Tracheotomy - Revision history

Chris.Rishel: Text replacement - "Art line" to "Arterial line"

2022-04-05T19:40:16Z

Text replacement - "Art line" to "Arterial line"

← Older revision		Revision as of 12:40, 5 April 2022
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	Tracheostomy tube (TT)		Tracheostomy tube (TT)
	\| lines_access = PIV		\| lines_access = PIV
	± ~~Art~~ line		± Arterial line
	\| monitors = Standard		\| monitors = Standard
	5-lead ECG		5-lead ECG

Chris.Rishel at 07:52, 5 April 2022

2022-04-05T07:52:53Z

← Older revision		Revision as of 00:52, 5 April 2022
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General~~, awake~~/~~local~~		\| anesthesia_type = General or local/MAC
	\| airway = ETT~~, tracheostomy~~ tube (TT)		\| airway = ETT
	\| lines_access = PIV~~, arterial/central access depending on patient condition~~		Tracheostomy tube (TT)
	\| monitors = Standard~~, invasive depending on patient condition~~		\| lines_access = PIV
	\| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy under general vs awake~~, avoidance~~ of premedication if concern for airway obstruction		± Art line
	\| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using dexmedetomidine, then converting to general when the tube is secured		\| monitors = Standard
	\| considerations_postoperative = ~~Complications with the highest morbidity/mortality to be aware of include creation~~ of a false passage~~, occlusion~~ of tracheostomy tube~~, tube~~ displacement~~, tracheoinnominate~~ artery fistula~~, airway~~ stenosis		5-lead ECG
			± ABP
			\| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy under general vs awake
			Avoidance of premedication if concern for airway obstruction
			\| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT.
			Do not remove past the vocal cords until surgeon indicates.
			If an awake tracheostomy, consider sedation using dexmedetomidine, then converting to general when the tube is secured
			\| considerations_postoperative = Creation of a false passage
			Occlusion of tracheostomy tube
			Tube displacement
			Tracheoinnominate artery fistula
			Airway stenosis
	}}		}}

Helen.Heymann at 19:06, 19 March 2022

2022-03-19T19:06:27Z

← Older revision		Revision as of 12:06, 19 March 2022
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	\| considerations_postoperative = Complications with the highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis		\| considerations_postoperative = Complications with the highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis
	}}		}}











	A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.<ref name=":1">{{Cite journal\|last=Cheung\|first=N. H.\|last2=Napolitano\|first2=L. M.\|date=2014-06-01\|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes\|url=http://dx.doi.org/10.4187/respcare.02971\|journal=Respiratory Care\|volume=59\|issue=6\|pages=895–919\|doi=10.4187/respcare.02971\|issn=0020-1324}}</ref>		A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.<ref name=":1">{{Cite journal\|last=Cheung\|first=N. H.\|last2=Napolitano\|first2=L. M.\|date=2014-06-01\|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes\|url=http://dx.doi.org/10.4187/respcare.02971\|journal=Respiratory Care\|volume=59\|issue=6\|pages=895–919\|doi=10.4187/respcare.02971\|issn=0020-1324}}</ref>
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	\|		\|

	* Consider TIVA with propofol/remifentanil		* Consider TIVA with propofol/remifentanil; remifentanil may not be necessary however consider small boluses of fentanyl

	* Muscle relaxation required, may use rocuronium		* Muscle relaxation required, may use rocuronium
	* Usually no antibiotics indicated		* Usually no antibiotics indicated

Helen.Heymann at 16:19, 26 February 2022

2022-02-26T16:19:52Z

← Older revision		Revision as of 09:19, 26 February 2022
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	\| airway = ETT, tracheostomy tube (TT)		\| airway = ETT, tracheostomy tube (TT)
	\| lines_access = PIV, arterial/central access depending on patient condition		\| lines_access = PIV, arterial/central access depending on patient condition
	\| monitors = Standard, ~~Invasive~~ depending on patient condition		\| monitors = Standard, invasive depending on patient condition
	\| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy ~~awake vs~~ under general, avoidance of premedication if concern for airway obstruction		\| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy under general vs awake, avoidance of premedication if concern for airway obstruction
	\| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using ~~precedex~~, then converting to general when the tube is secured.		\| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using dexmedetomidine, then converting to general when the tube is secured
	\| considerations_postoperative = Complications with highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis		\| considerations_postoperative = Complications with the highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis
	}}		}}

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	A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.<ref name=":1">{{Cite journal\|last=Cheung\|first=N. H.\|last2=Napolitano\|first2=L. M.\|date=2014-06-01\|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes\|url=http://dx.doi.org/10.4187/respcare.02971\|journal=Respiratory Care\|volume=59\|issue=6\|pages=895–919\|doi=10.4187/respcare.02971\|issn=0020-1324}}</ref>		A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.<ref name=":1">{{Cite journal\|last=Cheung\|first=N. H.\|last2=Napolitano\|first2=L. M.\|date=2014-06-01\|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes\|url=http://dx.doi.org/10.4187/respcare.02971\|journal=Respiratory Care\|volume=59\|issue=6\|pages=895–919\|doi=10.4187/respcare.02971\|issn=0020-1324}}</ref>

	Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),<ref>{{Cite journal\|last=Ranes\|first=Justin L.\|last2=Gordon\|first2=Steven M.\|last3=Chen\|first3=Pam\|last4=Fatica\|first4=Cynthia\|last5=Hammel\|first5=Jeffrey\|last6=Gonzales\|first6=Jeffrey P.\|last7=Arroliga\|first7=Alejandro C.\|date=2006-10-01\|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia\|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract\|journal=The American Journal of Medicine\|language=English\|volume=119\|issue=10\|pages=897.e13–897.e19\|doi=10.1016/j.amjmed.2005.12.034\|issn=0002-9343}}</ref><ref>{{Cite journal\|last=HOLZAPFEL\|first=L.\|last2=CHEVRET\|first2=S.\|last3=MADINIER\|first3=G.\|last4=OHEN\|first4=F.\|last5=DEMINGEON\|first5=G.\|last6=COUPRY\|first6=A.\|last7=CHAUDET\|first7=M.\|date=1994-06\|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia\|url=http://dx.doi.org/10.1097/00132586-199406000-00057\|journal=Survey of Anesthesiology\|volume=38\|issue=03\|pages=177???178\|doi=10.1097/00132586-199406000-00057\|issn=0039-6206}}</ref><ref>{{Cite journal\|last=Cavaliere\|first=S.\|last2=Bezzi\|first2=M.\|last3=Toninelli\|first3=C.\|last4=Foccoli\|first4=P.\|date=2016-02-03\|title=Management of post-intubation tracheal stenoses using the endoscopic approach\|url=http://www.monaldi-archives.org/index.php/macd/article/view/492\|journal=Monaldi Archives for Chest Disease\|volume=67\|issue=2\|doi=10.4081/monaldi.2007.492\|issn=2465-1028}}</ref> as well as ~~to improve patient comfort, reducing~~ need for sedation~~, lowering airway resistance,~~ and ~~improving~~ overall airway care<ref>{{Cite journal\|last=Heffner\|first=John E.\|last2=Hess\|first2=Dean\|date=2001-03\|title=Tracheostomy Management in the Chronically Ventilated Patient\|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3\|journal=Clinics in Chest Medicine\|volume=22\|issue=1\|pages=55–69\|doi=10.1016/s0272-5231(05)70025-3\|issn=0272-5231}}</ref><ref>{{Cite journal\|last=Diehl\|first=J\|last2=El Atrous\|first2=S\|last3=Touchard\|first3=D\|last4=Lemaire\|first4=F\|last5=Brochard\|first5=L.\|date=1999\|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.\|url=http://dx.doi.org/10.1097/01823246-199910020-00013\|journal=Cardiopulmonary Physical Therapy Journal\|volume=10\|issue=2\|pages=60\|doi=10.1097/01823246-199910020-00013\|issn=1541-7891}}</ref>. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.<ref name=":3" /> Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.<ref name=":3" />		Indications for tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as in critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),<ref>{{Cite journal\|last=Ranes\|first=Justin L.\|last2=Gordon\|first2=Steven M.\|last3=Chen\|first3=Pam\|last4=Fatica\|first4=Cynthia\|last5=Hammel\|first5=Jeffrey\|last6=Gonzales\|first6=Jeffrey P.\|last7=Arroliga\|first7=Alejandro C.\|date=2006-10-01\|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia\|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract\|journal=The American Journal of Medicine\|language=English\|volume=119\|issue=10\|pages=897.e13–897.e19\|doi=10.1016/j.amjmed.2005.12.034\|issn=0002-9343}}</ref><ref>{{Cite journal\|last=HOLZAPFEL\|first=L.\|last2=CHEVRET\|first2=S.\|last3=MADINIER\|first3=G.\|last4=OHEN\|first4=F.\|last5=DEMINGEON\|first5=G.\|last6=COUPRY\|first6=A.\|last7=CHAUDET\|first7=M.\|date=1994-06\|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia\|url=http://dx.doi.org/10.1097/00132586-199406000-00057\|journal=Survey of Anesthesiology\|volume=38\|issue=03\|pages=177???178\|doi=10.1097/00132586-199406000-00057\|issn=0039-6206}}</ref><ref>{{Cite journal\|last=Cavaliere\|first=S.\|last2=Bezzi\|first2=M.\|last3=Toninelli\|first3=C.\|last4=Foccoli\|first4=P.\|date=2016-02-03\|title=Management of post-intubation tracheal stenoses using the endoscopic approach\|url=http://www.monaldi-archives.org/index.php/macd/article/view/492\|journal=Monaldi Archives for Chest Disease\|volume=67\|issue=2\|doi=10.4081/monaldi.2007.492\|issn=2465-1028}}</ref> as well as reduce the need for sedation and improve overall patient comfort and airway care<ref>{{Cite journal\|last=Heffner\|first=John E.\|last2=Hess\|first2=Dean\|date=2001-03\|title=Tracheostomy Management in the Chronically Ventilated Patient\|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3\|journal=Clinics in Chest Medicine\|volume=22\|issue=1\|pages=55–69\|doi=10.1016/s0272-5231(05)70025-3\|issn=0272-5231}}</ref><ref>{{Cite journal\|last=Diehl\|first=J\|last2=El Atrous\|first2=S\|last3=Touchard\|first3=D\|last4=Lemaire\|first4=F\|last5=Brochard\|first5=L.\|date=1999\|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.\|url=http://dx.doi.org/10.1097/01823246-199910020-00013\|journal=Cardiopulmonary Physical Therapy Journal\|volume=10\|issue=2\|pages=60\|doi=10.1097/01823246-199910020-00013\|issn=1541-7891}}</ref>. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.<ref name=":3" /> Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.<ref name=":3" />

	A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques.		A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques.
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	\|Endocrine		\|Endocrine
	\|Consider adrenal suppression, hyperglycemia if ICU patient		\|Consider adrenal suppression, hyperglycemia if ICU patient
	\|-
	~~\|Other~~
	~~\|Note nutritional status~~
	\|}		\|}

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	* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula<span class="reference" id="cite_ref-:2_2-0"></span>		* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula<span class="reference" id="cite_ref-:2_2-0"></span>
	* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ~~ventilation proves~~ impossible		* Most institutions have a "trach set" for the surgical team
			* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventil<span class="reference" id="cite_ref-:2_2-0"></span>ation is impossible

	=== Patient preparation and premedicatio<span class="reference" id="cite_ref-:2_2-0"></span>n<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===		=== Patient preparation and premedicatio<span class="reference" id="cite_ref-:2_2-0"></span>n<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
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	* Supine, head extended with shoulder roll		* Supine, head extended with shoulder roll
	** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon~~; important~~ to tape securely		** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon
			** Important to tape ETT securely

	* Table may be turned 180 degrees in awake cases		* Table may be turned 180 degrees in awake cases
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	* Consider TIVA with propofol/remifentanil		* Consider TIVA with propofol/remifentanil
	* Muscle relaxation required, may use rocuronium		* Muscle relaxation required, may use rocuronium
			* Usually no antibiotics indicated
			* PONV prophylaxis with dexamethasone, ondansetron
	* Normovolemia, normothermia		* Normovolemia, normothermia
	* PONV prophylaxis with dexamethasone, ondansetron
	* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened		* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened
	* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss		* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss

Helen.Heymann at 20:17, 24 February 2022

2022-02-24T20:17:43Z

← Older revision		Revision as of 13:17, 24 February 2022
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General, awake/local		\| anesthesia_type = General, awake/local
	\| airway = ETT, ~~tracheotomy~~		\| airway = ETT, tracheostomy tube (TT)
	\| lines_access = PIV, arterial/central access depending on patient condition		\| lines_access = PIV, arterial/central access depending on patient condition
	\| monitors = Standard, Invasive depending on patient condition		\| monitors = Standard, Invasive depending on patient condition

Helen.Heymann at 19:05, 24 February 2022

2022-02-24T19:05:14Z

← Older revision		Revision as of 12:05, 24 February 2022
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	In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.<ref>{{Cite journal\|last=De Leyn\|first=Paul\|last2=Bedert\|first2=Lieven\|last3=Delcroix\|first3=Marion\|last4=Depuydt\|first4=Pieter\|last5=Lauwers\|first5=Geert\|last6=Sokolov\|first6=Youri\|last7=Van Meerhaeghe\|first7=Alain\|last8=Van Schil\|first8=Paul\|date=2007-09\|title=Tracheotomy: clinical review and guidelines\|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018\|journal=European Journal of Cardio-Thoracic Surgery\|volume=32\|issue=3\|pages=412–421\|doi=10.1016/j.ejcts.2007.05.018\|issn=1010-7940}}</ref><ref name=":3">{{Cite book\|last=Jaffe\|first=Richard A.\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2020\|isbn=9781496371256\|location=Philadelphia\|pages=209-214}}</ref>		In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.<ref>{{Cite journal\|last=De Leyn\|first=Paul\|last2=Bedert\|first2=Lieven\|last3=Delcroix\|first3=Marion\|last4=Depuydt\|first4=Pieter\|last5=Lauwers\|first5=Geert\|last6=Sokolov\|first6=Youri\|last7=Van Meerhaeghe\|first7=Alain\|last8=Van Schil\|first8=Paul\|date=2007-09\|title=Tracheotomy: clinical review and guidelines\|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018\|journal=European Journal of Cardio-Thoracic Surgery\|volume=32\|issue=3\|pages=412–421\|doi=10.1016/j.ejcts.2007.05.018\|issn=1010-7940}}</ref><ref name=":3">{{Cite book\|last=Jaffe\|first=Richard A.\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2020\|isbn=9781496371256\|location=Philadelphia\|pages=209-214}}</ref>

	In a percutaneous tracheostomy, ~~many~~ methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.<ref>{{Cite journal\|last=Nates\|first=Joseph L.\|last2=Cooper\|first2=D. James\|last3=Myles\|first3=Paul S.\|last4=Scheinkestel\|first4=Carlos D.\|last5=Tuxen\|first5=David V.\|date=2000-11\|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:\|url=http://journals.lww.com/00003246-200011000-00034\|journal=Critical Care Medicine\|language=en\|volume=28\|issue=11\|pages=3734–3739\|doi=10.1097/00003246-200011000-00034\|issn=0090-3493}}</ref>		In a percutaneous tracheostomy, various procedure methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.<ref>{{Cite journal\|last=Nates\|first=Joseph L.\|last2=Cooper\|first2=D. James\|last3=Myles\|first3=Paul S.\|last4=Scheinkestel\|first4=Carlos D.\|last5=Tuxen\|first5=David V.\|date=2000-11\|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:\|url=http://journals.lww.com/00003246-200011000-00034\|journal=Critical Care Medicine\|language=en\|volume=28\|issue=11\|pages=3734–3739\|doi=10.1097/00003246-200011000-00034\|issn=0090-3493}}</ref>
	== Preoperative management ==		== Preoperative management ==

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	* Head and Neck CT/MRI		* Head and Neck CT/MRI
			* Neck ultrasound to identify anatomy
	* CXR, ABG as indicated from H&P		* CXR, ABG as indicated from H&P

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	\|		\|
	* Convert ICU sedation to GA with carefully titrated inhalational agent		* Convert ICU sedation to GA with carefully titrated inhalational agent
			* May consider TIVA if patient at decreased risk for hemodynamic instability
	\|-		\|-
	\|As part of scheduled procedure		\|As part of scheduled procedure
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	\|+		\|+
	!		!
	~~!General~~
	~~!Awake~~
	!Bedside - Percutaneous		!Bedside - Percutaneous
	\|-		\|-
	\|Unique considerations		\|Unique considerations
	\|
	\|
	\|Advantages over tracheostomies in the OR		\|Advantages over tracheostomies in the OR

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	\|-		\|-
	\|Potential complications		\|Potential complications
	\|
	\|
	\|2.2x more likely to have early postoperative complications vs open<ref name=":0" />		\|2.2x more likely to have early postoperative complications vs open<ref name=":0" />
	\|}		\|}

Helen.Heymann at 17:55, 24 February 2022

2022-02-24T17:55:38Z

← Older revision		Revision as of 10:55, 24 February 2022
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	\| monitors = Standard, Invasive depending on patient condition		\| monitors = Standard, Invasive depending on patient condition
	\| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction		\| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction
	\| considerations_intraoperative =		\| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using precedex, then converting to general when the tube is secured.
	\| considerations_postoperative =		\| considerations_postoperative = Complications with highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis
	}}		}}

Line 23:		Line 23:
	Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),<ref>{{Cite journal\|last=Ranes\|first=Justin L.\|last2=Gordon\|first2=Steven M.\|last3=Chen\|first3=Pam\|last4=Fatica\|first4=Cynthia\|last5=Hammel\|first5=Jeffrey\|last6=Gonzales\|first6=Jeffrey P.\|last7=Arroliga\|first7=Alejandro C.\|date=2006-10-01\|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia\|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract\|journal=The American Journal of Medicine\|language=English\|volume=119\|issue=10\|pages=897.e13–897.e19\|doi=10.1016/j.amjmed.2005.12.034\|issn=0002-9343}}</ref><ref>{{Cite journal\|last=HOLZAPFEL\|first=L.\|last2=CHEVRET\|first2=S.\|last3=MADINIER\|first3=G.\|last4=OHEN\|first4=F.\|last5=DEMINGEON\|first5=G.\|last6=COUPRY\|first6=A.\|last7=CHAUDET\|first7=M.\|date=1994-06\|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia\|url=http://dx.doi.org/10.1097/00132586-199406000-00057\|journal=Survey of Anesthesiology\|volume=38\|issue=03\|pages=177???178\|doi=10.1097/00132586-199406000-00057\|issn=0039-6206}}</ref><ref>{{Cite journal\|last=Cavaliere\|first=S.\|last2=Bezzi\|first2=M.\|last3=Toninelli\|first3=C.\|last4=Foccoli\|first4=P.\|date=2016-02-03\|title=Management of post-intubation tracheal stenoses using the endoscopic approach\|url=http://www.monaldi-archives.org/index.php/macd/article/view/492\|journal=Monaldi Archives for Chest Disease\|volume=67\|issue=2\|doi=10.4081/monaldi.2007.492\|issn=2465-1028}}</ref> as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care<ref>{{Cite journal\|last=Heffner\|first=John E.\|last2=Hess\|first2=Dean\|date=2001-03\|title=Tracheostomy Management in the Chronically Ventilated Patient\|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3\|journal=Clinics in Chest Medicine\|volume=22\|issue=1\|pages=55–69\|doi=10.1016/s0272-5231(05)70025-3\|issn=0272-5231}}</ref><ref>{{Cite journal\|last=Diehl\|first=J\|last2=El Atrous\|first2=S\|last3=Touchard\|first3=D\|last4=Lemaire\|first4=F\|last5=Brochard\|first5=L.\|date=1999\|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.\|url=http://dx.doi.org/10.1097/01823246-199910020-00013\|journal=Cardiopulmonary Physical Therapy Journal\|volume=10\|issue=2\|pages=60\|doi=10.1097/01823246-199910020-00013\|issn=1541-7891}}</ref>. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.<ref name=":3" /> Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.<ref name=":3" />		Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),<ref>{{Cite journal\|last=Ranes\|first=Justin L.\|last2=Gordon\|first2=Steven M.\|last3=Chen\|first3=Pam\|last4=Fatica\|first4=Cynthia\|last5=Hammel\|first5=Jeffrey\|last6=Gonzales\|first6=Jeffrey P.\|last7=Arroliga\|first7=Alejandro C.\|date=2006-10-01\|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia\|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract\|journal=The American Journal of Medicine\|language=English\|volume=119\|issue=10\|pages=897.e13–897.e19\|doi=10.1016/j.amjmed.2005.12.034\|issn=0002-9343}}</ref><ref>{{Cite journal\|last=HOLZAPFEL\|first=L.\|last2=CHEVRET\|first2=S.\|last3=MADINIER\|first3=G.\|last4=OHEN\|first4=F.\|last5=DEMINGEON\|first5=G.\|last6=COUPRY\|first6=A.\|last7=CHAUDET\|first7=M.\|date=1994-06\|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia\|url=http://dx.doi.org/10.1097/00132586-199406000-00057\|journal=Survey of Anesthesiology\|volume=38\|issue=03\|pages=177???178\|doi=10.1097/00132586-199406000-00057\|issn=0039-6206}}</ref><ref>{{Cite journal\|last=Cavaliere\|first=S.\|last2=Bezzi\|first2=M.\|last3=Toninelli\|first3=C.\|last4=Foccoli\|first4=P.\|date=2016-02-03\|title=Management of post-intubation tracheal stenoses using the endoscopic approach\|url=http://www.monaldi-archives.org/index.php/macd/article/view/492\|journal=Monaldi Archives for Chest Disease\|volume=67\|issue=2\|doi=10.4081/monaldi.2007.492\|issn=2465-1028}}</ref> as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care<ref>{{Cite journal\|last=Heffner\|first=John E.\|last2=Hess\|first2=Dean\|date=2001-03\|title=Tracheostomy Management in the Chronically Ventilated Patient\|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3\|journal=Clinics in Chest Medicine\|volume=22\|issue=1\|pages=55–69\|doi=10.1016/s0272-5231(05)70025-3\|issn=0272-5231}}</ref><ref>{{Cite journal\|last=Diehl\|first=J\|last2=El Atrous\|first2=S\|last3=Touchard\|first3=D\|last4=Lemaire\|first4=F\|last5=Brochard\|first5=L.\|date=1999\|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.\|url=http://dx.doi.org/10.1097/01823246-199910020-00013\|journal=Cardiopulmonary Physical Therapy Journal\|volume=10\|issue=2\|pages=60\|doi=10.1097/01823246-199910020-00013\|issn=1541-7891}}</ref>. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.<ref name=":3" /> Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.<ref name=":3" />

	A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques.		A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques.

	In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ~~ring~~ is ~~made and~~ secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.<ref>{{Cite journal\|last=De Leyn\|first=Paul\|last2=Bedert\|first2=Lieven\|last3=Delcroix\|first3=Marion\|last4=Depuydt\|first4=Pieter\|last5=Lauwers\|first5=Geert\|last6=Sokolov\|first6=Youri\|last7=Van Meerhaeghe\|first7=Alain\|last8=Van Schil\|first8=Paul\|date=2007-09\|title=Tracheotomy: clinical review and guidelines\|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018\|journal=European Journal of Cardio-Thoracic Surgery\|volume=32\|issue=3\|pages=412–421\|doi=10.1016/j.ejcts.2007.05.018\|issn=1010-7940}}</ref><ref name=":3">{{Cite book\|last=Jaffe\|first=Richard A.\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2020\|isbn=9781496371256\|location=Philadelphia\|pages=209-214}}</ref>		In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.<ref>{{Cite journal\|last=De Leyn\|first=Paul\|last2=Bedert\|first2=Lieven\|last3=Delcroix\|first3=Marion\|last4=Depuydt\|first4=Pieter\|last5=Lauwers\|first5=Geert\|last6=Sokolov\|first6=Youri\|last7=Van Meerhaeghe\|first7=Alain\|last8=Van Schil\|first8=Paul\|date=2007-09\|title=Tracheotomy: clinical review and guidelines\|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018\|journal=European Journal of Cardio-Thoracic Surgery\|volume=32\|issue=3\|pages=412–421\|doi=10.1016/j.ejcts.2007.05.018\|issn=1010-7940}}</ref><ref name=":3">{{Cite book\|last=Jaffe\|first=Richard A.\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2020\|isbn=9781496371256\|location=Philadelphia\|pages=209-214}}</ref>

	~~Although there are many methods to perform~~ a percutaneous ~~tracheotomy~~, ~~most~~ commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased bleeding.<ref>{{Cite journal\|last=Nates\|first=Joseph L.\|last2=Cooper\|first2=D. James\|last3=Myles\|first3=Paul S.\|last4=Scheinkestel\|first4=Carlos D.\|last5=Tuxen\|first5=David V.\|date=2000-11\|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:\|url=http://journals.lww.com/00003246-200011000-00034\|journal=Critical Care Medicine\|language=en\|volume=28\|issue=11\|pages=3734–3739\|doi=10.1097/00003246-200011000-00034\|issn=0090-3493}}</ref>		In a percutaneous tracheostomy, many methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.<ref>{{Cite journal\|last=Nates\|first=Joseph L.\|last2=Cooper\|first2=D. James\|last3=Myles\|first3=Paul S.\|last4=Scheinkestel\|first4=Carlos D.\|last5=Tuxen\|first5=David V.\|date=2000-11\|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:\|url=http://journals.lww.com/00003246-200011000-00034\|journal=Critical Care Medicine\|language=en\|volume=28\|issue=11\|pages=3734–3739\|doi=10.1097/00003246-200011000-00034\|issn=0090-3493}}</ref>
	== Preoperative management ==		== Preoperative management ==

Line 95:		Line 95:
	\|+		\|+
	\|-		\|-
	\|~~Intubated~~		\|Critically ill patients, already intubated
	\|		\|
	* Convert ICU sedation to GA with carefully titrated inhalational agent		* Convert ICU sedation to GA with carefully titrated inhalational agent
	\|-		\|-
	\|~~Not intubated with plan for GETA~~		\|As part of scheduled procedure
	\|		\|
	* Standard IV induction		* Standard IV induction
Line 106:		Line 106:
	\|Awake		\|Awake
	\|		\|
	* Consider sedation using precedex		* Consider sedation using precedex; avoid bolusing as it may cause airway obstruction
	* Consider calming music such as classical		* Consider calming music such as classical
	\|}		\|}
Line 240:		Line 240:
	* prior neck surgery		* prior neck surgery
	* some believe anticoagulation		* some believe anticoagulation
	\|-
	~~\|Postoperative disposition~~
	\|
	\|
	\|
	\|-
	~~\|Pain management~~
	\|
	\|
	\|
	\|-		\|-
	\|Potential complications		\|Potential complications

Helen.Heymann at 17:07, 24 February 2022

2022-02-24T17:07:13Z

← Older revision		Revision as of 10:07, 24 February 2022
Line 26:		Line 26:

	In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.<ref>{{Cite journal\|last=De Leyn\|first=Paul\|last2=Bedert\|first2=Lieven\|last3=Delcroix\|first3=Marion\|last4=Depuydt\|first4=Pieter\|last5=Lauwers\|first5=Geert\|last6=Sokolov\|first6=Youri\|last7=Van Meerhaeghe\|first7=Alain\|last8=Van Schil\|first8=Paul\|date=2007-09\|title=Tracheotomy: clinical review and guidelines\|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018\|journal=European Journal of Cardio-Thoracic Surgery\|volume=32\|issue=3\|pages=412–421\|doi=10.1016/j.ejcts.2007.05.018\|issn=1010-7940}}</ref><ref name=":3">{{Cite book\|last=Jaffe\|first=Richard A.\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2020\|isbn=9781496371256\|location=Philadelphia\|pages=209-214}}</ref>		In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.<ref>{{Cite journal\|last=De Leyn\|first=Paul\|last2=Bedert\|first2=Lieven\|last3=Delcroix\|first3=Marion\|last4=Depuydt\|first4=Pieter\|last5=Lauwers\|first5=Geert\|last6=Sokolov\|first6=Youri\|last7=Van Meerhaeghe\|first7=Alain\|last8=Van Schil\|first8=Paul\|date=2007-09\|title=Tracheotomy: clinical review and guidelines\|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018\|journal=European Journal of Cardio-Thoracic Surgery\|volume=32\|issue=3\|pages=412–421\|doi=10.1016/j.ejcts.2007.05.018\|issn=1010-7940}}</ref><ref name=":3">{{Cite book\|last=Jaffe\|first=Richard A.\|title=Anesthesiologist's Manual of Surgical Procedures\|publisher=Wolters Kluwer\|year=2020\|isbn=9781496371256\|location=Philadelphia\|pages=209-214}}</ref>

			Although there are many methods to perform a percutaneous tracheotomy, most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased bleeding.<ref>{{Cite journal\|last=Nates\|first=Joseph L.\|last2=Cooper\|first2=D. James\|last3=Myles\|first3=Paul S.\|last4=Scheinkestel\|first4=Carlos D.\|last5=Tuxen\|first5=David V.\|date=2000-11\|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:\|url=http://journals.lww.com/00003246-200011000-00034\|journal=Critical Care Medicine\|language=en\|volume=28\|issue=11\|pages=3734–3739\|doi=10.1097/00003246-200011000-00034\|issn=0090-3493}}</ref>
	== Preoperative management ==		== Preoperative management ==

Line 206:		Line 208:
	** Airway stenosis		** Airway stenosis
	*** Posterior glottic, subglottic, tracheal		*** Posterior glottic, subglottic, tracheal
	*** Risk factors: inappropriately large ~~tracheal tube~~ (>7.5), obese patients (often sized with inappropriately large ~~tracheal tube~~)<ref name=":0" />		*** Risk factors: inappropriately large TT (>7.5), obese patients (often sized with inappropriately large TT)<ref name=":0" />
	*** Tracheal airway diameters do not correlate with body weight<ref name=":0" />		*** Tracheal airway diameters do not correlate with body weight<ref name=":0" />

Helen.Heymann at 16:55, 24 February 2022

2022-02-24T16:55:30Z

← Older revision		Revision as of 09:55, 24 February 2022
Line 146:		Line 146:
	\|Awake or as part of scheduled procedure		\|Awake or as part of scheduled procedure
	\|		\|
			* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties
	\|}		\|}
	== Postoperative management ==		== Postoperative management ==
Line 166:		Line 167:
	\|Awake or as part of scheduled procedure		\|Awake or as part of scheduled procedure
	\|		\|
			* Inpatient unit
	\|}		\|}

Helen.Heymann at 16:45, 24 February 2022

2022-02-24T16:45:07Z

Show changes