Tracheostomy: temporary

Aim

• To provide temporary access to the trachea, most commonly via making a tracheotomy incision and placing of a temporary tracheostomy tube.
• The two key indications are to alleviate upper airway obstruction and to allow for ventilatory management intraoperatively or within a full ICU setting.
• Method for permanent tracheostomy is not described in this component.

Uses

Bypass of upper airway obstructions

• Laryngeal injuries/obstruction, tracheal trauma.​
• Nasomaxillary trauma or electrical/chemical burns.
• Neoplastic lesions Trachea: neoplasia.
• Foreign bodies Trachea: foreign body.
• Severe laryngeal edema, laryngospasm Larynx: miscellaneous conditions.

Ventilatory management

• Means of maintaining postoperative mechanical ventilation within an ICU setting for a critical patient.
• For some surgical procedures, the presence of the endotracheal tube within the mouth compromises access; using a temporary tracheostomy tube for anesthesia allows an unobstructed view.

Technical problems

• Lack of familiarity with the technique can result in significant complications, eg making an incision that is too big or incorrectly located.
• Appropriate size and length tracheostomy tube must be available.
• Once a tracheostomy tube is placed the patient will require constant monitoring and (initially at least) intensive management.

Time required

Preparation

• If the procedure is elective (ie for surgical access) then normal routine surgical preparation of ventral neck.
• In most cases requiring emergency tracheostomy small doses of an analgesic or sedative will be sufficient to help restrain the patient.
• If it's possible to pass an endotracheal (ET) tube Endotracheal intubation then this should be done ASAP to give a safe airway; once an ET tube is in place securing the airway the rest of the tracheostomy can follow.
• If however the patient cannot be intubated due to complete obstruction (traumatic injury or large tumor for example) then the emphasis is on speed for a minimal clip and prep to get the tracheostomy done and obtain an airway.
• Speed and competence may be vital in an emergency.

Decision taking

Criteria 

• The obstruction MUST be proximal to the tracheostomy site - if the obstruction is within the distal trachea or lower airways, then the tracheostomy will not achieve anything.
• If being performed to facilitate surgical access to the head/face/mouth, give consideration to implications for postoperative care and how morbidity may be affected.

Risk assessment

• Emergency: analgesia or sedation and local anesthesia Local anesthesia: overview alone may be appropriate.
• Elective: aseptic preparation under general anesthesia General anesthesia: overview.