State of the art: percutaneous tracheostomy in the intensive care unit

Abstract

Percutaneous tracheostomy is a commonly performed procedure for patients in the intensive care unit (ICU) and offers many benefits, including decreasing ICU length of stay and need for sedation while improving patient comfort, effective communication, and airway clearance. However, there is no consensus on the optimal timing of tracheostomy in ICU patients. Ultrasound (US) and bronchoscopy are useful adjunct tools to optimize procedural performance. US can be used pre-procedurally to identify vascular structures and to select the optimal puncture site, intra-procedurally to assist with accurate placement of the introducer needle, and post-procedurally to evaluate for a pneumothorax. Bronchoscopy provides real-time visual guidance from within the tracheal lumen and can reduce complications, such as paratracheal puncture and injury to the posterior tracheal wall. A step-by-step detailed procedural guide, including preparation and procedural technique, is provided with a team-based approach. Technical aspects, such as recommended equipment and selection of appropriate tracheostomy tube type and size, are discussed. Certain procedural considerations to minimize the risk of complications should be given in circumstances of patient obesity, coagulopathy, or neurologic illness. Herein, we provide a practical state of the art review of percutaneous tracheostomy in ICU patients. Specifically, we will address pre-procedural preparation, procedural technique, and post-tracheostomy management.

Impact of early percutaneous dilatative tracheostomy in patients with subarachnoid hemorrhage on main cerebral, hemodynamic, and respiratory variables: A prospective observational study

“…Increased PaCO 2 is considered a major determinant of HICP by several authors ( 13 , 37 , 47 , 48 , 59 ).…”

“…Tracheostomy was performed by a team of experienced physicians and nurses, consistently with a previously published protocol ( 43 ), according to the Ciaglia approach ( 44 , 45 ), and using the “Blue Rhino” set (Cook Critical Care, Bloomington, IN). Continuous airway monitoring through bronchoscopy was performed during the procedure ( 46 , 47 ) over an endotracheal tube (7.5/8 mm OD) ( 48 ). A moderate anti-Trendelenburg position (20°) with neck hyperextension was obtained, guided by ICP monitoring, and maintained throughout PDT.…”

“…This could have contributed to the maintenance of CPP consistently above 65 mmHg at all time points. Increased PaCO 2 is considered a major determinant of HICP by several authors (13,37,47,48,59).…”

Risk Factors and Protective Factors against Ventilator-Associated Pneumonia—A Single-Center Mixed Prospective and Retrospective Cohort Study

“…Intubated patients older than 18 years whose duration of mechanical ventilation was over 48 h qualified for both cohorts. Percutaneous tracheostomy (Blue Rhino Ciaglia 2) [22] was performed in all patients requiring prolonged mechanical ventilator support (for more than 14 days). In addition, in the prospective cohort, patients admitted to ICUs already intubated with a standard tube for less than 12 h, required re-intubation.…”

ICU nurses´ lived experience of caring for adult patients with a tracheostomy in ICU: a phenomenological-hermeneutic study

“…Despite the large number of international publications over the last decade [7][8][9] relating to tracheostomy care, there is still a paucity of research data from studies which explicitly investigated or described ICU nurses' lived experiences of caring for adult patients with a tracheostomy in ICU. A qualitative perspective using the French Philosopher Paul Ricoeur's [10] phenomenological-hermeneutic approach was chosen for this study because it is concerned with reaching a new understanding of the meaning of the phenomenon (caring for adult patients with a tracheostomy) as experienced by ICU nurses in the ICU.…”