Tracheostomy

 

VBMC TRAUMA CARE SERVICES GUIDELINE

 

Tracheostomy

            Tracheostomy is frequently required for the management of airway, pulmonary toilet, and/or respiratory failure in patients with complex critical illness and/or injury. The vast majority of these are performed percutaneously although some are still placed using the older, but still reliable, open surgical technique. Regardless of placement technique, complications, daily tracheostomy tube/site care, and downsizing/decannulation are the same.

Complications

            Dislodgement: The most common early and lethal complication of tracheostomy is tube dislodgement. In order to prevent this complication, the tracheostomy tube is secured to the skin with sutures and fixed in place with a secure neck strap. Sutures often give a false sense of security and will not in and of themselves eliminate dislodgement. The most important defense against early dislodgement is a secure neck strap and strict avoidance of undue tension and/or torque on the fresh tracheostomy. It takes about four days after insertion to develop a mature tract. After four days, dislodgement rarely results airway compromise and the tube can simply be reinserted through the neck. Prior to four days, airway loss is likely if the tracheostomy tube is dislodged, and the patient may require endotracheal intubation ORALLY to reestablish the airway. This is a true emergency that requires the immediate attention of the surgical house staff. The patient can be temporized with 100% oxygen delivered via bag valve mask and gentle occlusion of the tracheostomy site.

 

Plugging: The most common intermediate complication of tracheostomy is mucous plugging. This will be the most frequent problem encountered with ward patients. Secretions build up in the tracheostomy tube lumen leading to sudden occlusion and airway compromise. Virtually all the tracheostomy tubes in use at VBMC have a removable inner cannula. The routine practice of maintaining cuff deflation and routine inspection/cleaning of the inner cannula will prevent this complication.

 

Stenosis: Tracheal stenosis is a late complication of tracheostomy. Virtually all tracheostomies (85%) are associated with some degree of tracheal stenosis. Only 1-2% of patients develop critical stenosis that compromises the airway and produces clinical symptoms. The duration of endotracheal intubation (> 11 days) prior to tracheostomy, technique used (open > percutaneous), higher placement (between rings 1-2 vs. 2 or lower), and smaller airway (children, females) all increase the rate of clinically significant tracheal stenosis. Almost all clinically significant stenosis occurs within twelve weeks of tracheostomy. The hallmark of clinically significant tracheal stenosis is respiratory distress and/or stridor and wheezing when the tracheostomy tube is plugged or removed. If plug removal or tracheostomy tube reinsertion alleviates symptoms the tube should remain in place until a diagnostic evaluation can be performed.

 

Tracheal-arterial fistula: Small amounts of bleeding may occur simply from the irritation of suctioning, site care and/or the tube itself. A rare but lethal complication of tracheostomy is tracheal-arterial fistula that occurs from erosion of the tip of the tracheostomy tube into the great vessels of the upper thorax. The hallmark of this complication is a “herald bleed” defined as a moderate to large amount of bleeding that stops spontaneously. If bleeding persists or produces airway compromise, the endotracheal tube cuff can be inflated to tamponade bleeding and maintain the airway. Herald bleeding requires immediate investigation!

 

Infection: Tracheostomy site infection is exceedingly rare. The presence of purulent, foul–smelling secretions accompanied by an expanding zone of erythema establishes the diagnosis. Site care and appropriate antimicrobial therapy are effective in controlling this complication.

 

Tracheocutaneous fistula: This is a rare complication of tracheostomy that is defined as a persistent air leak present for more than one week after decannulation. While a small percentage of these will close after 7 days most will require a surgical intervention to achieve closure.

 

Bronchorrhea: Copious secretions usually indicate a residual or recurrent pulmonary problem. Occasionally, these secretions are due to the endotracheal tube itself. The tube can and does irritate the upper airway producing excessive secretions. Decannulation is the treatment of choice. If the patient still requires a tracheostomy (coma), a drying agent such as Robinul (glycopyrrolate) can be used.

 

Tracheostomy tube/site care

            The tracheostomy tube and site should be inspected at least once daily. The site itself should be inspected for purulence and erythema. Gentle cleansing with a small amount of soap and water followed by a dry dressing provides ample site care. The inner cannula should be removed, inspected, and cleaned as necessary to remove buildup of dried secretions. The tracheostomy tape should be snug enough to prevent excess movement of the tube but not so tight as to produce skin breakdown/ulceration. When the patient is not being mechanically ventilated, the balloon should be deflated on cuffed tubes. Sutures, if present, can be removed after six days. Tracheostomy bypasses the normal humidification provided by the oro/nasopharynx so patients are prone to evaporative water loss and desiccation of the airway mucosa. Humidified air or oxygen (if required) should be always used to prevent the latter complications. 

 

Downsizing and decannulation

            The general practice of downsizing a tracheostomy tube prior to decannulation is controversial. Be that as it may, downsizing the tracheostomy tube prior to decannulation is the routine practice at VBMC. The stated advantages are a reduction in size of the tract to reduce tracheocutaneous fistulas and to detect tracheal stenosis prior to decannulation. After four days a well-established tract exists between the surface and the trachea. Downsizing can proceed safely at this point. Decannulation should not proceed until the patient is clinically stable. Respiratory failure should be stable or improving and suctioning requirements should be nominal (>2-4 hours). The patient should have a vigorous cough and be able to handle their secretions. There should be no residual airway issues. As a first step, the plastic tracheostomy tubes, usually Shiley, are removed and replaced with a 6mm tube (Jackson). These can then be plugged. If the patient tolerates plugging (see complications: tracheal stenosis), has a good cough and minimal secretions, decannulation can proceed. The tracheostomy site should be covered with an occlusive dressing. The patient should be monitored closely over the next 24 hours for any evidence of respiratory distress. Closure of the tract usually requires 24-48 hours. Comatose patients can be downsized but should not be decannulated. This group of patients rarely has a good cough and cannot protect their airway. Consequently, they remain at risk for aspiration and/or respiratory compromise.

 

Dysphagia and aspiration following tracheostomy

            Dysphagia and/or aspiration following tracheostomy are very common. Most patients who require a tracheostomy have not had oral intake for some time. This is complicated by the fact that the tracheostomy itself may interfere with swallowing. This is simply a problem of training/initiating a swallowing bolus! To initiate oral intake, cuffed tracheostomy tubes should be deflated or downsized to a smaller metal tracheostomy. Oral intake should never begin with liquids. It is much harder to develop a swallowing bolus with liquids. The initial oral feeding challenge should be with thickened liquids and/or solids. Most importantly, the patient should be sitting upright. Why don’t you try to swallow liquids in a supine position! If managed correctly, this is rarely a clinical problem, and oral feeding can be safely resumed. Nurse-performed dysphagia screens are our first line of evaluation of patients at risk. Give the patient good instructions and several attempts before conceding failure. Decannulation, if indicated, can also be accomplished prior to another try. The dysphagia team should be consulted if nursing is concerned that aspiration is, in fact, occurring. Contrast studies can, however, overestimate the problem and can lead to unnecessary, complicated, and expensive alternatives. Fortunately, only an occasional patient will fail and require an alternative feeding access.