9 - Tracheostomy

Summary

Introduction

Despite having existed as a therapeutic intervention since Egyptian times, there remain controversies regarding the timing and method of performing tracheostomy. It is undoubtedly a valuable therapeutic intervention, and is commonly seen on cardiac critical care units.

Indications

The commonest indication is to aid weaning from mechanical ventilation, after either predicted or actual failed removal of the endotracheal tube. The American Society of Thoracic Surgeons has estimated the need for prolonged ventilation (>24 hours) at 5% for first-time coronary artery bypass grafting and more than 10% for other cardiac surgery. If mechanical ventilation is still required after 10 to 14 days, then a tracheostomy is commonly performed. Many clinicians would also consider it necessary after two failed attempts at tracheal extubation. Prolonged ventilation or failed extubation may be due to:

1. • excessive secretions, persistent chest infection;

2. • reduced compliance, such as after acute lung injury;

3. • high oxygen requirements; or

4. • tracheostomy is also often performed in cases of obtunded neurological state (e.g. after stroke) or reduced airway protection reflexes.

Contraindications

There are no absolute contraindications to tracheostomy. Relative contraindications include:

1. • previous neck surgery or radiation, because distorted anatomy could lead to damage of associated anatomical structures, including vascular injury;

2. • impaired coagulation (should be corrected before procedure);

3. • high oxygen requirements, high positive end-expiratory pressure (PEEP) or airway pressures (may be difficult to ventilate effectively during the procedure).