the way of the practitioner, such as bed rails or tables.
The patient should be supine with the neck in hyperextension over a shoulder roll or pillow so that the tracheal orifice is closer to the surface with the neck structures stretched adequately. A right-hand dominant practitioner should stand to the right of the patient, and the reverse is recommended for a left-hand dominant person.
An assistant should stand on the opposite side, ready to assist before tube change occurs. Usually, the assistant provides suction and helps with securing the tube. It is good practice for practitioners to rehearse or verbally go through the steps with their assistant prior to the procedure, as this makes sure that they are familiar with the steps and are able to coordinate accordingly with each other.
Studies have compared the complication rates between surgically and percutaneously performed a tracheostomy. Oliver et al. The major or serious complications are I hemorrhage requiring transfusion or due to tracheo-innominate artery fistula, II trachea-oesophageal fistula, III subglottic stenosis, IV tracheal stenosis, V tracheomalacia, and VI death.
Although routinely performed, tracheostomy tube change is not without complications or potential pitfalls; thus, it is imperative to understand the procedure in addition to anticipating potential problems. Certain institutions may have established protocols or guidelines in place to facilitate an uneventful tracheostomy tube change, whereas continuous education and quality improvement projects certainly aim to improve competence and reduce complications.
The commonly encountered complication, if at all, of tracheostomy tube change is displacement or creation of a false passage. It is recommended that the first tube change be performed under direct vision and preferably not sooner than 7 days since the tracheostomy procedure. If a false passage is suspected, remove and replace the tracheostomy tube expeditiously. An airway exchange catheter may be used to reduce the risk of tube displacement. Dislodgement is specifically associated with increased rates of morbidity and mortality.
When this rare complication occurs, it is important to follow the basic life support or advance life support algorithms, and help must be called so that experienced personnel, typically anesthetists or otolaryngologists may help to re-establish an airway. The usual practice in this instance is to reinsert the tracheostomy tube with the use of an obturator or tracheal dilator. Oral or nasal intubation may be attempted to establish a definitive airway, especially in cases of respiratory arrest.
Tracheostomy tube change is probably the single most critical procedure after tracheostomy is made. It is important in the continuous care of patients with tracheostomy, and regular changes are associated with reduced risk of granulation and infection.
However, competence and experience in tube exchange are necessary to ensure that the procedure remains uneventful with minimal discomfort to patients, morbidities, and complications. Although there are currently no published recommendations for the standards in tracheostomy tube change, many institutions and hospitals have a local protocol or guideline in place to facilitate uneventful tube changes and improve outcomes.
The Global Tracheostomy Collaborative was formed in by Dr. David Robertson, an otolaryngologist from Harvard. Indeed, evidence shows that collaborative and coordinated tracheostomy care is achievable, implementable, and improves care.
On the other hand, it is recognized that tracheostomy care outcomes are better where there is a concerted effort between various parties, including patient, surgeon, primary physician, otolaryngologist, and interdisciplinary teams such as nurses and speech and language therapists.
In the U. Similar to their North American counterparts, the team dedicated to looking after patients with tracheostomy tubes comprise of otolaryngologists, anesthetists, chest physicians, specialist nurses, speech and language therapists, and respiratory therapists. There is increasing evidence that coordinated interprofessional teams influence the safety and quality of care delivered to patients with tracheostomy and their families.
Studies have described deficits in knowledge and comfort with tracheostomy care among health care providers. The main roles of the interprofessional team members are described here. They administer therapy that includes manual hyperinflation, passive positive pressure breaths, clearance of sputum, and recruitment of collapsed or dependent areas of the lung. Speech and language therapists have an integral role in tracheostomy tube change, as their assessment and therapy may dictate the type of tubes required, such as changing a cuffed tube to an uncuffed tube, etc.
Specialist nurses provide continuous coordination of care, education, and dissemination of knowledge, as well as ensuring standards are always maintained or improved. Other allied health members involved in the care of tracheostomized patients are dietitians, psychologists.
Evidence shows that tracheostomy-related complications are minimized, and outcomes are improved when there is a multidisciplinary, ward-based approach to tracheostomy care. Weekly tracheostomy ward rounds should be the ideal practice, with the team comprising of a physician commonly an intensivist, respiratory physician or otolaryngologist , chest physiotherapist, speech and language therapist, and specialist nurse. The team ensures standards of routine tracheostomy care are achieved, provides a weaning or decannulation plan, and troubleshoots potential issues surrounding tracheostomy care, such as competencies, logistics, and shortfalls.
The care of tracheostomy requires both competencies and experience. The most important aim of caring for patients with a tracheostomy is to prevent tube blockage. As the native upper airway is bypassed, numerous physiological changes occur, therefore care that mimics the normal functions of the upper airway should be undertaken e. The commonest measures or elements of care that are carried out and monitored regularly are: I going through daily tracheostomy care checklist, II humidification, III suction clearance, IV stoma care, V inner cannula care, VI oral care and swallowing, and VII cuff management.
Monitoring of these elements by the various team members is paramount in ensuring the safety and quality of tracheostomy care. Especially after tracheostomy tube change, monitoring of respiratory function such as respiratory rate, oxygen saturation, work of breathing, waveform capnography and secretions management are critical as this is when any complications, such as tube dislodgement or false passage creation, may be detected promptly.
Contributed by Wikimedia Commons, Klaus D. Peter, Wiehl, Germany CC by 2. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet]. Search term. Affiliations 1 Imperial College London.
Continuing Education Activity Tracheostomy is a procedure where an artificial airway is established surgically or percutaneously in the cervical trachea. Introduction Tracheostomy is a procedure where an artificial airway is established surgically or percutaneously in the cervical trachea. Anatomy and Physiology Tracheostomy can be done via open surgery or percutaneously.
Surgical Tracheostomy A transverse skin incision avoiding anterior jugular venous is preferred for cosmetic reasons, is made between the cricoid cartilage and suprasternal notch approximately over the second or third tracheal rings. Indications The first recorded tracheostomies were performed for upper airway obstruction.
Contraindications There are no absolute contraindications to exchanging a tracheostomy tube in the emergency department as long as the stomal tract has matured. Equipment There are many pieces of equipment required for the procedure, but they can be divided into several categories for ease of memory.
The equipment required for I tube change are: Two tracheostomy tubes of appropriate make or type, where one is the same size, and the other is smaller, which can be used when stomal obstruction or collapse is encountered. Personnel An initial tube change in general wards is associated with a higher risk of airway loss in comparison to the intensive care unit or step-down unit Preparation It is essential to ensure that all airway equipment is at the patient's bedside before performing the tube exchange.
Most tracheostomy tubes have three standard components: an outer cannula, an obturator, and an inner cannula Inspect all equipment for proper function, including the replacement tube cuff for leaks and the obturator for ease of insertion and removal Anesthesia is generally not required for tube exchange. Coat the replacement tracheostomy tube with a water-based lubricant It is important to ensure that consent is appropriately obtained from the patient prior to the procedure.
The key to preparation is the positioning of the patient. Technique Tracheostomy tube exchange is swift to minimize changes of stoma collapse and patient discomfort, or time when the patient is left hypoxic. Once the patient is prepared, and the necessary equipment is available and checked for functionality, the procedure may commence.
Pre-oxygenation may be required in those who may not tolerate the procedure well physiologically. If there is an inflated cuff on the indwelling tracheostomy tube with a subglottic suction port, first use a syringe to aspirate any secretions that may be sitting above, prior to cuff deflation. In any tube, it is also important to perform gentle suction in the lower airway. Note the amount, color, and consistency of secretions suctioned.
Remove any sutures or ties attached to the tracheostomy tube and patient. When doing this, the assistant must stabilize the flange at all times to prevent premature removal. Next, the cuff may be deflated. The tube is now ready to be removed. In a smooth semi-circular fashion mimicking the curvature of the tracheostomy tube, remove the tube.
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