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396 PART 4: Pulmonary Disorders

TABLE 45-9 Bedside Considerations CHAPTER Tracheostomy
1. Save the brain. Jeffrey D. Doyle
2. Save the circulation. 46 Damon C. Scales
3. A spontaneously breathing patient has at least one vital sign; an apneic patient
may soon have none.
4. Mask ventilation is better than esophageal intubation.
KEY POINTS
5. The worst time for a patient to aspirate is when it is time to intubate.
6. If you do not give any IV anesthetics, the CODE cannot be blamed on you. • In critically ill patients, tracheostomy is most commonly per-
formed to facilitate delivery of prolonged mechanical ventilation.
7. The patient who asks for a tube needs one. Less frequently, it may be performed for relief of upper airway
8. A patient who does not mind a tube needs one. obstruction or for management of chronic pulmonary secretions.
9. The best procedure for a patient may be the one that you know how to do best. • The most compelling reason to perform tracheostomy for patients
10. The place to learn basic airway management skills is the operating room, not the ICU. requiring prolonged mechanical ventilation is to improve patient
comfort and decrease sedation requirements.
• The available evidence base suggests that performing tracheos-
tomy early in patients expected to require prolonged mechanical
KEY REFERENCES ventilation does not reduce mortality, rates of ventilator-associated
pneumonia, or duration of intensive care unit admission.
• Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines
for management of the difficult airway. An updated report by the • Surgical tracheostomy and percutaneous dilational tracheostomy
American Society of Anesthesiologists Task Force on Management (PDT) have comparable complication rates, but PDT is often more
of the Difficult Airway. Anesthesiology. 2013;118:251. convenient and requires less resources to perform.
• Avidan MS, Harvey A, Chitkara N, et al. The intubating laryngeal • Cricothyroidotomy, rather than tracheostomy, should be the surgi-
mask airway compared with direct laryngoscopy. Br J Anaesth. 1999; cal airway of choice in emergency situations, except in the unusual
83:615. case of subglottic obstruction.
• De Jong A, Molinari N, Conseil M, et al. Video laryngoscopy ver- • In cases of accidental tracheostomy tube dislodgement occurring
sus direct laryngoscopy for orotracheal intubation in the intensive before a mature tract has formed, blind attempts at reinserting the
care unit: a systematic review and meta-analysis. Intensive Care tracheostomy tube risk creating a false passage anterior to the tra-
Med. 2014;40:629-639. chea. Endotracheal intubation from above is the safest method of
• Frerk CM: Predicting difficult intubation. Anaesthesia. 1991;46:1005. airway control in the early posttracheostomy period (eg, <7 days).
• Gillespie MB, Elise DW. Outcomes of emergency surgical air-
way procedures in a hospital wide setting. Laryngoscope. 1999;
109:1766. INTRODUCTION
• Holzapfel L, Chevret S, Madinier G, et al. Influence of long-term
oro- or naso-tracheal intubation on nosocomial maxillary sinusitis Tracheostomy has become one of the most commonly performed proce-
and pneumonia: results of a prospective, randomized clinical trial. dures in the intensive care unit (ICU), yet there still exists considerable
Crit Care Med. 1993;21:1132. uncertainty regarding its preferred technique, indications, and timing.
• Koenig SJ, Lakticova V, Narasimhan M, Doelken P, Mayo PH. Between 6% and 20% of patients requiring mechanical ventilation will
1-3
Safety of propofol as an induction agent for urgent endotracheal receive a tracheostomy, including a large proportion of patients requir-
intubation in the medical intensive care unit. J Intensive Care Med. ing prolonged mechanical ventilation, accounting for up to one-third
4,5
2014; Epub ahead PMID 24536033. of all ventilator days. The use of the procedure also appears to have
6
• Mort TC. Complications of emergency tracheal intubation: hemo- increased over time, possibly due to the emergence of percutaneous
dilational tracheostomy, which has made the procedure more conve-
dynamic alterations-Part I. J Intensive Care Med. 2007;22:157-165. nient to perform at the bedside. Determining and refining the appro-
7
• Mort TC. Continuous airway access for the difficult extuba- priate indications for tracheostomy are likely to become increasingly
tion: the efficacy of the airway exchange catheter. Anesth Analg. important as more patients survive the acute phase of critical illness and
2007;105:1357-1362. as pressures increase on critical care providers to facilitate patient flow
• O'Connor MF, Ovassapian A. Management of the airway and through critical care areas.
tracheal intubations. In: Murray MJ, Coursin DB, Pearl RG,
Prough DS, eds. Critical Care Medicine Perioperative Management. INDICATIONS FOR TRACHEOSTOMY
Philadelphia, PA: Lippincott Williams & Wilkins; 2002:89. Tracheostomy may be considered for a variety of different situations
• Rashkin MC, Davis T. Acute complications of endotracheal intu- in critically ill patients, but the underlying rationale for the procedure
bation: Relationship to reintubation, route, urgency, and duration. may be simplified to three general indications (Table 46-1). The first
Chest. 1986;89:165. is to establish or maintain a patent airway in a patient who has upper
• Schwartz DE, Matthay MA, Cohen NH. Death and other compli- airway obstruction or who is incapable of adequate airway protection.
cations of emergency airway management in critically ill adults. The second is to assist with the delivery of positive pressure ventilation
Anesthesiology. 1995;82:367. in patients with respiratory failure, in an effort to facilitate weaning
from mechanical ventilation by reducing dead space and decreasing
airway resistance, or to reduce sedative requirements by providing a
REFERENCES more comfortable conduit to receive mechanical ventilation. The third
is to facilitate clearing of secretions in patients with a need for ongoing
Complete references available online at www.mhprofessional.com/hall pulmonary toilet.

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