Abstract
Tracheostomy is a common surgical procedure, and is increasingly performed in the intensive care unit (ICU) as opposed to the operating room. Procedural knowledge is essential and is therefore outlined in this review. We also review several high-quality studies comparing percutaneous dilational tracheostomy and open surgical tracheostomy. The percutaneous method has a comparable, if not superior, safety profile and lower cost compared with the open surgical approach; therefore the percutaneous method is increasingly chosen. Standard and specialized varieties of tracheostomy tubes are available and the appropriate type is determined by patient anatomy and the indication for the tracheostomy. Fibre optic endoscopic evaluation of swallowing should be considered in assessment of bulbar function and tracheostomy weaning. A patient with a tracheostomy who develops respiratoryDistress during the ward weaning process should be investigated for upper airway pathology. Studies comparing early versus late tracheostomy suggest morbidity benefits that include less nosocomial pneumonia, shorter mechanical ventilation and shorter stay in the ICU. However, we discuss the questions that remain regarding the optimal timing of tracheostomy. We outline the potential acute and chronic complications of tracheostomy and their management, and we review the different tracheostomy tubes, their indications and when to remove them.
Highlights
1 Chevalier Jackson is credited with the first clear open surgical (OS) description in 1909, 2 and Ciaglia is credited with the first percutaneous dilatational tracheostomy (PDT) in 1985.3 A procedure that previously required an operating room (OR) is commonly performed in the Intensive Care Unit (ICU). 4,5
There was no statistical difference in peri procedural complications when both PDT and OS were performed in the ICU
Long-term follow-up is needed, and patients excluded from PDT owing to anatomy or coagulopathy remain inadequately studied, emerging evidence suggests the procedure is safe in this population. 18,19 Evidence suggests that an estimated 7% of elective PDTs require conversion to OS. 6
Summary
Reports of surgically securing the airway date back to ancient times. 1 Chevalier Jackson is credited with the first clear open surgical (OS) description in 1909, 2 and Ciaglia is credited with the first percutaneous dilatational tracheostomy (PDT) in 1985.3 A procedure that previously required an operating room (OR) is commonly performed in the Intensive Care Unit (ICU). 4,5. 1 Chevalier Jackson is credited with the first clear open surgical (OS) description in 1909, 2 and Ciaglia is credited with the first percutaneous dilatational tracheostomy (PDT) in 1985.3 A procedure that previously required an operating room (OR) is commonly performed in the Intensive Care Unit (ICU). The present review will focus on tracheostomy as a nonemergency procedure for stable ICU patients on mechanical ventilation. A tracheostomy provides many other beneficial effects for the patient when compared with tracheal intubation. These include allowance of speech, increased comfort with oral hygiene care and suctioning, and earlier commencement of oral nutrition. The insertion techniques, review the literature comparing the OS and PDT techniques and explore optimal timing of insertion. We discuss when removal (i.e., decannulation) can be considered
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