Tracheostomy In ICU: An Insight into the Present Concepts

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1 Indian Journal of Anaesthesia 2008; 52 (1): Indian Journal of Anaesthesia, February Special Article 2008 Tracheostomy In ICU: An Insight into the Present Concepts Muralidhar K. Summary Tracheostomy is a commonly performed surgical procedure in the intensive care units. Indications for tracheostomy are mainly four-fold namely airway obstruction, aspiration of secretions, airway protection from aspiration and provision of mechanical ventilation. Anaesthesia technique used for tracheostomy is varied and is dictated by the general condition of the patient. Percutaneous tracheostomy is an alternative to the surgical approach that can be done at the bedside and has several advantages. Though a simple procedure, tracheostomy can be associated with a number of life threatening complications like hypoxia, cardiac arrest, injury to structures immediately adjacent to the trachea, pneumothoax and haemothorax. Key words Tracheostomy; Percutaneous tracheostomy; Permanent tracheostomy; Tube, tracheostomy; Emergency tracheostomy. Introduction Tracheostomy is one of the most frequently performed surgical procedures on critically ill patients requiring prolonged mechanical ventilation in the intensive care unit. It is performed in about 24% of all patients in intensive care units 1. Tracheotomy is the procedure involving making incision over the trachea where as the term Tracheostomy is used to indicate a procedure Table 1 Comparison of translaryngeal intubation with tracheostomy Advantages of Translaryngeal Intubation Easy and rapid initial placement of the airway device acute surgical complications Bleeding Posterior tracheal wall injury Barotrauma Lower initial cost Avoids late surgical complications Wound infections Recurrent laryngeal nerve injury Stomal stenosis involving incision on the trachea followed by insertion of a tube which maintains the patency of the opening in trachea either temporarily or permanently. Tracheostomy has several advantages over translaryngeal endotracheal intubation including lower airway resistance, smaller dead space, less movement of the tube within the trachea, greater patient comfort and more efficient suction. The relative merits of both the methods of airway access is highlighted in the Table 1 below: Advantages of Tracheostomy Ease of reinsertion if displaced (after the tract has matured) Allows less skilled care Reduced laryngeal damage Reduced laryngeal stenosis Less voice damage Better secretion removal with suctioning Lower incidence of tube obstruction Less oral injury (tongue, teeth, palate) Improved patient comfort Less sedation/analgesia required Better oral hygiene Improved ability to communicate Improved lip reading Allows speaking valve Preservation of glottic competence Less aspiration risk Lower incidence of ventilator-associated pneumonia Preservation of glottic competence Better preserved swallowing, which allows earlier oral feeding Lower resistance to gas flow Less tube dead space Lower work of spontaneous breathing More rapid weaning from mechanical ventilation Director (Academic) President, IACTA, Consultant & Professor Anaesthesia and Intensive Care, Narayana Hrudayalaya Institute of Medical Sciences,Correspondence to:muralidhar. K, #258/A Bommasandra Industrial Area, Anekal Taluk, Bangalore ,India, kanchi_rules_300a@lycos.com / kanchirulestheworld@gmail.com Accepted for publication on:

2 Muralidhar K. Tracheostomy in ICU Indications for tracheostomy The following clinical scenarios illustrate the indications for tracheostomy: 1.A 69-year female presented with a history of stiffness of joints, paraesthesia and weakness of both upper and lower limbs for 3 months. She was a known case of rheumatoid arthritis. CT scan of cervical spine revealed atlanto-axial subluxation and basilar invagination with significant spinal canal stenosis and spinal cord compression. Preoperative medications included atenolol for hypertension and methotrexate for rheumatoid arthritis. She underwent foramen magnum decompression and fixation of occipital C2 3 using a plate and rod system, screws and iliac crest grafting. Anaesthesia included propofol, rocuronium, fentanyl, isoflurane and mechanical ventilation (IPPV). At the end of surgery, the trachea was extubated after reversal of neuromuscular blockade. However, the patient developed respiratory failure and endotracheal intubation proved difficult due to cervical fixation and anterior larynx. Airway was maintained with laryngeal mask airway (LMA) and emergency tracheostomy was performed. (Fig. 1) Indication for tracheostomy: difficult airway, respiratory failure and need for mechanical ventilation. Fig-1: Indication for tracheostomy: difficult airway, respiratory failure and need for mechanical ventilation 2.A 60-year female underwent off pump coronary artery bypass grafting (CABG). Postoperative recovery was delayed due to neurological deficits. CT scan revealed acute cerebral infarction involving both frontal lobes. Tracheostomy was done to protect airways from aspiration (Fig. 2). Indication for tracheostomy: airway protection from aspiration pneumonitis. Fig-2: Indication for tracheostomy: airway protection from aspiration pneumonitis A 75-year male underwent CABG. Postoperative course was complicated by pneumonia. Tracheostomy was done for aspiration of secretions (Fig. 3). Indication for tracheostomy: broncho- pulmonary toilet and aspiration of secretions. Fig-3: Indication for tracheostomy: broncho- pulmonary toilet and aspiration of secretions. Thus the indications for tracheostomy include the following: 1. Upper airway obstruction 2. Prolonged mechanical ventilation 3. Access for tracheal toilet 4. Airway protection form aspiration of gastric / pharyngeal contents. The presence of a difficult airway in patients requiring prolonged mechanical ventilation is an absolute indication for tracheostomy. Patients with difficult airway include those with conditions such as maxillo-facial trauma, angioedema, obstructive upper airway tumors or other anatomical characteristics that would render translaryngeal intubation technically difficult to perform in the event of inadvertent airway loss. Patients needing prolonged ventilation undergo tracheostomy to facilitate ventilator weaning, diminish the incidence of serious infections, promote oral hygiene, pulmonary toilet, enhance patient comfort, provide airway security and in selected patients allow nutrition and speech. Anaesthesia for tracheostomy Anaesthesia requirements are variable and are dictated by the state of patient s sensorium and the nature and extent of co-morbid conditions. The procedure can be done safely with local infiltration supplemented with intravenous sedation / or narcotic drugs appropriate to the general condition of the patient. The advantage of

3 Indian Journal of Anaesthesia, February 2008 this technique is that it allows for the administration of high levels of inspired oxygen. Inpatients with stable cardiovascular system general anaesthesia with or without supplemental local infiltration are satisfactory. Monitoring techniques are dictated by the extent of comorbidity but ECG, BP, pulse oximetry and end-tidal CO 2 monitoring is mandatory. Surgical procedure The patient is placed in the supine position, the neck extended with the help of either a rolled towel or a small pillow placed beneath the shoulders (Fig. 4). The head is positioned in a head-ring for additional stability. These maneuvers provide for maximal surface exposure and, in most patients, bring the trachea from the intrathoracic to the cervical position. After appropriate preparation of the skin and surgical draping, the procedure is accomplished through a short horizontal incision placed at the level of the second tracheal ring. The strap muscles are separated in the midline, and the thyroid isthmus is divided and sutured appropriately to obtain haemostasis. Counting down from the easily palpable cricoid cartilage makes specific identification of the location of the tracheal rings (Fig. 5). The second and third rings are opened vertically in the midline for access to the trachea. The tracheostomy tube should be placed so that it does not erode the ring and press against the cricoid cartilage. In addition, the opening should not be placed too low, or the tip of the tube and its cuff will be too close to the carina. Low placement of the tracheostomy tube is also hazardous because the innominate artery crosses anteriorly to the trachea low in the neck and the possibility of erosion into the vessel by either the cuff or tip of the tracheostomy tube exists. Segments of the trachea should not be removed because this might lead to a greater loss of tracheal wall stability and predispose the remaining segments to stenosis, once healing is accomplished after removal of the tube. The lateral tracheal walls are retracted and the appropriately sized tracheostomy tube is inserted into the airway after slow withdrawal of the previously placed oral or nasal endotracheal tube to a more proximal position in the trachea. Once the tracheostomy tube is positioned and an adequate airway is demonstrated through positive pressure ventilation and visual inspection of chest wall expansion, confirmed by the end-tidal CO 2 tracing the previously placed endotracheal tube is removed from the trachea. The wound is closed appropriately, skin sutures are placed through the flange ends, and a tie is secured around the neck. Fig-4: Position of head for tracheostomy Fig-5: Identification of thyroid, cricoid cartilage & tracheal rings Timing of tracheostomy in acute respiratory failure The advantages of performing early tracheostomy in patients needing long-term ventilation are mentioned in the Table 2: Table 2 Advantages of performing early tracheostomy Decreased duration of mechanical ventilation Decreased incidence of pneumonia Enhancement of ventilator weaning Decreased ICU stay Decreased hospital cost There are several reasons why a tracheostomy may facilitate weaning from mechanical ventilation. Resistance to airflow in an artificial airway is proportional to air turbulence, tube diameter, and tube length. Air turbulence is increased in the presence of extrinsic compression and inspissated secretions. Because of its rigid design, shorter length, and removable inner cannula (to allow for evacuation of secretions), airflow resistance and associated work of breathing should theoretically be less with tracheostomies relative to endotracheal tubes. Furthermore, the presence of a tracheostomy may allow clinicians to be more aggressive about weaning patients from mechanical ventilation. Specifically, if a patient with a tracheostomy tube in place does not tolerate liberation 30

4 Muralidhar K. Tracheostomy in ICU from mechanical ventilation, he or she may be reconnected to the ventilator without difficulty. In contrast, if a patient who is translaryngeally intubated does not tolerate extubation, he or she must be sedated and re-intubated. This might represent a potential barrier to extubation in patients who are of a marginal pulmonary status. Finally, efforts to determine the relative advantages of tracheostomy and translaryngeal intubation with respect to aspiration are inconclusive. However, if the presence of a tracheostomy does translate into earlier liberation from mechanical ventilation, one might expect the incidence of ventilator-associated pneumonia in this group to be lower. A clinical study that adequately addresses the question as to optimal timing of tracheostomy in the setting of prolonged mechanical ventilation must have a homogeneous patient population, protocols in place for ventilator weaning and other facets of clinical management, and well-defined endpoints. Given the lack of evidence on which to base decision-making on this issue, the following guidelines have been formulated 2. For patients in whom the need for ventilatory support is anticipated to be less than 10 days, translaryngeal intubation is preferred. If the need for ventilatory support is anticipated to exceed 21 days, a tracheostomy is preferred. When the anticipated need for mechanical ventilation is unclear, daily assessment is required to determine when conversion to tracheostomy is indicated. Percutaneous tracheostomy Percutaneous tracheostomy (PCT), which has been used to some extent for the past 50 years, is an alternative to the open surgical approach. The advantages and different techniques of percutaneous tracheostomy are highlighted in the Table 3: Table 3 Advantages of PCT and types of PCT Advantages of PCT Decreased incidence of surgical complications Quicker than surgical tracheostomy(st) Done bedside: transporting patient to OT avoided Expense of OT resources avoided Types of PCT Ciaglia technique Grigg s technique Blue rhino / Rhino horn technique Fantony s technique Perc twist technique The most popular technique, known as percutaneous dilatational tracheostomy (PDT), was originally described by Ciaglia in In principle, the technique employs the use of serial dilators introduced into the trachea over a guide wire and is generally done with bronchoscope visualization. Modifications to improve this technique have included design of special dilating forceps and use of a single-tapered dilator rather than multiplesized ones. Several commercial PDT kits are currently available, providing all of the necessary equipment for efficient and expedient application. The steps in performing percutaneous tracheostomy using Rhino-horn is depicted in Fig It is likely that the general trend toward minimally invasive surgery and the increase in procedure done by nonsurgical, interventional specialists will continue to promote use of this beside procedure Advocates of this technique frequently focus on use in critically ill patients in an intensive care unit (ICU) setting. Obvious advantages in this setting include avoidance of inherent risks associated with transport to and from the operating room, availability of existing monitoring, and cost savings with respect to operating room charges and anaesthesia fees. Although multiple published studies have attempted to compare the risk and benefits of the percutaneous pro- Fig-6: The part is prepared and draped as for surgical tracheostomy 31

5 Indian Journal of Anaesthesia, February 2008 Fig-7 Cricoid cartilage is palpated and local anaesthetic infiltrated. Injection of local anaesthetic solutions containing adrenaline may help reduce bleeding at the incision site. Fig-8: Horizontal incision made at the chosen insertion site of sufficient size to accept a tracheostomy tube (say about cm long). At this stage it may be of benefit to perform an exploratory blunt dissection (keeping in the mid line) to identify the anatomical landmarks. Fig-9: A 14 G needle and cannula (with syringe attached) is inserted in the midline in a caudal direction (to avoid the likelihood of the guide wire being passed into the pharynx). The needle is advanced until free withdrawal of air into the syringe confirms the entry of the needle and cannula into the trachea. This may be facilitated by using a fluid filled syringe, allowing visualization of withdrawn air bubbles. Some secretion and mucus may be aspirated during this process, which is normal. Fig-10. The guide wire introducer is eased out from its sheath and the J tip is straightened, the introducer is inserted into the cannula and the guide wire is advanced into the trachea through the 14G cannula. 32

6 Muralidhar K. Tracheostomy in ICU Fig-11: The 14FR short (plastic) dilator is passed over the guide wire through the soft tissues, until resistance is felt on the trachea wall. With a gentle twisting movement of the dilator the dilator is pushed forward to penetrate the anterior trachea wall, dilating both the tissues and tracheal wall. Then the 14FR short dilator is removed, leaving the guide wire in place. Fig-12: Immediately prior to insertion, the distal end of the single stage dilator, the Rhino horn is immersed in sterile water or saline to act as the lubricious coating on the dilator. The dilator is passed over the guiding catheter until it reaches the safety stop Fig-13: The lubricated tracheostomy tube is inserted loaded on its lubricated introducer over the guiding catheter through the stoma with a slight twisting motion. The cuff of the tube is inflated and the tube secured using sutures and/or cotton tapes 33

7 Indian Journal of Anaesthesia, February 2008 cedure with the open procedure, problems with study design and the multiple variables that exist in patient populations, techniques, and operator experience create problems in analysis of outcome 4,5. Two recently published meta-analyses summarize the potential difference in complications with both approaches. Stomal infection, bleeding, and trauma to structures adjacent to the trachea are some of the most commonly cited complications. The following guidelines are taken into account when the question of whether surgical or percutaneous approach is to be decided. Surgical Tracheostomy preferable to PCT in the following situations: Coagulation abnormality High level of ventilatory support (FiO2 >.7 & PEEP > 10 cm H2O) Unstable / Fragile cervical spine Neck injury Unfavorable neck anatomy (previous surgery, tumor etc.) Obesity aspiration risk, the cuffed tube is exchanged for a cuffless tube. Tracheostomy caps are generally provided with tracheostomy tubes for use in the decannulation process. Fenestrated tubes are used to promote speech and are generally used in individuals who tolerate liberation from mechanical ventilation for varying periods. Fenestrated tubes have an opening or openings on their superior aspect such that when the inner cannula is removed, the cuff deflated, and the external orifice occluded (e.g., with a Passey-Muir type valve), air can pass the vocal cords allowing phonation. Minitracheostomy Sputum retention, by definition, exists whenever a patient is incapable of clearing his own tracheobronchial secretions. Diagnosis of this condition is essentially clinical and is based on clinical evidence of respiratory distress with rapid, shallow and bubbly respiration 6. Chest physiotherapy when used early and frequently aided with Tracheostomy tubes Most tracheostomy tubes are manufactured from polyvinyl chloride, silicone, a combination of these materials, or metal (Fig.14 & 15). They are available in either single-lumen (no removable inner cannula) or dual-lumen (removable inner cannula) configurations. The purpose of the removable inner cannula is to facilitate cleaning of inspissated secretions that may lead to tube occlusion. Because silicone is relatively secretion resistant, tubes manufactured from this material frequently do not have an inner cannula. Tracheostomy tubes are available with and without cuffs (balloon surrounding the outer cannula). The purpose of the cuff is to maintain a seal between the tube and the trachea sufficient to prevent escape of air from around the tracheostomy tube during mechanical ventilation (e.g., cuff leak). Furthermore, the cuff minimizes but does not prevent aspiration. Tracheostomy tubes with foam cuffs conform to a patient s trachea and remain consistently inflated at low pressure. These tubes are indicated in patients who have sustained damage from excessive cuff pressure (e.g, tracheomalacia). Once a cuffed tracheostomy tube is no longer required, that is, the patient no longer requires mechanical ventilatory support and is not considered on 34 Fig-14: A cuffed tracheostomy tubes with obturator. Fig-15: A metal tracheostomy tube (uncuffed) cough maneuvers prevents sputum retention. If this fails, secretions have to be removed actively by suction. Minitracheostomy provides a permanent access to the trachea for suction while avoiding the disadvantages of the conventional methods. The procedure of

8 Muralidhar K. Tracheostomy in ICU Fig-16: Components of minitracheostomy tube include a stab knife and a short 4 mm endotracheal tube over an introducer minitracheostomy is simple and consists of percutaneous tracheal cannulation using a 4 mm portex paediatric endotracheal tube inserted through a 1 cm incision in the cricothyroid membrane. The patient is positioned as for a routine tracheostomy with extension of the head and the neck. After cleansing the skin and local infiltration with 1% lidocaine, a midline vertical 1 cm stab incision is made through the cricothyroid membrane. The introducer is then passed through the stab incision into the trachea. The cannula is passed over the introducer and into the trachea; the introducer is then removed. The wings on the cannula are bent laterally and then sutured to the skin. The relative advantages of minitracheostomy over the conventional methods are: (1) It allows constant tracheal access for suction, (2) All natural mechanisms are retained; the function of the glottis is preserved. Patients retain an expulsive cough even if only by reflex response to suction catheter; minitracheostomy thus supplements the intrinsic clearing mechanisms, (3) Used early, it can prevent the onset of respiratory failure, (4) It is a simple technique to perform, (5) It has quick healing with minimal scarring, (6) It can be kept isolated from a median sternotomy wound, (7) Retention of voice and the ability to communicate confers significant advantages (8) Can be used for administration of humidified air / O 2 mixture or nebulised drugs (9) Can be used to obtain samples of sputum without salivary contamination for bacteriological studies, (10) It can be used in the management of acute airway obstruction and in certain forms of faciomaxillary surgery and (11) It can be used as a route for high frequency jet ventilation and intra-airway pressure monitoring 7. Decannulation Patients who remain stable for 24 to 48 hours after discontinuation of mechanical ventilation may be evaluated for decannulation. The patient s ability to protect the airway should be assessed for 24 hours by deflating the tracheostomy tube balloon and observing for signs of aspiration. If aspiration is present, laryngoscopic examination should be performed. Deflating the tracheostomy tube balloon and occluding the tracheostomy tube can assess airway for strictures and adequacy of the native airway. Patients who are able to breathe around a capped and deflated. No.8 tracheostomy tube most likely have adequate respiratory reserve and a sufficiently preserved native airway to tolerate decannulation. Patients who have difficulty in breathing around a capped No.8 tube should be reassessed with a capped No.7 tracheostomy tube. Successful breathing with a capped and deflated No.7 tube in place suggests that a patient will tolerate decannulation. Patients who fail breathing trials with capped tracheostomy tubes should undergo laryngoscopic evaluation to exclude the presence of tracheal stenosis. Many patients recovering from long-term mechanical ventilatory support may have normal airways but fail breathing around a capped No.7 or No.8 tracheostomy tube because of limited ventilatory reserve (e.g., neuromuscular disease or underlying chronic obstructive pulmonary disease). These patients may benefit from downsizing of the tracheostomy stoma using progressively smaller cuff-less tracheostomy tubes with intermittent capping using stomal obturators. Tracheostomy tubes with foam cuffs should not be used for decannulation trials because these cuffs spontaneously reinflate, making the assessment of airway stenosis difficult. Complications A variety of complications resulting from tracheostomy placement have been described. A brief discussion of common complications occurring in the critical care setting and their management follows. Complications of tracheostomy Intra operative Bleeding Damage to adjacent structures False passage 35

9 Indian Journal of Anaesthesia, February 2008 Post procedural Cuff leak Tube occlusion Tube dislodgement Tracheo-esophageal fistula Tracheo-innominate fistula Tracheal stenosis Intraoperative complications Intraoperative complications generally occur as a result of anaesthesia, underlying disease. Surgical complications generally fall into three major categories, including hemorrhage, injury to structures adjacent to the trachea, and no airway cannula. Bleeding from the surgical incision is usually controlled easily but can be complicated by the difficulty of exposure. Vascular structures (such as the thyroid isthmus) might bleed easily when divided for exposure. Injuries to adjacent structures include damage to recurrent laryngeal nerves, entrance into major vessels, and rare (but possible) laceration of the esophagus. The inability to cannulate the trachea is possible because of inadequate surgical exposure, an inability to bring the trachea to a superficial location, or selection of a tracheostomy tube too large to fit into the tracheal stoma. Cuffleaks Cuff leak is a commonly encountered problem in patients with tracheostomies and may be manifested by either an audible leak around the tracheostomy tube or loss of returned volume in mechanically ventilated breaths. A mechanical problem with the tracheostomy tube should first be excluded by determining that when the cuff is inflated it does not leak air. A malfunctioning tracheostomy tube requires exchange. Once tracheostomy tube malfunction is excluded, the most common cause of cuff leak is tracheomalacia with resulting dilation adjacent to the tracheostomy tube cuff. This is particularly common in patients who have been maintained on mechanical ventilation for extended periods. It should not be treated by hyperinflating the tracheostomy tube cuff in an effort to achieve total occlusion, in that this will result in further dilation of the trachea and may lead to mucosal ischemia. If the cuff leak is well tolerated, such that the ability to ventilate the patient is not compromised, we recommend maintaining the tracheostomy tube in place at the appropriate inflation pressure (e.g., 20 to 25 mm Hg). Conversely, if the cuff leak is sufficient so as to impair gas exchange, consideration should be given to exchanging the tracheostomy tube for either a larger size or for a tracheostomy tube design that incorporates a large-volume, low-pressure cuff (e.g., a foam cuffed tracheostomy tube). Tube occlusion A frequently encountered problem in patients with tracheostomies is tracheostomy occlusion. This is typically manifested by either high airway pressures or inability to pass a suctioning catheter. Tracheostomy tube occlusion is frequently the result of inspissated secretions. Many commonly used tube designs have a removable inner cannula to facilitate cleaning of the inner portion of the tracheostomy tube. A second common cause of tracheostomy tube occlusion is tube malpositioning, such that the end of the tracheostomy tube abuts the tracheal wall or the tube has migrated such that its tip resides in the pretracheal tissues. If tracheostomy malpositioning is suspected, the operating surgeon should assist in assessing it for either reinsertion or use of another tube design. Tube dislodgement Although dislodgment of the tracheostomy tube may occur at any time after tracheostomy placement, this complication is most problematic in the immediate postoperative period, before the tracheostomy tract has matured. Factors predisposing to tracheostomy tube dislodgment include an inadequately secured tube, excessive coughing, and patient agitation. Tracheostomy tube dislodgement should be suspected when a patient is able to speak immediately after tracheostomy placement, the airway becomes obstructed, or respiratory distress develops. Because it is generally technically difficult to reinsert the tracheostomy tube in this situation, the authors recommend that the airway be reestablished by means of translaryngeal intubation. The tracheostomy should then be reinserted in the operating room with appropriate anaesthetic assistance, lighting, and instrumentation. If tracheostomy tube dislodgement occurs once the tracheostomy track is sufficiently mature (i.e., the tracheostomy track is at least 1 week old), it is generally technically feasible to reinsert the tracheostomy tube at the patient s bedsides 36

10 Muralidhar K. Tracheostomy in ICU Tracheoesophageal fistula The development of tracheoesophageal fistulas after tracheostomy is rare, occurring in less than 1% of patients and is typically the result of pressure necrosis of the tracheal and esophageal mucosa from the tracheostomy cuff. A number of potential risk factors have been reported (e.g., high airway pressures, excessive cuff inflation pressures, the use of nasogastric tubes, excessive tracheostomy tube movement). Clinical manifestations are nonspecific and include excessive tracheal secretions, coughing, and gastric distention. The presence of a tracheoesophageal fistula can be demonstrated on fiberoptic examination after removal or retraction of the tracheostomy tube. Because the use of fiberoptic examination alone is insensitive, it should be combined with an enterally contrasted esophageal evaluation if clinical suspicion exists (e.g., water-soluble contrast swallow or computed tomography). Tracheoesophageal fistula requires surgical repair. Temporizing measures include positioning of an endotracheal tube cuff below the level of the fistula to limit aspiration, removal of nasogastric tubes, and placement of feeding gastrostomy tubes. Tracheoinnominate artery fistula Tracheoinnominate artery fistula likewise is a rare complication after tracheostomy formation and theoretically results from pressure necrosis or injury to the trachea adjacent to the course of the innominate artery. A number of risk factors have been postulated, including excessive tube movement, aberrant innominate artery anatomy, use of an excessively long or curved tracheostomy tube that erodes through the tracheal wall, inferior positioning of the tracheostomy tube, tracheal infection, and corticosteroid therapy. Tracheoinnominate artery fistula may become apparent as quickly as a few days or as late as several months after tracheostomy placement. The classic presentation is of a sentinel hemorrhage in which a large volume of blood emanates from the tracheostomy tube. Fiber optic examination to evaluate for the presence of tracheoinnominate artery fistula should be performed in the operating room in the 37 event that airway manipulation results in massive hemorrhage. Temporizing measures in patients who develop massive bleeding include hyperinflation of the tracheostomy cuff, insertion of an endotracheal tube through the tracheostomy stoma in an effort to tamponade bleeding, or translaryngeal intubation and digital compression of the bleeding site through the tracheostomy stoma. Definitive repair entails median sternotomy, ligation of the innominate artery and generous drainage of the mediastinum. Acknowledgement The author acknowledges with thanks that parts of the text are derived from Wilson RS, Tracheostomy and tracheal resection and reconstruction, Chapter 10, in Thoracic Anaesthesia, Kaplan(ed), 6 th edition, 2003 & Freeman BD and Buchman TG, Indications and management of tracheostomy, Chapter 72 Abraham F and Kochnek V(ed) in Text book of Critical care, 5th edition, References 1. Esteban A, Anzueto A, Alia I, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review, Am J Respir Crit Care Med 2000, 161: Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest 1989; 96: Ciaglia P, Fishing R, Synice C. Elective percutaneous dilatational tracheostomy dilatational trachestomy; a new simple bedside procedure, Chest 1985;87: Dulgueriv P, Gysin C, Perneger TV, et al. Percutaneous or surgical tracheostomy; a meta-analysis, Crti Care Med 1999; 27: Freeman BD, Isabella K, Lin N, et al. A meta analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients, Chest 2000;118: Matthews HR, Fischer BJ, Smith BE,et al. Minitracheostomy, a new delivery system for jet ventilation. J Thorac Cardiovasc. Surg 1986;92: Rao M, Muralidhar K. Treatment of sputum retention with minitracheotomy in postoperative cardiac surgical patients. J Anaesth Clin Pharmacol 1988;4: FAMILY BENEFIT SCHEME The Indian Society of Anaesthesiologists through its family welfare programmes support the next kin of the deceased member of ISA to the tune of RS.10,00,000/-! Contact : Dr.S.S.C.Chakra Rao, Secretary, Family Benefit Scheme, ISA. 67 B, Shanti Nagar, Kakinada , Tel : , chakrarao@yahoo.co.in

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