Clinical context on trache B C - aasiyahrashan/PhD-Aasiyah GitHub Wiki

C

Thinks the question is different for neuro (As in TBI, etc) patients, who are very common there. Neuro patients normally get a trache within a couple of hours of admission to ICU. These patients are expected to have an indefinite amount of time on the ventilator.

Neurosurgery patients, after a tumour removal etc are also given a tracheotomy very quickly.

Similarly tetanus patients are expected to need a very long time on a ventilator and are given a tracheostomy quite quickly.

There are process benefits to giving tracheostomies. Patients with ETTs need very skilled care. Patients with tracheotomies can be cared for by less experienced nurses, there's lower risk of dislodgement or infection. Patients with traches can also be stepped down a level of care to free up an ICU bed. Tracheostomies are almost always given surgically at the bedside by the ENT team.

Younger patients with no comorbidities and acute illnesses get a bit more time on ETT. Eg covid or pneumonias. They wait a few days, and give a tracheostomy if it looks like recovery will be prolonged.

Special note for patients with HIV. If well controlled, stage 0 etc they're treated as if no comorbidities and given longer on the ETT. If stage 4, they expect recovery to be prolonged and give a tracheostomy more quickly.

If ETT patients have a catastrophic event like cardiac arrest, or have another failed organ, they get a few more days on the ETT, but are generally given a tracheostomy within a couple of weeks after the event. Similarly patients with infections, specially antibiotic resistant ones get a few days on ETT and are then given a tracheostomy.

Patients with accidental extubations get given a tracheostomy more quickly.

The following patients will not be given a tracheostomy. Patients who are too sick to have a tracheostomy. Based on level of organ support, severe ARDS and high ventilatory pressures to maintain oxygen. Patients with poor haemodynamics, or oxygen requirement> 60%. Patients who have sepsis have a propensity to bleed so it's delayed for as long as possible with them. Patients who are going to die anyway.

Asked about when trache goes wrong/fails. Very rare for trache to fail. Normally happens for patients very short/thick necks. Tube gets dislodged, caused by thick neck, need longer tube, which is harder to find.

Normally, if patients are having a tracheostomy, it would be within a week. So the RCT he'd be interested is tracheostomy within a week vs longer than a week. Neuro patients have to be excluded. Warns that it's really important to look for non-clinical indications for giving a tracheostomy in lower resource settings.

B

Would do a tracheostomy in 2 situations.

Situation 1. Patients expected to have prolonged need for ventilatory support. eg, Pneumonia, bad respiratory muscles,

It has the advantage of being easier to clear secretions from, and can put speaking valve if they’re fit enough. If respiratory system is not looking good, they sometimes wait 10-11 days because of the trac man data.

Situation 2. Second situation is neuro patients whose respiratory muscles work fine, but who not conscious enough to prevent themselves choking when they breathe. They don't need a ventilator. These patients get a trache fairly quickly, normally in the first 2-3 days. If they get pneumonia as well, trache is more likely to happen.

Care has to be paid for, so there's also the advantage of getting them off a higher level ICU faster.

So the question is different for 2 groups of patients. Recommends restricting it to the first group to start with.
First group would be medical patients, patients who came with sepsis, pneumonia, chemical/inhalation injury, drug overdose, pancreatitis.

Second group, neurological patients, neurosurgical.

Medical patients advantages of doing trache. If very sick doesn’t change much. If they’re beginning to get better, it helps them reduce sedation. More involved in rehabilitation. Family visit. Eat.

ETT harder to protect. Do the advantages outweigh the risk.

Trache is normally done percutaneously by intensivists. If it's very complicated, it's done by an ENT surgeon either in operating room or ICU.

Risk of bleeding. Mild, or delayed catastrophic. Local site infection. If the tube is long

Fistula longer term complication. Also, they could have a narrowed trachea or collapsed one for rest of life.

The trache normally happens after a couple of weeks in ICU. Then there's normally another 2-3 week stay in the main ICU before their care gets stepped down.