15.7 Perc Trache

Question 1

a) What are the indications for (20%) elective percutaneous tracheostomy (PCT)?

Answer 1

1&raquo_space; For long-term ventilation
or anticipated prolonged ventilatory wean.

2&raquo_space; To avoid complications
of long-term tracheal intubation (vocal cord
damage, laryngeal damage and consequent stenosis).

3&raquo_space; To allow sedation to be stopped
whilst invasive ventilation is ongoing.

4&raquo_space; To facilitate patient communication
if patient is able, a tracheostomy with
speaking valve is used.

5&raquo_space; To reduce dead space.

6&raquo_space; To facilitate tracheal suctioning.

7&raquo_space; For airway protection in patient with poor airway reflexes, e.g. due to bulbar dysfunction.

Question 2

Possible contraindications to (25%) elective percutaneous tracheostomy (PCT)?

Answer 2

Contraindications:
Absolute:
» Unstable cervical spine.

> > Severe local infection of the anterior neck.

> > Uncontrollable coagulopathy.

Relative:

> > High PEEP or inspired oxygen requirements.

> > Difficult anatomy
(e.g. morbid obesity, short thick neck, reduced neck
extension, excessive goitre, tracheal deviation, overlying blood vessels, extensive scarring).

> > Proximity to extensive burns or surgical wounds.

> > Haemodynamic instability.

> > Previous neck radiotherapy.

Question 3

b) List the potential early (40%) patient complications of PCT.

Answer 3

Early:
» Airway:
• Loss of airway
(with attendant risks of
hypoxic brain damage and
death).

• Damage to airway:
fracture of tracheal cartilages,
damage to posterior
wall of trachea,
paratracheal placement.

• Obstruction by blood,
secretions, foreign body.

> > Respiratory:

• Derecruitment.

• Pneumothorax.

• Surgical emphysema.

> > Cardiovascular:

• Bleeding from any vessels of the neck.

> > Neurological:

• Damage to recurrent laryngeal nerve.

Question 4

List the potential late (15% patient complications of PCT.)

Answer 4

Late:
» Airway:

• Displaced or blocked tube
causing loss of airway (with attendant risks
of hypoxic brain damage and death).

• Tracheal stenosis and scarring
(causing stridor, dyspnoea, poor
cough, altered voice, dysphagia).

• Tracheomalacia.

> > Cardiovascular:
• Erosion into blood vessels causing bleeding.

> > Immune, infection:
• Localised infection.

> > Cutaneomusculoskeletal:
• Scarring, persistent stoma.