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Tracheostomies
152
One of the most troubling problems with fenestrated tubes is the growth
of granulation tissue within the fenestration, which was originally reported in
tubes with one large fenestration. Since that time, fenestrated tubes with different designs have been developed. For example, the Shiley FEN and CFN tubes
typically have one large oval fenestration, while the Shiley DCFN and DFEN
as well as the Portex tubes have several elongated channels. However, no matter what the design of the fenestration, the risk of granulation tissue is greatest
when the fenestration is not centered in the airway. For this reason, many centers
choose not to place fenestrated tracheostomy tubes. If a fenestrated tube remains the best option for phonation and ventilation, however, it is imperative to
ensure a proper fit.
The procedure to fit a fenestration involves measuring the distance from
the stoma to the anterior and posterior tracheal walls. One technique was originally reported by Cane, Woodward, and Shapiro (1982); however, they further
described lengthening the established fenestration, which is no longer a recommended practice. To measure the tracheal depth, one can use a probe, a cottontipped swab, or a bent pipe cleaner to mark the distance between the anterior
and posterior walls. As shown in Figure 4.9, the “handle” of a cotton-tipped swab
is placed at the anterior tracheal wall and a mark is made at the stomal opening.
Then the applicator is placed further within the airway until it reaches the posterior wall. A second mark is made on the applicator at the stomal skin level.
The two marks should be aligned with the intended fenestrated tube by
placing the tip of the applicator on the neck flange of the tube to determine the
ideal location of the fenestration. The fenestration should lie completely between the two marks to ensure proper fit. If the fenestration does not fit within
these marks, a custom fenestration should be ordered, rather than cutting the
shaft oneself. A cut tube may have irregular edges, which could result in inflammation or an even greater risk of granuloma. The Moore tracheostomy tube is
the only one that can be modified, as small fenestration holes can be punched
into the shaft with an awl that comes with the kit.
Great caution must be taken when removing a fenestrated tracheostomy
tube. When granulation tissue has grown within the fenestration(s), manual
removal is potentially dangerous. The mobility of a fenestrated tube should always be assessed by exerting gentle pressure to determine if it moves easily
within the stoma. Shining a light within the tube itself will reveal a pinkish hue
in the presence of granulation. In this case, an otolaryngologist should conduct
a visual examination of the trachea. The forceful removal of a fenestrated tracheostomy tube can result in hemorrhage, leading to a surgical emergency.
Granulation tissue is not the only complication of a fenestrated tracheostomy tube. Subcutaneous emphysema has also been reported when the inner
cannula is not properly aligned with the outer cannula and air escapes through
the tissue planes. For this reason, a fenestrated tracheostomy tube should not
be placed within an immature stoma (Orme & Welham, 2006).
Criner, Make, and Celli (1987) reported a case of a woman who experienced
increased airway resistance and chronic airflow obstruction when using a fenestrated tracheostomy tube for nocturnal ventilation. The tube was confirmed
to be in the correct position within the airway and the cuff was deflated, but
her pressure measurements continued to be elevated. Upon decannulation and
a return to mouth breathing, her minute ventilation and resultant exercise
Chapter 4 Fitting and Changing a Tracheostomy Tube
4.9
Fitting a fenestrated tracheostomy tube. The anterior and posterior tracheal walls are
measured with a probe. These measurements are then compared to the fenestration
on the tube. If the markings do not line up with the fenestration, a custom tube (ideal
fenestration) should be ordered.
153
endurance dramatically increased. The investigators concluded that a deflated
cut on a fenestrated tracheostomy tube significantly increases airway resistance and can further limit ventilatory muscle performance in patients with
compromised ventilatory reserve.
Upsizing
Occasionally, there is a need to place a tracheostomy tube that is larger than the
one in place. Typical conditions that require upsizing include a hemodynamically
Tracheostomies
154
unstable patient who is exhibiting high airway pressures on the ventilator and
a patient who has been in the process of downsizing and breathing around the
tube who is currently presenting with respiratory distress. Either the tube itself or secretions within the tube can increase resistance within the respiratory
system and manifest as respiratory distress. For example, it is unreasonable
to expect an average-sized adult to breathe through a size 4 cuffed tube; it is
simply too small. If positive-pressure ventilation is applied to a small tube, the
problem will become immediately apparent.
When possible, it is advisable to provide some analgesic premedication
and/or benzodiazepine prior to upsizing a tracheostomy tube. Placing a larger
tube often involves some degree of resistance and discomfort. In addition, lidocaine gel can serve a dual purpose as a local anesthetic and lubricant. Occasionally, it may be necessary to dilate the stoma in order to allow the placement
of a larger tube. The cuff of the tracheostomy tube in situ can be used to dilate
the opening of the stoma by maneuvering the tube in several positions and
hyperinflating the cuff.
Fitting a Tracheostomy Button
A tracheostomy button is used as a stent to maintain patency of the stoma. It
is intended for temporary use and is indicated in patients who may require repeated tracheostomies such as those who have myasthenia gravis, spinal cord
injuries, or sleep apnea. It can also be used with patients who are undergoing
rehabilitation while working toward decannulation or in patients for whom a
future surgery is planned. Olympic Medical recommends that their tracheostomy buttons are not intended for permanent use, as the Teflon material will
fatigue and deteriorate over time.
When properly placed, the tracheostomy button fits solely within the stoma,
eliminates resistance within the airway, and allows the patient to breathe entirely through his or her upper airway. The tracheostomy button consists of
three primary parts: the cannula, the closure plug, and a range of spacers that
can be used to ensure a snug fit against the anterior tracheal wall. Spacers included are one each of the following: 1 mm, 2 mm, 4 mm, 7 mm, and 10 mm.
The length of the stoma is determined by measuring the distance from the
cutaneous stoma to the anterior tracheal wall. The Olympic tracheostomy button comes in two standard lengths: 27 mm and 40 mm. If the distance between
the cutaneous stoma and the anterior tracheal wall is less than 27 mm, the
27-mm length should be used. If this distance is between 28–40 mm, the 40-mm
length should be used. Combinations of spacers are then used to ensure the
exact stomal length is achieved. For example, if the measured stomal length is
20 mm, the 27-mm cannula should be used with the 7-mm spacer. If the stomal
length is 32 mm, the 1-mm and 7-mm spacers should be used on the 40-mm
cannula. Prior to insertion, the spacers should be placed on the distal end of the
cannula and the tip lubricated.
The cannula should be inserted into the stoma until a give is felt when the
distal tip clears the anterior tracheal wall. The closure plug is then inserted into
the cannula, which splays the petals on the tip of the cannula, locking it into place
against the anterior tracheal wall. When positioned properly (Figure 4.10), the
Chapter 4 Fitting and Changing a Tracheostomy Tube
4.10
Tracheostomy button in
place. Note that a properly
fit tracheostomy button
creates no obstruction
within the airway. Image
courtesy of Natus Medical
Incorporated.
4.11
Fitting a tracheostomy button. (A) A tracheostomy button with proper fit. (B) A button fitted
too short, allowing closure of the tracheal lumen. (C) A button fitted too long, creating an
obstruction within the airway.
155
button should resist gentle pulling against the cannula. The closure plug should
always remain in place in order to ensure the security of the button. If immediate access to the airway is required, the closure plug can be replaced with a
separate ventilator adapter that provides a standard 15-mm connector. However,
if long-term access to the airway is required such as for frequent suctioning, replacement of the button with a standard tracheostomy tube is recommended.
When a tracheostomy button is properly placed, there is no obstruction
within the airway. Figure 4.11 illustrates a tracheostomy button that is properly
Tracheostomies
156
placed (A); one that is too short (B), allowing the tracheal lumen to close; and
one that is too long (C), creating an obstruction within the airway. There are two
conditions that prevent proper fit of the tracheostomy button: irregular shape
of the stoma and posterior angling of the trachea. When the stoma is irregular,
a separate flange can be used to prevent irritation of the cannula against the
stoma. The flange is placed next to the skin of the neck between the cannula
and the spacers, where it stabilizes the cannula and prevents its movement
within the stoma.
Another condition that prevents proper fit of the tracheostomy button is a
posterior angle to the trachea (see Figure 4.12). In this case, the length of the
stoma varies between its superior and inferior aspects. Because of this difference, the tracheostomy button will not fit properly because the shaft of the cannula has uniform length. The best solution for this condition is a tracheal stent
with an angle to the internal flange that abuts the anterior tracheal wall. The
Montgomery cannula and the Hood stoma stent have special internal angles
designed for the posteriorly angled trachea (Figure 4.13).
4.12
Posterior
angulation of the
trachea, showing
a difference in
superior and
inferior stomal
length and an
improperly fitting
a tracheostomy
button.
4.13
Hood stoma stent in
place. Note that the stent
is angled at the posterior
flange to fit properly
against a posteriorly
angled trachea. Hood
Labs (Pembroke, MA).
Chapter 4 Fitting and Changing a Tracheostomy Tube
Summary
The process of sizing and fitting a tracheostomy tube requires planning and
consideration of goals. The tube should be long enough for the patient’s anatomy and large enough to provide adequate ventilation. There are several factors
that must be considered when fitting and changing a tracheostomy tube. These
include determining whether a cuff is necessary in addition to assessment of
airway protection and secretions. Identifying goals is the first step toward a determination of the proper tube.
Key Points
The first decision when fitting a tracheostomy tube is if the patient re- ■
quires a cuffed tube.
■
A dual-cannula tube should be chosen for a patient who has a large
amount of thick secretions.
■
A larger tube size is optimal for a patient who is breathing through the
tube; whereas, a smaller tube size is more appropriate for a patient who
is breathing around the tube.
■
The tracheostomy tube can be changed by using either the classic method
or the tube exchanger method; the latter is used when the patient is hemodynamically unstable or there is concern about loss of the airway.
■
Fenestrated tracheostomy tubes must be fitted carefully to prevent granulation growth in the aperture.
157
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Orme, R. M., & Welham, K. L. (2006). Subcutaneous emphysema after percutaneous
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Special
Considerations
for the
Tracheostomy
Patient
Linda L. Morris
5
Each patient with a tracheostomy is unique, and individual circumstances must
be taken into account during assessment, planning, and management. Some
of these special circumstances deserve discussion. When a critically ill patient
on mechanical ventilation develops high airway pressures, one must assess
whether there is increased resistance within the tracheostomy tube or whether
lung compliance is decreasing. The cough is the primary defense mechanism
against retained secretions, and efforts to mobilize secretions are vital in tracheostomy patients. Leaks may develop within the cuff, around the cuff, or
within the tube itself, and a plan for the management of cuff leaks is presented.
A discussion is also included of pistoning and the management of cuff changes
that occur at altitude and with anesthesia. Complex tracheostomy wounds can
also be a challenging management issue. The chapter concludes with a discussion of tracheostomy as a lived experience and dealing with tubes with defects
or missing parts.
159
Tracheostomies
160
The Critically Ill Patient on Mechanical Ventilation
Critically ill patients on mechanical ventilation present a challenge. There are numerous conditions that require intubation and maintenance when on mechanical
ventilation. These include acute respiratory failure; airway obstruction; and neurological conditions rendering the patient without sufficient respiratory drive,
adequate spontaneous endurance, or the ability to protect his or her airway. All
these factors must be evaluated when planning for a long-term artificial airway.
The majority of patients in ICUs receive tracheostomies because of prolonged
mechanical ventilation and failure with the weaning process. The reasons for
this difficulty in weaning vary according to the patient’s underlying conditions.
Like endotracheal intubation, the conditions that require a tracheostomy fall into
four broad categories: difficulties with ventilation, obstruction, airway protection,
and secretions (Shapiro, Harrison, Kacmarek, & Cane, 1985)—remember VOPS
for a mnemonic. Current practice in critical care reports a varied lifespan for the
placement of an endotracheal tube in an adult that ranges from a few short days
up to 2 weeks. A tracheotomy should be considered when the expected need for
an artificial airway outlasts that time frame.
Time to Tracheotomy
When patients cannot be weaned soon after intubation, the practitioner must
determine whether to place a tracheostomy or whether efforts to wean should
continue. Tracheotomy is performed more frequently than in years past due to
several factors, including increased use of percutaneous techniques. Numerous
studies have attempted to identify the optimal time to place a tracheostomy;
however, no definitive recommendations have been developed. The difficulty
lies in the interpretation of results because different studies use different time
frames as well as different outcome measures. Several authors have shown
no mortality rate benefit with early tracheotomy (Arabi et al., 2009; Marsh,
Gillespie, & Baumgartner, 1989), while other studies have shown a decreased
mortality rate (Rumbak et al., 2004; Scales & Kahn, 2008). The definitions of
early tracheotomy in these studies have included those done within 48 hours to
1 week of intubation and mechanical ventilation.
Kluge and colleagues (2008) used a questionnaire to survey physician directors of ICUs in Germany. They found that 67.2% of tracheostomies were performed during the second week of mechanical ventilation, while only 21.7%
were performed within 7 days of initiation of mechanical ventilation.
Blot and others (2008) recruited patients from 25 ICUs in France to show the
benefit of early tracheostomy compared to prolonged intubation. They recruited
patients on mechanical ventilation and randomized them into two groups: early
tracheostomy within 4 days of intubation versus patients with prolonged intubation. The sample size of the early tracheotomy group was calculated to be 470
patients; however, the study was stopped early because there was no difference
in the study’s primary endpoint of mortality. They concluded that the sole benefit of the tracheostomy was greater comfort as self-reported by patients.
Other studies have examined the benefit of tracheostomy on weaning from
mechanical ventilation. However, this is also difficult to study because of the
Chapter 5 Special Considerations for the Tracheostomy Patient
numerous factors that affect the weaning process, including work of breathing,
dead space, secretions, sedation, and an aggressive weaning protocol. Pier son
(2005) and Scales and Kahn (2008) suggest that perhaps the benefit of tracheostomy on weaning can be appreciated in less dramatic ways, such as by decreasing complications from overexposure to mechanical ventilation, facilitating
improved removal of secretions, and improved comfort leading to reduced sedation requirements.
Project IMPACT, a multi-institutional database adopted by the Society of
Critical Care Medicine (SCCM), attempted to identify not only optimal time
to tracheotomy but also to evaluate clinical and nonclinical factors on tracheostomy practice. With a database of nearly 44,000 patients, they found
the median time to tracheotomy was 9 days and that prolonged intubation
led to increased duration of mechanical ventilation, increased ICU length of
stay, and increased hospital length of stay (Freeman, Borecki, Coopersmith, &
Buch man, 2005). Currently, the recommended critical care practice is withholding sedation and initiating a weaning trial with spontaneous breathing on
a daily basis. When the patient is unable to be weaned after 7–10 days, a tracheotomy is usually considered. See chapter 2 for further discussion on time
to tracheostomy.
Airway Pressures and Work of Breathing
161
The tracheostomy patient on a ventilator presents a special challenge. It is important to minimize airway pressure and resistance and maximize the mobilization of secretions. A mechanical ventilator provides the power to insufflate
the lungs, aerate the alveoli, and remove carbon dioxide. Numerous modes are
used to adjust a graded work of breathing. Whenever a patient is mechanically
ventilated, the clinician monitors the trend in compliance of the respiratory system (the balance between pressure and volume). Often the progression of mechanical ventilation and the mode, whether on volume-limited ventilation (e.g,
synchronized intermittent mandatory ventilation, SIMV) or pressure-limited
ventilation (e.g., pressure support ventilation, PSV), are driven by changes in
lung compliance. Empirically, in a volume-limited ventilation mode, a preset
tidal volume is delivered to the patient, and lung pressure is dependent on
compliance. With a pressure-limited ventilation mode, the ventilator delivers
a flow of gas to the patient until a preset pressure is achieved, and the generated tidal volumes are dependent on compliance. Of particular concern to
the tracheostomy patient is the development of high airway pressures, and
this concern is magnified as the tube caliber gets smaller or airway secretions
accumulate.
Peak and Plateau Pressures.
), is the highest pressure in the system during inspiration. It is a dynamic
(P
peak
pressure reflecting changes in compliance due to changes within the lung itself, secretions, obstruction, and other factors that affect driving pressure. When
tidal volume is constant, an increased peak pressure can reflect reduced lung
compliance or increased airway resistance (Pilbeam, 1998). Because peak pressure is measured during airflow, it consists of both lung and chest wall recoil
plus the resistance created by the tracheostomy tube and the airway itself. Lung
The peak pressure, or peak inspiratory pressure