Thread by @TylerLarsenMD

1/ "Who feels comfortable evaluating a tracheostomy?"

Today on the wards we talked trachs. Though we see patients with trachs regularly I find it is a topic that few learners are comfortable with.

The following 🧵 is my "Hospitalists' Guide to Tracheostomies"

2/

Where are trachs placed anatomically?

Trachs are placed between the cricoid cartilage and the sternal notch around the 2nd to 4th tracheal ring. These can be placed surgically or percutaneously at the bedside.

3/
Anatomy of a Trach

When evaluating a trach, I find it helpful to consider the following:
🔹 Diameter - Is there an inner cannula or single lumen?
🔹 Length - Is it regular size or an Extended Length Trach (XLT)?
🔹 Cuffed or cuffless?
🔹 Fenestrations present?

4/
Anatomy of a Trach - Diameter

What size tube does a patient have?

🔹 Larger tube: ⬆️ clearance of secretions, may make phonation difficult

🔹 Smaller tube: makes phonation easier, more comfortable, ⬆️ airway resistance

5/
Anatomy of a Trach - Length

Is the length regular or extended?

XLT may be:
🔹 Proximal - for thicker necks
🔹 Distal - for getting past stenosis or other issues.

6/
Anatomy of a Trach - Fenestrations/One-way valves

🔹 Fenestrations - allow for phonation without a speaking valve but may be more difficult to suction

🔹 One-way valves - allow for phonation but require supervision/training and should never be used with cuff inflated!

7/
Anatomy of a Trach - Cuff vs Cuffless

🔹 Cuffed trachs can be use for mechanical ventilation when cuff is inflated

🔹 Cuffless trachs should NEVER be used for mechanical ventilation

Pro-tip: If there is a balloon present, it is a cuffed trach

8/
What are some indications for a tracheostomy?
▪️ Upper airway obstruction
▪️ Trauma
▪️ Prolonged mechanical ventilation

9/
What are some benefits of trach placement?
▪️ Facilitates weaning from ventilator ( ⬇️ dead space ventilation, ⬇️ airway resistance, ⬆️ patient comfort)
▪️ Facilitates secretion clearance
▪️ ? lower risk of ventilator-associated pneumonia (conflicting data)

10/
Tracheostomy Complications - Early (< 7 Days)
🔹 Loss of airway - replacement may create a false lumen (highest incidence in first 7 days). If falls out, bag the patient (or intubate) and call for help.
🔹 Hemorrhage
🔹 Injury to surrounding structures

11/
Tracheostomy Complications - Late (>7 days)
🔹 Loss of airway
🔹 Infections
🔹 Soft tissue necrosis
🔹 Tracheomalacia/Stenosis
🔹 Tracheoesophageal fistula
🔹 Tracheoinnominate artery fistula - can be temporized by the Utley maneuver

12/
And that's all for my quick on-service thread. This grew out of my own discomfort managing trachs as a resident and hope it helps others. As a disclaimer I am not an intensivist (though I did think about it), pulmonologist, or ENT and I happily defer to their expertise.

Thanks to everyone for correcting this tweet and educating me. I’ll say that in general in the acute inpatient setting for adult patients we do ventilation with cuffed trachs and patients who develop new/worsening resp failure with an uncuffed trach are usually switched.

I appreciate there are many nuances/exceptions and apologize for any misinformation.

Thanks to everyone for correcting/educating me about tweet 7 and the use of cuffless trachs for mechanical ventilation. In general I treat adults in the acute setting and we always use cuffed trachs for new/worsening resp failure require ventilation.

https://twitter.com/tylerlarsenmd/status/1251510105297817603?s=21

https://twitter.com/tylerlarsenmd/status/1251510105297817603