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  • Shared airway

  • Possible difficult airway

  • Close communication with surgeon, backup plan discussed

  • Indication for tracheostomy & concomitant injuries (traumatic brain injury, C-spine injury)

  • Potentially critically ill patient with limited reserve, multi-organ failure

  • Potential catastrophic complications:

    • Loss of airway, hemorrhage, pneumothorax, pneumomediastinum, subcutaneous emphysema, aspiration, false passage/tracheal disruption

    • Airway fire (low FiO2, limited cautery use)



Goals & Conflicts


  • Optimize underlying disease state: assessment of stability for elective tracheostomy (high FiO2 & ventilator support, high dose inotropes/vasopressors, raised ICP, severe volume overload, coagulopathy/DIC)

  • Surgical plan discussed along with backups & additional equipment

  • Reduce risk of aspiration: NPO status, gastric suction applied

  • Motionless surgical field (paralysis)

  • Low FiO2 (protect against airway fire) vs. high FiO2 requirements



Considerations for the patient with a tracheostomy


  • Difficult airway:

    • Difficult BMV & supraglottic device ventilation (air leak)

    • Dangerous placement of ETT (direct vision preferred)

  • Indications for tracheostomy:

    • Pulmonary toilet

    • Respiratory failure/chronic ventilation

    • Threatened airway

    • Aspiration risk

  • Comorbid disease:

    • ICU patient with multi-organ failure, sepsis, lung injury, etc

    • Neuromuscular disorders, chronic high spinal cord injury

  • Complications of long term tracheostomy:

    • Tracheoinnominate fistula, suctioning injuries, trachea/stoma site infection/bleeding, laryngomalacia, tracheomalacia, tracheal rupture, tracheal stenosis

  • Ensure emergency tracheostomy equipment available:

    • Various sizes of cuffed/uncuffed tracheostomy tubes, suction catheters, graspers, ambubag & ties

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