Page 583 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 46: Tracheostomy 403

These patients should also undergo laryngoscopy and bronchoscopy to AREAS OF CONTINUED CONTROVERSY
identify areas of stenosis, granulation tissue, or tracheomalacia, which AND FUTURE STUDY
may be contributing to airway obstruction around or above the trache-
ostomy tube. 66 Tracheostomy—and in particular tracheostomy timing—has been
The actual process of decannulation is very straightforward. The extensively studied in ICU patients for its effect on traditional mea-
tube is simply removed and the tracheostomy site is covered with an sures associated with good ICU outcomes, such as a shorter duration
occlusive dressing. However, we recommend that all elective decan- of mechanical ventilation, fewer pneumonias and decreased mortality.
nulations be treated with the same degree of caution as an inadvertent To date, there is little convincing evidence that these outcomes are sig-
or premature decannulation, with suitable personnel and resources nificantly altered by performing tracheostomy earlier in patients that
present to manage an obstructed airway or respiratory distress, if nec- are anticipated to require prolonged mechanical ventilation. Arguably,
essary. Figure 46-1 describes our suggested algorithm for proceeding the greatest benefit of tracheostomy is to improve patient comfort. In
to tracheostomy decannulation. The actual tracheostomy tract will patients who are at risk for recurrent airway obstruction or inadequate
start to close by 24 to 48 hours after removal of the tube. A small per- pulmonary toilet, tracheostomy may also facilitate patient transfer out
centage of patients will have a persistent tracheocutaneous fistula after of the ICU in a safe and expedient manner. However, these potential
decannulation. This can be treated by excision of the tract and primary benefits must be weighed against the risk of complications occurring
closure of the wound. in patients that are already critically ill. Future research is required to
further refine the most appropriate patient populations and indications
SPEECH AND SWALLOWING for tracheostomy in the ICU, and these studies should focus on patient-
centered outcomes rather than simply on costs or ICU length of stay.
Conventional endotracheal tubes generally do not permit any form
of vocal communication or swallowing. However, for patients having
a prolonged need for an artificial airway, tracheostomy does offer the KEY REFERENCES
potential for both speech and swallowing. Both are obviously important
contributors to quality of life. • Blot F, Similowski T, Trouillet JL, et al. Early tracheotomy versus
Normal speech is possible with adequate flow and pressure through prolonged endotracheal intubation in unselected severely ill ICU
the larynx. This is most often accomplished when the patient is liber- patients. Intensive Care Med. 2008;34(10):1779-1787.
ated from mechanical ventilation and the tracheostomy cuff is deflated. • Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tra-
Insertion of a smaller tracheostomy tube, a cuffless tube, or a fenestrated cheostomy versus surgical tracheostomy in critically ill patients: a
tube will all typically increase airflow through the larynx. Speech can systematic review and meta-analysis. Crit Care. 2006;10(2):R55.
then be accomplished by intermittent tracheostomy tube occlusion, • Engels PT, Bagshaw SM, Meier M, Brindley PG. Tracheostomy:
most expediently delivered with a finger. A one-way valve (such as a from insertion to decannulation. Can J Surg. 2009;52(5):427-433.
Passy-Muir valve) may be fitted to the tracheostomy of a patient breath- • Freeman BD, Borecki IB, Coopersmith CM, Buchman TG.
ing spontaneously; this one-way valve provides occlusion of the tracheo- Relationship between tracheostomy timing and duration of
stomy tube during exhalation. However, these valve devices generally mechanical ventilation in critically ill patients. Crit Care Med.
67
increase the resistance to expiration and therefore may be poorly toler- 2005;33(11):2513-2520.
ated in patients with significant upper airway stenosis. The one-way
valve may help a patient to cough more effectively because higher airway • Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and
pressures can be generated, but patients with excessive secretions can be meta-analysis of studies of the timing of tracheostomy in adult
at risk of worsened secretion clearance because the tracheostomy tube patients undergoing artificial ventilation. BMJ. 2005;330(7502):1243.
becomes effectively occluded during coughing. • Heffner JE. The technique of weaning from tracheostomy. Criteria
In less common situations, a patient that requires ongoing mechani- for weaning; practical measures to prevent failure. J Crit Illn.
cal ventilation but who is able to tolerate intermittent or continuous 1995;10(10):729-733.
cuff deflation may be also able to speak while on the ventilator through • Scales DC, Thiruchelvam D, Kiss A, Redelmeier DA. The effect of
the use of a one-way valve placed in line with the ventilator circuit. tracheostomy timing during critical illness on long-term survival.
Manipulations of the ventilator settings, such as increasing PEEP in the Crit Care Med. 2008;36(9):2547-2557.
circuit, may also help provide airflow preferentially through the native • Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tra-
airway to allow speech. Caution must be exercised that inappropriate cheotomy for prevention of pneumonia in mechanically venti-
68
ventilator cycling does not occur with these maneuvers. Tracheostomy lated adult ICU patients: a randomized controlled trial. JAMA.
tubes are also available that have a cannula providing flow into the upper 2010;303(15):1483-1489.
airway which may allow very weak speech even with the tracheostomy • Trouillet JL, Luyt CE, Guiguet M, et al. Early percutaneous tra-
cuff inflated. 69 cheotomy versus prolonged intubation of mechanically ventilated
Although a patient with a tracheostomy should theoretically be able to patients after cardiac surgery: a randomized trial. Ann Intern Med.
eat and swallow because the esophagus remains patent and oropharynx 2011;154(6):373-383.
remains clear of tubes, there is still a high incidence of swallowing dys-
function and aspiration in patients with tracheostomy. 70,71 Some of this • Young JD. The TRACMAN Trial. Conference presentation, 29th
International Symposium on Intensive Care and Emergency
dysfunction may be attributable to prior endotracheal intubation, but
the presence of a tracheostomy tube also interferes with normal mecha- Medicine (ISICEM), March 26, 2009. Brussels, Belgium; 2009.
nisms to ensure glottis closure during deglutination. A tracheostomy • Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan C.
72
tube may lead to a degree of functional obstruction of the esophagus, Effect of early vs late tracheostomy placement on survival in
particularly with larger tubes and while the cuff remains inflated. patients receiving mechanical ventilation: the TracMan random-
Careful selection of patients for possible oral intake, with assessment ized trial. JAMA. 2013;309(20):2121-2129.
by a speech-language pathologist, likely assisted by studies such as
video barium swallow, is critical to ensure safe feeding. Patients who are
deemed to be at risk for impaired swallowing and aspiration may require REFERENCES
placement of a more permanent feeding tube, such as a percutaneous
endoscopic gastrostomy (PEG) tube. Complete references available online at www.mhprofessional.com/hall

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