Tracheostomy care and management

Contents

Indications

Tracheostomy is considered when:

  1. Prolonged mechanical ventilation is anticipated (>7–14 days) — allows sedation reduction, facilitates ventilator weaning
  2. Upper airway obstruction — head and neck cancer, angioedema, laryngeal trauma (definitive bypass of obstruction)
  3. Airway protection — severe bulbar failure (neuromuscular disease, stroke) with inability to manage secretions, aspiration risk
  4. Weaning failure — recurrent failure to tolerate extubation; allows intervals off ventilator without intubation
  5. Pulmonary toilet — facilitates suction of secretions in patients with impaired cough

Advantages Over Prolonged ETT

  • Improved patient comfort, reduced sedation requirement
  • Allows communication (with speaking valve) and oral feeding
  • Easier secretion management
  • Reduced work of breathing (shorter, wider tube, lower resistance)
  • Facilitates mobilisation and rehabilitation

Timing — TracMan and TRACH Trial Evidence

TracMan Trial (see Journal Club)

  • UK multicentre RCT, n=909 patients in 70 ICUs (Young, JAMA 2013)
  • Population: mechanically ventilated ICU patients expected to need MV for ≥7 more days
  • Intervention: early tracheostomy (~day 4) vs late tracheostomy (~day 10)
  • Primary outcome: 30-day mortality — no significant difference (30.8% vs 31.5%)
  • Key secondary finding: in the late group, 53% of patients did not receive tracheostomy (they were extubated or died before day 10)
  • Conclusion: early routine tracheostomy offers no mortality benefit; a selective, later approach avoids unnecessary procedures in patients who will be extubated anyway

TRACH Trial (Terragni, JAMA 2010)

  • Italian RCT, n=600; early (6–8 days) vs late (13–15 days) tracheostomy in ARDS patients
  • Result: early tracheostomy reduced VAP rate but no mortality benefit

Practical Implication

Tracheostomy should not be performed routinely at day 7 for all ICU patients. A selective approach guided by clinical assessment of:

  • Anticipated ventilation duration
  • Neurological prognosis
  • Feasibility of extubation
  • Patient preference (where possible)

Tracheostomy is appropriate when extended ventilation is clearly anticipated (neurological injury, complex weaning failure), not as a default at a fixed time point.

Surgical vs Percutaneous Tracheostomy

Surgical Tracheostomy

  • Performed in operating theatre by ENT/general surgeon
  • Formal skin incision, tracheal window cut, direct visualisation
  • Indications: coagulopathy (can achieve haemostasis under direct vision), obesity (difficult anatomy), short neck, neck pathology (goitre, previous surgery, malignancy), paediatric patients, emergency surgical airway

Percutaneous Dilatational Tracheostomy (PDT)

  • Bedside procedure in ICU, typically performed by intensivists
  • Seldinger technique: needle puncture of trachea (usually between rings 1–2 or 2–3), guidewire insertion, sequential dilation, tube insertion
  • Bronchoscopic guidance: strongly recommended — confirms midline placement, avoids posterior tracheal wall injury, visualises correct inter-ring space
  • Contraindications to PDT:
    • Coagulopathy (uncorrected INR >1.5, platelets <50)
    • Obesity (BMI >45) or short, immobile neck — difficult anatomy
    • Unstable cervical spine
    • Haematological malignancy with mediastinal masses
    • Age <12 years
    • Emergency (surgical airway preferred)
  • Complications of PDT:
    • Immediate: haemorrhage, false passage, tracheal injury, posterior wall perforation, pneumothorax, tube malposition
    • Late: subglottic stenosis (lower incidence than surgical in some studies), tube displacement, tracheomalacia

Tracheostomy Tubes

Components

  • Outer cannula: main structural tube, sits in trachea
  • Inner cannula (removable): for cleaning without disturbing tube position; critical for routine care
  • Cuff (in cuffed tubes): inflatable to seal airway for ventilation and prevent aspiration
  • Fenestration (in fenestrated tubes): holes in outer cannula allow airflow through larynx for speech

Types

Type Use
Cuffed, non-fenestrated Standard: ventilated patients; airway protection
Cuffed, fenestrated Weaning: allows speaking valve use with cuff deflated; also allows limited airflow through larynx
Uncuffed Patients with established tracheostomy no longer requiring ventilation or airway protection; or in children
Adjustable flange Obesity or unusual anatomy; outer flange length adjustable
Extended length Long trachea, obesity, anatomical variants
Silver Negus tube Long-term; for patients with permanent tracheostomy; allows speaking

Cuff Management

  • Inflate cuff to minimum occlusion pressure while maintaining seal (target cuff pressure 20–25 cmH₂O)
  • Avoid over-inflation: tracheal mucosal ischaemia, necrosis, tracheomalacia
  • Check cuff pressure with manometer every shift
  • Minimum occlusion volume (MOV) technique: inflate until no air leak during positive pressure breath

Tracheostomy Care Bundle

National Tracheostomy Safety Project (NTSP) and FICM recommend a systematic approach:

Daily Assessment (NTSP Mnemonic: TALKS)

  • Tube: type, size, cuff status; date of insertion
  • Airway: assess for secretion volume, character; is suction needed?
  • Lung: assess ventilation, breath sounds, secretion clearance
  • Know your patient: is tracheostomy still needed? Progress towards decannulation?
  • Safety: emergency equipment at bedside; bedside team competent

Essential Bedside Equipment

NTSP requires at bedside for all tracheostomy patients:

  • Same size and ONE SIZE SMALLER tracheostomy tube
  • 10 mL syringe (cuff inflation/deflation)
  • Tracheal dilators (emergency tube displacement)
  • Suction equipment
  • NTSP bedhead signs indicating tube type, date, emergency instructions
  • Cuffed ETT and laryngoscope (in case of emergency requiring oral re-intubation)

Humidification

  • Bypassing the upper airway removes normal humidification → thick secretions, tube blockage, tracheal damage
  • All tracheostomy patients require either: heated humidifier (HPHH) — for ventilated patients; or heat-moisture exchanger (HME/Swedish nose) — for weaning/spontaneously breathing patients

Speaking Valves

Speaking (one-way) valves (e.g., Passy-Muir valve, PMV) allow speech in tracheostomy patients:

Mechanism: valve opens on inspiration (air enters through tracheostomy), closes on expiration (air is redirected upward through larynx and mouth) → allows vocalisation.

Prerequisites for safe speaking valve use:

  1. Cuffed tube: cuff must be completely deflated before applying valve (otherwise air cannot exit through larynx — complete obstruction → patient cannot breathe)
  2. Uncuffed or fenestrated tube: valve can be used without deflating cuff
  3. Patient must have adequate laryngeal function and airway above tracheostomy
  4. First use should always be with speech and language therapy (SALT) — assess for aspiration risk
  5. Never leave patient unattended during first speaking valve trial

SPICE III context: the SPICE III trial demonstrated dexmedetomidine as primary sedative did not improve outcomes but may allow lighter sedation facilitating earlier communication. Early communication — including via speaking valves and communication boards — is a component of ICU liberation strategies (ABCDEF bundle) and is associated with reduced delirium and better psychological outcomes.

Decannulation

Decannulation is removal of the tracheostomy tube — should be planned and assessed systematically.

Decannulation Criteria

All criteria should be met:

  1. Adequate respiratory function: tolerates capping (tube occluded — all breathing through larynx) for ≥24 hours without distress; SpO₂ adequate; no significant RR increase
  2. Adequate cough: can cough to clear secretions
  3. Protective reflexes: intact swallow reflex; no aspiration on SALT assessment
  4. Reduced secretions: manageable volume; patient can clear with cough
  5. No ongoing MV requirement
  6. Stoma closure: usually within 48–72 hours; cover with hydrocolloid dressing; close with sutures if not closing

Sequential Downsizing

In complex patients: downsize to smaller tube, then uncuffed tube, then capping trial, then decannulation.

Emergency Management of the Obstructed Tracheostomy

National Tracheostomy Safety Project Emergency Algorithm

Patient with tracheostomy who is deteriorating or obstructed:

Step 1: Call for help — airways emergency

Step 2: Apply oxygen to face AND tracheostomy

Step 3: Assess patency of tracheostomy:

  • Remove speaking valve or cap if present
  • Deflate cuff
  • Pass suction catheter to assess and clear obstruction

Step 4: If catheter passes and obstruction clears → manage secretions; stabilise

Step 5: If catheter does not pass — tube is blocked or displaced:

  • Remove inner cannula (if applicable) and retry suction
  • If obstruction persists: remove tracheostomy tube

Step 6: After tube removal:

  • Apply oxygen to face AND stoma (patent stoma may allow ventilation)
  • If the original tracheostomy was for airway obstruction (not prolonged ventilation): primary airway may be compromised — attempt oral intubation immediately
  • Cover stoma with gauze and face mask if not intubating via stoma

Step 7: Replace tube if possible — use same size or smaller; insert under direct vision or with bronchoscopy if uncertain of tract

Key principle: never remove inner cannula without a plan for what happens next — practice this emergency as a team regularly (simulation). The NTSP bedside emergency signs provide the algorithm in condensed form at the patient bedside.

Viva Questions

1. What did the TracMan trial show about timing of tracheostomy, and how does it influence your practice?

TracMan (Young, JAMA 2013) randomised 909 ICU patients expected to require >7 more days of mechanical ventilation to early tracheostomy (~day 4) or late tracheostomy (~day 10). The primary outcome — 30-day mortality — showed no significant difference (30.8% vs 31.5%). Crucially, 53% of patients in the late group never received a tracheostomy because they were extubated or died before day 10 — demonstrating that clinicians cannot reliably predict at day 1–2 which patients will need prolonged ventilation. The trial's message is not "never do early tracheostomy" but rather "routine early tracheostomy has no benefit and avoids unnecessary procedures in ~half of patients who end up not needing one." In practice, I do not perform tracheostomy on a fixed day-7 default. I reassess daily: if the patient clearly requires extended ventilation (e.g., cervical spinal injury, Guillain-Barré, failed extubation attempts × 2), tracheostomy is appropriate and should not be unduly delayed. If weaning is progressing or prognosis is uncertain, I continue assessment.

2. Describe the emergency management of a patient with a blocked tracheostomy who is desaturating and distressed.

This is a life-threatening airway emergency — follow the NTSP algorithm. (1) Call for help immediately — anaesthetics, intensivist, senior nurse. (2) Apply oxygen to both face and tracheostomy stoma simultaneously — both routes may provide some oxygenation. (3) Assess and attempt to clear obstruction: remove speaking valve or cap; deflate cuff; pass suction catheter. (4) If suction catheter does not pass: remove inner cannula (if tube has one) and reattempt suction. (5) If still obstructed: remove the tracheostomy tube completely — a mucus plug or clot is preventing airflow and it will not resolve with the tube in situ. (6) After removal: cover stoma with gauze and apply face mask oxygen; attempt oral intubation via standard laryngoscopy if the original indication was not subglottic obstruction. (7) If spontaneous ventilation via stoma — consider reintubation via stoma with smaller ETT or replacement tube. The most dangerous action is leaving an obstructed tube in place and trying to suction around it — if the tube is blocked, it must come out. Ensure all ICU staff regularly practise this scenario with simulation and that all tracheostomy bedspaces have NTSP emergency equipment.

3. A patient with a tracheostomy is ready to attempt speaking valve use. What do you assess before application and what do you warn the family?

Before speaking valve application: (1) Ensure the cuff is completely deflated — this is essential; a valve on a cuffed inflated tube creates complete upper airway obstruction and the patient cannot breathe at all (this is the most dangerous mistake); (2) Assess that the patient can tolerate cuff deflation without severe aspiration or haemodynamic compromise; (3) Refer to speech and language therapy (SALT) — SALT assess for laryngeal function and aspiration risk before first use; secretion management must be adequate; (4) Patient must be awake, cognitively engaged, and able to signal distress; (5) Ensure tube size is appropriate — a tube too large relative to the trachea may not allow adequate airflow around the tube when the cuff is deflated; (6) Have oxygen and suction immediately available. I would explain to the family and patient: the valve allows air to exit through the voice box on breathing out, which is how speech is produced; first use is always a supervised trial; if there is any distress, the valve is removed immediately; some patients tolerate it immediately, others need gradual build-up of time; it also helps with swallowing assessment and may reduce aspiration risk over time by restoring subglottic pressure. I would emphasise that even a speaking valve trial carries some risk and always requires supervision — they must not apply or remove the valve themselves without training.