Good morning, everybody. We're going to go ahead and get started with our session. Thank you for joining us today. Today's session is tracheostomy in the ICU from beginning to end. So there's going to be a progression throughout the course of this session. My name is Van Holden. I'm currently an associate professor of medicine at the University of Maryland. I'll be discussing patient selection and timing. The next, Dr. Christian Gattis, who's an assistant professor of medicine at the Ohio State University and program director for the IP Fellowship, will discuss challenging tracheostomy cases, which include patients with obesity and coagulopathy. Dr. Vivek Murthy is joining us today. He's an assistant professor from NYU and also the program director for the IP Fellowship. He'll be discussing management of early and late tracheostomy complications. And finally, we have Dr. Eric Fulch, who's the chief of the Complex Chest Diseases Center and co-director of the IP program at MGH. He'll be discussing what happens after tracheostomy, so the journey towards decannulation. First, I'll be speaking on patient selection and timing. I have no disclosures. The lesson objectives for my talk will be to discuss the indications for tracheostomy, followed by appropriate patient selection and timing. So just to start off, there are 58,000 tracheostomies performed each year in the United States. And among Medicare beneficiaries, 5% will receive a trach, a gastrostomy, or both. And you can see here that the majority of patients will receive both procedures, more so than just tracheostomy alone. And there are several benefits to having a tracheostomy placed. These include improving patient comfort, which then decreases the need for sedation, while facilitating effective communication, airway clearance, and oral care. Decreased need for sedation then facilitates more aggressive weaning trials, thus shortening the ICU length of stay. Physiologically, tracheostomy tubes are shorter and may have a larger outer diameter than endotracheal tubes. Thus, there's less resistance, and this decreases the work of breathing. Tracheostomy tubes are also more rigid than endotracheal tubes, so they're less likely to be kinked. In terms of how tracheostomies are placed, there's generally two methods, percutaneous versus surgical. And several meta-analyses have evaluated the safety of both approaches. And there's no significant difference in rates of mortality, intraoperative and postoperative bleeding, life-threatening events, such as loss of the airway, false passage, injuring the trachea, developing subcutaneous emphysema, or pneumothorax. And there's also no difference in complications of developing subglottic stenosis. So both approaches can be performed safely in critically ill patients. However, there are additional benefits of doing percutaneous tracheostomy. And this is decrease in rates of wound infection and stomatitis because the wound incision is smaller, there's less tissue trauma. It also takes less procedural time, sometimes up to half the time of a surgical tracheostomy. There's lower costs associated with a percutaneous approach, and there's less morbidity with transferring patients to the operating room. So therefore, PDT, or percutaneous dilatational tracheostomy, should be considered the procedure of choice for elective tracheostomies in eligible critically ill patients. And in general, the way that the procedure is done is that a small skin incision is made, followed by a blunt dissection. And a catheter over the needle device is inserted between the first and second, or second and third tracheal rings under bronchoscopic visualization. Then serodilation is performed using a modified Saldinger technique, and the tracheostomy is placed into the airway. Indications for tracheostomy, not just percutaneous but also surgical, could be to facilitate weaning from mechanical ventilation. And some of the benefits of tracheostomy that I previously mentioned, such as pulmonary hygiene, mucociliary clearance, and improving patient comfort. Some clinical indications for tracheostomy placement may be progressive or persistent neuromuscular weakness, upper airway obstruction, or severe sleep apnea with recurrent respiratory failure. Specifically for the percutaneous approach, there are some absolute and relative contraindications. Absolute contraindications include operator inexperience. So the learning curve for tracheostomy in order to achieve competency is around 20 tracheostomies. If there's superficial or deep infection at the insertion site, that's also an absolute contraindication. And unstable spinal injuries and uncorrected coagulopathy. In terms of relative contraindications, this would be at the discretion of the proceduralist. So some clinical and relative contraindications or clinical instability, for example, if they are impressors. If they have high ventilatory or PEEP settings. So this includes the need for high minute ventilation, because part of the procedure is done under apnea. So it's not just the level of oxygenation, but also ventilation that's important. Coagulopathy, and then finally some anatomical features, such as obesity or large neck size, in which it's difficult to palpate the landmarks. If they have an anatomic or pulsatile vascular abnormality, that could be a relative contraindication. Maxillofacial trauma and prior tracheostomy. And finally, if it's an emergent airway, that it's not when a tracheostomy should be performed, that would be a cricothyroidotomy. And if there's patient, family, or physician disagreement, then an ethics committee may be warranted. So one of the most important aspects of patient selection, besides the indications, making sure they don't have any of the contraindications, is the anatomic considerations for patients. So patients need to have the appropriate anatomy in order to increase the success of the procedure and decrease the risk of complications. So starting with the landmarks, the thyroid cartilage with the notch in the front should be able to be palpated with the cricoid underneath. Examination of the neck should be performed after appropriate patient positioning, which is with a shoulder roll, to hyperextend their neck, which increases the distance from their suprasternal notch to the cricoid. It's important that the neck roll is low enough where their shoulders are pushed outward. If the neck roll is too high, you can actually push your shoulders in, and that decreases the length of neck extension. In this image here, the thyroid cartilage is marked, followed by the cricoid cartilage, the first and second tracheal ring, and the suprasternal notch. Ideally, there should be around three to four centimeters between the cricoid and the sternal notch. And typically, the incision is performed halfway between those two landmarks. So again, the ability to palpate the landmarks is very important. And it's also important to keep in mind that the trachea anatomically dives more posteriorly the further down you go. So the further down you go in the neck, there's gonna be more distance between the skin and the trachea in terms of what you would need to dissect. You have to think about where the thyroid isthmus is. It usually crosses the second and third tracheal rings. And so there may be a little bit of bleeding associated with the procedure. Lateral lobes of the thyroid are highly vascular, as you can see in this image here. So it's very important to stay midline. Pre-procedure ultrasound is very important to improve the safety of the procedure, and it's ubiquitous. Most ICUs have an ultrasound machine, and this can help to identify the vasculature prior to doing tracheostomy. You can use a linear probe to identify not only your vascular structures, but also your cricoid cartilage and your tracheal rings. Using a pre-procedure ultrasound has been shown to lower the rates of complications, but more importantly, it actually changed the puncture site. In a study, it changed the puncture site in 24% of patients, in order to avoid injury to the vessels. So routine pre-procedure ultrasound should be done if possible. And using the ultrasound, you can use a linear probe to look at the neck transversely and longitudinally. So in the image on the right, with the ultrasound transverse, you can see that there's a tracheal cartilage, the ermicosal interface here, and then comatose artifact, CTA. On either side, you can see the thyroid gland. In the longitudinal view, you can see that there's a cricoid here, the first, second, third, and fourth tracheal rings. It's also important to review the CT imaging before the procedure. You don't have to have a CT before doing a tracheostomy, but most patients in the ICU already have one. And looking at the CT, you can identify, again, anatomic variants like an enlarged thyroid or aberrant vessels. And you can use the CT to measure the distance from the skin to the trachea, a diameter of the trachea, and also the length. And this helps with tracheostomy tube selection. This is an example of an aberrant high-riding anomina artery. So you can see on the CT image in the bottom, where the white arrow is, that's a high-riding anomina artery, and you can see it's positive on Doppler. So looking at the images, and even just examining the patient's neck, if you see something pulsatile, you wanna make sure you ultrasound that and don't go in that area. And this is the video here showing the pulsations. In terms of timing for tracheostomy, there's really no consensus on the optimal timing of tracheostomy in ICU patients. Studies have compared greater or less than seven days, 10 versus 14 days. But there's been no difference in mortality, the development of venilator associated pneumonia, a number of ICU free days, or duration of mechanical ventilation. So really, the determination of when to do a tracheostomy depends on the patient's prognosis, the ability to wean, and their comorbidities. The caveat, though, is that there is benefit in early tracheostomy in patients that have a severe cervical spine injury, particularly if it's high. If they have Guillain-Barre syndrome or severe traumatic brain injury. The other thing to consider is not just the timing of the tracheostomy, but considering whether or not the patient needs a gastrostomy at the same time. Most of the time, I would say the majority of the time, patients do need both. And using a stepwise procedure, doing one first, followed by the other one separately, can prolong their time in the ICU and in the hospital. So looking at this study where they did a combined tracheostomy and gastrostomy tube in the neuro ICU, it showed that patients who underwent both procedures had a lower neuro ICU length of stay, hospital length of stay, and also saved the hospital their money in terms of their overall hospital costs. Recently, there's been development of a percutaneous ultrasound guided gastrostomy, and this has been done by intensivists doing both tracheostomy and PUGs, and in this small study, they also showed that there's a lower ICU length of stay, hospital length of stay, and lower costs. So not just the timing of when tracheostomies are performed is important, but thinking about, should I also combine this with a gastrostomy to decrease their length of time in the hospital? So in conclusion, tracheostomy provides many advantages over prolonged intubation. The careful patient selection, including review of ultrasound and CT images, optimizes success while minimizing complications. And the timing of tracheostomy should be individualized and considered concomitantly with gastrostomy placement when needed. Thank you. Hi everyone, my name is Christian Gadas, and I have no disclosures for this talk. I was asked to talk about some challenging tracheostomy cases. I didn't take pictures during any complication, but I'm gonna review the literature on two subgroups of patients that are considered high risk, which is patients that are obese and patients with coagulopathy. I'm gonna also talk about some how to risk certify patients undergoing tracheostomy. So first starting talking about who is considered a high risk patient for a tracheostomy, mainly patients with coagulopathy and those with abnormal anatomy. So coagulopathy we all know. You just need to know when to draw the lines, and this is what we're gonna talk about today. So for thrombocytopenia, usually it's less than 150, but less than 50,000 would be considered the higher risk. Elevated INR, PTT, mainly more than 50 seconds. Patient being on anti-platelet treatment, mainly when they're on dual anti-platelet treatment. And those on therapeutic anti-coagulation, heparin or low molecular weight heparin. On the other hand, what makes a patient higher risk for complication is the abnormal anatomy. So looking at the next neck, shorter, thicker neck, difficult to palpate the landmarks is one reason. Limited mobility with patient that has prior neck fracture surgeries and screws. You always wanna ask this in the history of the patient that you're gonna go to do a tracheostomy on. Scars, whether of prior tracheostomy, or infection, or radiation to the neck. So this is one of the overlooked relative contraindication, just prior radiation to the neck. I would avoid those patients for sure. And obesity, which we're gonna talk about, and having a large goiter. On the other side, vasculature, if you have enlarged vessels at the midline where you're gonna be doing your procedure, you definitely wanna avoid those cases or pick a different puncture point. So it's important to do the prescreening ultrasound. So tracheostomy in patients with higher BMI. So traditionally, these are considered relative contraindication, mainly because it's difficult to palpate the landmarks for those patients. And they are considered to be at higher risk of preoperative complications. So reviewing the literature on this subgroup of patients, one study of about 227 patients examined the safety of percutaneous tracheostomy in obese patients, and they found that the subgroup that were considered obese had a higher incidence of major complications. If you look at the highlighted section, 6% aborted procedure cases, 2% paratracheal insertion, and 4% accidental extubation. But when you look deeper into that literature, that paper, all these cases were done without a bronchoscopic guidance. Another study looked at the safety of percutaneous tracheostomy in obese patients. Obesity in this study was defined as BMI more than 27.5, probably done not in the US. And in this study, bronchoscopic guidance was done in all the patients, was used in all the patients. And they had also higher incidence of complication in patients that were obese or considered obese. Mainly, posterior tracheal wall puncture, one airway loss, and one accidental extubation. But also in this paper, they have used four different percutaneous techniques. So I would say there was no learning curve for the providers. And they used four techniques, so that's something to be taken into consideration when we review the literature. Also, there is no concrete evidence that surgical tracheostomy is superior to percutaneous tracheostomy in patients that are having higher BMI. A retrospective study in more than 400 patients found that the risk of complication in surgical tracheostomy in obese patients was fourfold, more than fourfold, compared to non-obese patients. So we always wanna learn how to mitigate the risk when we perform procedures in this subgroup of patients. So I would say direct visualization is very important. And pre-screening with ultrasound, as Dr. Holder was mentioning, is very important as well. So the role of bronchoscopy, this is a meta-analysis of more than 2,200 patients looking at patients doing percutaneous tracheostomy. So the blind or the population who underwent percutaneous tracheostomy without bronchoscopic guidance had more than two-fold incidence of complication compared to that. The group that underwent was guided by bronchoscopy. Another study that we just discussed earlier from the anesthesia literature, they found that undergoing a blind percutaneous tracheostomy has a six-fold more risk of complication compared to those who had bronchoscopic guidance. So definitely having a direct visualization is very important to decrease the risk of complication in this group, or any percutaneous tracheostomy, actually. Also the ultrasound, re-emphasizing the point that we mentioned earlier, the pre-screening of the neck with the ultrasound would definitely help you to avoid those cases that might encounter risk of bleeding. So we always pre-screen the neck with the ultrasound. And if you have high vasculature, even if you can't avoid the puncture site, I would just avoid doing the case on those patients. Just send them to surgery. And your choice of the tracheostomy is also important. So when you have a patient with higher BMI, you expect that they would have a higher circumference of the neck. So the anatomy of the tracheostomy, there is a proximal limb and a distal limb, and there is the radial curve portion. So if you are undergoing a tracheostomy on someone who is obese that has a higher neck circumference, always choose a brain that has a longer proximal limb. The same as what you do when you have someone with a longer trachea, just choose a tracheostomy that has a longer distal limb. Just know your anatomy so you can choose the proper tracheostomy. Next, talking about tracheostomy in patients who are at higher risk of bleeding. So bleeding is one of the most common complications, early complication, when undergoing tracheostomy. So this paper looked at the risk of bleeding during percutaneous tracheostomy. And there was an increased risk of bleeding with prolonged PTT or mainly with the presence of two or more coagulation abnormality. High PTT or being on therapeutic heparin or low molecular weight heparin. Another study, smaller size, 42 patients. Looked at patient who underwent percutaneous tracheostomy was a mean platelet count of 26,000 requiring transfusion before the procedure. And only two patients out of 42 developed complication that didn't require any surgery, however, these two patients were on heparin infusion. So that's something to keep in mind when you read the literature. A larger study, probably this is the largest one I found, 671 patients from 12 sites in Europe. Actually, the population was in the cardiac ICU. So all these patients are high risk group for bleeding because all of them are on some sort of anticoagulation or antiplatelets. So in this study, there was an independent association of bleeding during percutaneous tracheostomy with low platelet count, chronic kidney disease, and history of stroke. There was subgroup of patients. One that was only on prophylactic heparin. Second was on therapeutic anticoagulation. Third was on antiplatelet with or in addition to therapeutic anticoagulation. And the fourth group was on a triple therapy, dual antiplatelet and therapeutic anticoagulation. The first three groups, there was no difference in the incidence of complications. So with exception of the triple therapy. So that's something to keep in mind. So just looking at the literature, I don't feel there is very strong evidence not to do percutaneous tracheostomy on most of the patient, even if they're obese or they have coagulopathy. I think we just need to mitigate the risk. So always when you're undergoing, when you're gonna go and do a case, just try to correct coagulopathy. And ask yourself if you can discontinue the antiplatelets for a few days or the therapeutic anticoagulation for like six hours, just to do the procedure and then you can resume it again. Can you postpone it for a few days? I mean, tracheostomy is never like an urgent procedure to be done. Always use bronchoscopic guidance, always ultrasound the neck prior to the case, especially with higher risk patients, and have a backup plan. I think accidental extubation is unrelated to the patient being obese or non-obese. I think that's just, if you have a dedicated team that do the procedure all the time, I think the risk of extubation is gonna be very low. But always, there is an airway cart outside, even if it happens, and you can re-intubate your patient very quickly. Have a portable coterie, so if you have some milder or bleeding, that you can stop it and manage it. So in summary, I think percutaneous tracheostomy is safe, with low risk of complications when performed with proper due diligence. Always use the real-time guidance, screen your airways with imaging, whether ultrasound or even CT of the chest, if you don't have the ultrasound. Be careful when you select the size of your tracheostomy and the length of your tracheostomy tube that you're gonna use, and correct coagulopathy, and always have a backup plan. And that was it for me. Thank you for listening. Thank you. Good morning, everyone. Thrilled to be in Honolulu with all of you. I'll be discussing complications of tracheostomy insertion in the ICU. Okay. My name is Vivek Murthy. I'm an interventional pulmonologist at NYU, and I have nothing to disclose. So a couple of things I'd like to go over in the next couple minutes. I'm gonna talk about some of the most common complications related to morbidity and mortality for tracheostomy insertion in the ICU. Discuss some of the differences in outcomes from PDT and open tracheostomy. And I'd like to talk a little bit about management strategies, and specifically data on early intervention approaches to reduce complications from per-trache. Before I start, I just wanna ask, who in the room, if you can raise your hand, is a trainee, a resident, fellow, medical student? Awesome, and who is a person who routinely, a faculty member who performs percutaneous tracheostomy routinely? Awesome. And who amongst those faculty has had a complication that they'd like to share with the group? I'm kidding, please don't do that. But complications happen, that's a reality, and we need to recognize that. And the more familiar we are with what the risk factors are, the more we can plan for our procedure. But more importantly, as Dr. Gattis and Dr. Holden discussed, plan our patient selection, because prevention is the best management strategy we can take. So let's start with mortality related to trachs. The largest review of the literature comes in the form of this meta-analysis that was published in 2013, looking at specifically per-trachs done from 1985 to 2013. So it encompassed 8,000 procedures. It was a really broad overview over a long period of time of outcomes. So what they found was that there was an overall procedure-specific mortality, so not mortality with a trach, but mortality from a trach of 2%. Subsequent studies have found rates closer to 0.1 to 0.5%, probably accounting for changes in our approach over the three decades. But looking specifically at the ideology of mortality, they found that 38% were due to hemorrhage, 29% were due to airway complications. So that's creation of a false passage or a loss of the airway. Tracheal perforation in 16%, and then pneumothorax, bronchospasm, and cardiac arrest. So complications that are all really nerve-wracking to manage, and 31% of those occurred during the procedure, half occurred in the first week post-procedure. So it's obviously a very important time to manage patients and watch them carefully in the post-operative period. So bronchoscopic guidance was reported in fewer than half of patients in this cohort, but it's a cohort that spans many studies over many decades. It's now really become standard of care for the percutaneous approach. So when they looked specifically at risk factors for these complications, two that really were very prominent were low tracheal access was significantly associated with the risk of hemorrhage. And a kinked guide wire was noted in one in five patients with tracheal perforation. So in the most common kits that you'll find, the guide wire has a catheter that goes over it before the large dilator goes in. And that's specifically to prevent injury to the posterior wall. So it's really important that you maintain that in position to avoid injury. So taking a step back from procedural complications, mortality associated with tracheostomy, there's a really nice review of national mortality data in patients with tracheostomies covering about a ten year period. And what they found was that there was a tenfold higher rate of trach-related death in children versus adults. And sadly, the odds ratio for death in black children was two compared to others. Interestingly as well, they found that there was a higher likelihood with an odds ratio of 1.2 for someone dying with a trach over the weekend, with one third of trach-related deaths occurring over the weekend. What does that tell us? This is a time when we have less staff in the hospital, less observation, and an opportunity to intervene if we had nursing or RT-driven approaches to screening patients for complications from trachs. So Dr. Holden and Dr. Gattas kind of both talked a little bit about the differences between percutaneous versus open approach. There have been a number of studies looking at outcomes. And as Dr. Holden said, there's really no study showing compelling evidence of difference in mortality between the two. But there are differences, subtle differences in morbidity between the two approaches that merit consideration. So there's a higher rate of technical difficulty with percutaneous tracheostomy, around 7 percent. This is from a meta-analysis of 1,800 patients with a conversion rate of just under 2 percent from percutaneous to open required amongst that broad range of patients, with a slightly higher rate of stomal infection for patients with open tracheostomies. So there's no area of medicine that was immune from the effects of the COVID pandemic, and that's especially true for airway management. So to kind of reflect on that, there was this really interesting multicenter retrospective observational study that was conducted in Italy and Spain called the Wien-Trach Study. So this was a study looking at patients who were on a vent with COVID-19 infection who underwent either an open or a perc trach, it was not randomized in any way. And 153 patients were ultimately enrolled. The median time to trach was 15 days, so there was no difference in mortality whether the trach was done before or after two weeks, but there was a significantly shorter ICU length of stay, as Dr. Holden said, for patients who had a percutaneous approach, with more pneumonias. So 83 percent of patients with an open trach had a pneumonia versus 53 percent in this cohort. So it seems like, you know, subtle differences in outcomes in terms of risk of infection being a little higher for the open trach versus technical difficulty with a percutaneous approach. So when I'm thinking about complications of a tracheostomy, actually my first question in my mind when I'm narrowing my differential is, when was the trach done? Are we talking about during or immediately after the trach was placed? Are we talking about a couple of days after the trach, or are we talking maybe a few weeks or a few months after? Because what we're looking for in those times is very different. So periprocedurally, of course, the things we worry most about are bleeding, tracheal ring fracture, which while not usually an issue while the trach is in, does become an issue much later on, loss of the airway. We always have, as Dr. Gattas mentioned, an airway box in the room, multiple airway options in case there's a loss of the airway for any reason. Hypoxia, malposition of the trach, posterior tracheal wall injury, these are all things we would expect at the time or the day of the procedure. Early complications include bleeding, pneumo-mediastinum pneumothorax, which is usually not life-threatening but can be serious in some patients, stomal infection, and then inadvertent decannulation. And then late complications, which usually manifest around the time of capping trials or decannulation would be tracheal stenosis, tracheomalacia, a fist chill-out from something to something else, and then dysphonia. So when it comes to bleeding, the manifestations and ideologies are very different for early versus late bleeding. So with early bleeding, it's usually due to injury in one of the superficial venous structures around the neck. These are predominantly the anterior jugular vein, the inferior thyroid vein, or rarely, and I'll show you some aberrant anatomy examples, the superior thyroid vein. So all of these are in that area. With the use of ultrasound, it's very unusual to have direct injury to one of them, but early bleeding is usually from one of these. And they can be variable in people. They usually are in paramedian, but not all the time. So 4, 5, and 6 are just examples of variants of the inferior thyroid vein, which can drain to the brachiocephalic, can drain to the jugular, can go in many different ways. Occasionally, the superior and inferior thyroid veins will join in a median thyroid vein, which can run midline. And if you recognize that, this is someone who may benefit from a surgical approach. And you've seen images of ultrasound colored out there. So actually, Dr. Gattis discussed these studies. So the risk of bleeding is more likely when you have more than one coagulopathy. Usually you can correct one, you can even correct two, but the risk of bleeding is just going to be higher. The specific things I think of when I'm correcting coagulopathy would be a platelet count at or above 50,000 is ideal. And INR as close to normal as we can get it. And with the uremia, it's an underappreciated cause for platelet dysfunction. And so we're very careful about, for patients with a BUN over 80, ensuring that they receive DDAVP 15 to 30 minutes before the procedure. So with all those kinds of preparations, usually serious bleeding is pretty unusual, even with coagulopathy. And prophylactic dose heparin is usually never an issue. Where bleeding becomes more relevant is for patients on VV ECMO. And again, this is something that we really, we had to learn a lot about in the course of the COVID pandemic. I think many centers, ours included, really changed our approach. So in 2020, our program was one that was doing 30 to 50 trachs every year, we did 150 in 2020 because New York was just so inundated with COVID patients. And also for ECMO patients, we found a lot of advantages to early tracheostomy. But ECMO patients are also very sick. They're on anticoagulation, they have platelet dysfunction, they have thrombocytopenia. So what we observed and what was demonstrated in this trial I'm gonna tell you about was more bleeding complications. So there was an international European multi-center retrospective study. It was actually not done in the context of COVID, it was for patients with severe ARDS. And it was published in 2018 that looked at four high volume ECMO centers and enrolled 1,200 patients over a nine year period. So experienced places doing a lot of ECMO, a lot of trachs. And what they found was that there was a four times higher rate of local bleeding for patients on ECMO even with pausing of anticoagulation around the time of the procedure compared to patients who did not require ECMO but had a trach. And 1.7% of those patients had major bleeding, which they defined as requiring intervention, not just stomal packing or something like that. This was typically seen between one and a half to five days post procedure. And as I mentioned, thrombocytopenia and platelet dysfunction are major factors, even with pausing of anticoagulation. It's usually manageable with local measures. However, 8% of patients required repeat bronchoscopy to manage airway clots, which were significant. Our observation is that preemptively packing the stoma of these patients with Surgicel Fibrillar, which is a highly malleable variant of Surgicel, not to mention a brand name, I'm sorry, but I don't know how else to call it, was very effective actually. We had far less bleeding when we were proactive in our approach to these patients. So that is more minor bleeding, serious bleeding. The thing we were most concerned about when it comes to bleeding in trach patients, of course, is the trachea nominate fistula. So the nominate artery, also called the brachiocephalic artery, comes off of the aortic arch usually, and usually runs anterior to the trachea, just deep to the sternal notch, but can be high-riding, as you saw in that Emerald video from Dr. Gadas. So fistulization is pretty uncommon between the trachea and the nominate. It's reported in 0.1 to 1% in different case series. It's less common with low-pressure cuffs, and especially low-pressure tapered cuffs. These are great because they help us avoid the risk of granulation tissue, tracheal stenosis, but also lower risk of tracheal nominate fistula. But it's more common with low insertions. So we generally are aiming for a trachea in the first and second or second or third tracheal rings. Anything lower than that, the cuff is more likely to be between the seventh and ninth tracheal ring, and the risk of fistulization becomes much higher. So when it comes to TI fistula, 72% of cases occur within the first three weeks of tracheal insertion, but it can be seen anywhere from a week to about three months typically. It can happen any time, but the vast majority will be in that time frame. And it's usually associated, this is very important, with sentinel or herald bleeds. So the first presentation of a TI fistula is usually not massive bleeding. It's usually bleeding from a trach, which is very nonspecific. It could be from suctioning. It could be from pneumonia. It could be from anything. But any time I have a patient with a trach who's bleeding, TI fistula is the first thing I'm thinking about because we need to be really proactive in excluding it. The herald bleed usually means early injury to the anterior tracheal wall that is a harbinger for something much worse. So these are patients for whom you want to get a CTA early. You really want to be proactive to avoid issues. Otherwise, you'll be doing this, which is not a nice way to have to manage a TI fistula. But what are the options if it happens? So for those who haven't seen one, it's probably one of the scariest things you'll see is blood pouring out of a trach. The first thing is to breathe and be calm. The second is to inflate the cuff. Most likely, we'll be able to tampon out some or all of the bleeding by over distending the cuff. If the bleed is happening just below the margin of the cuff, that may not be enough. And then your next approach is to secure the airway from above, ideally with an ET tube whose cuff is going to be beyond the site of injury. Having a bronchoscope, even a disposable bronchoscope in the room for that is really important because you'll probably be cleaning cloths out of the airway and positioning the ET tube. While perhaps your partner is intubating, one option, I've seen this done once successfully, is removing the trach. It's not doing anything in this situation anyway, and putting your finger in the stoma to occlude the TI fistula. Again, I hope no one in this room is ever in this situation, but ultimately, these are the things that we have to do to get the patient to the OR, which is where they need to be. Tracheal stenosis is another very common, unfortunately common, complication of percutaneous and open tracheostomy. There's really no difference in the likelihood of it happening for either, but there are some nuances in when they occur. So stenosis from percutaneous may occur earlier. One retrospective study suggested a mean time to onset of about five weeks after the procedure versus 28 weeks for open trach. And stenosis can happen for a lot of reasons. We see it from granulation tissue at the cuff, granulation tissue from the tip of the trach, granulation from the entry site or the stoma site, or worse than granulation is cartilage fracture. And the manifestation in this context is often so-called A-frame stenosis, where instead of a nice round anterior cartilaginous ring, you have one that's an A. And this is very frustrating and challenging to manage because none of our endoscopic approaches, which can include electrocautery, balloon dilation, rigid dilation, application of medications like mitomycin C or steroids, these are all okay treatments for granulation. They mostly work. Myospray is one that has had increasing popularity for management of tracheal stenosis. For an A-frame stenosis, none of them will really do anything because even if you put a stent in, it's not necessarily gonna remodel in the way granulation might. So these can be very frustrating to manage. They often require surgical intervention, tracheal resection, or placement of another tracheostomy. So the best way to manage it is, again, to avoid it. So if you're very careful about insertion between tracheal rings at the time of a percutaneous procedure, this is much less likely. But this is a common thing that we see. So amongst survivors of their ICU experience with a PRIC trach, up to one in three patients who've had a PRIC trach will have some degree of tracheal stenosis. But if it's mild, less than 10% of the airway lumen, it's probably not impacting their day-to-day life. Maybe they have a little bit of cough. Maybe they have a little bit of mild, mild stridor. But in up to 6% of patients, they can have symptomatic stenosis. And risk factors for that include elevated BMI, trach insertion late, so over 10 days after an intubation. I shouldn't use the word late. It's all relative, but over 10 days. Cough pressure is consistently over 30 millimeters of water or a larger initial trach tube size. And multidisciplinary management for these cases is key. I think that a lot of these cases really do require careful consideration of downstream effects. It's very easy to dilate something that's narrowed. But we know that the airway is gonna change every time you do a procedure. And so having a big picture approach to this is really very important. We collaborate a lot with our colleagues in ENT and thoracic on that. Tracheomalacia is something that it's hard to separate sometimes from tracheal stenosis because particularly with the A-frame or cartilage injury, tracheomalacia is just part of that process because now the connection from cartilage and posterior membrane has changed. It's also underappreciated because even if someone has a capping trial and does well, as long as the trach is in the airway, it is tempting the airway open to some degree. So this is only really appreciated in most people after decannulation. It seems like a decannulation failure. And also very challenging to manage. So as I alluded to earlier, one third of trach complications appear to occur on the weekend, kind of disproportionate to what we might expect. And there have been a number of studies looking at proactive approaches to this. There was this really nice prospective study of 150 patients who had consecutive tracheostomies at one center. It was published in 2014. And what they found was that having a nurse and RT-driven protocol, so this was not something that was unique to any one patient. It's like 150 trachs in a row. They did the exact same thing with all of them. They found that there were significantly fewer episodes of mucus plugging, obstruction, self-decannulation, infection, and bleeding. It makes sense. It's something that really should be, I think, incorporated into any high-volume center, or really any center, and can help avoid rapid response calls and ICU length of stay. Another area that we see this come up a lot is in stomal infection, and more importantly, post-tracheostomy skin breakdown, particularly at the inferior margin of the trach. So a couple of measures that many centers have taken to mitigate that have included, number one, thinking about whether we really want to suture these. This is a controversial subject. I don't think we need to get into it, but the amount of pressure that's being applied by sutures can be significant, and with a proactive nursing-driven approach to monitoring and managing trachs. Actually, we have found, in the last three years, no stomal injury because we've stopped suturing and we're just taking really good care of the trachs. It's very difficult to do. It requires a lot of buy-in, but it can have great outcomes. Two other things that many centers have done. One is using tracheostomies that don't have a hard flange, so one that's a little bit more flexible, and there are several brands that have options for that, and the third is preemptively using a tissue barrier, and the tissue barriers that are used for pressure ulcers are just preemptively put at the inferior margin of the trach. We've had no injuries in the last three years, so something to think about as you consider how you approach your trach programs. So in summary, understanding and mitigating risk factors is the most important thing to reduce complications. Patient selection is everything. Preventing serious bleeds means you have to recognize early bleeding as potentially serious down the line, and early intervention teams can help reduce the likelihood of serious complications. Thanks very much. Thank you for being here. I know I'm competing with Surf, Beach, etc., so. My disclosures are extensive. I've been a consultant for a multitude of companies, including Cook, who makes the percutaneous tracheostomy trach. However, none of what I will be speaking about pertains to these companies. My objectives are to identify the areas of improvement in the continuum of care, not just do the procedure, walk away, which is usually what happens when you first start doing this. And since most of the people in the audience are residents and fellows, I want to convey that if you want to do this procedure on a continuum basis, you should add value, not just procedure. Adding value is adding a clinic, adding longitudinal follow-up. I will also identify some barriers to patient care. The reason I was invited to speak today is because Dr. Holden knows that we worked in improving our decannulation process, our winging process during COVID, and I'm going to show you some data behind that to minimize aerosolization and the seamless transition. And I'm going to show you something that is partially based on randomized trials, partially based on our experience. This is, if there is one area where I would focus on is we have this ventilated patients. If they actually pass SVT, they get extubated, end of the story. If they actually require extensive mechanical ventilation, they will proceed to tracheostomy and hopefully PEG for the reasons that Dr. Holden mentioned and that I will emphasize again. And then during that time, they will have airway procedures and they will have clearance procedures as well as in-health therapy and diagnostics happen to them. Hopefully at some point, they will advance to a Passy Muir valve trial, which has impressive, if you haven't seen it in person, has impressive psych effects on the patients when they hear their own voice for the first time after this prolonged hospital stay. And finally, a TRACAP trial and decannulation. Each of this comes involved with varying degree of aerosolization of particles, which COVID taught us was very meaningful before widespread vaccination was available. So we identified that approximately 5% of patients with COVID eventually required mechanical ventilation and a sub-segment of those actually were frail and require prolonged mechanical ventilation. We develop an expert consensus with specialists from different areas in the middle of this happening. And we wrote some guidance on the tracheostomy and the placement of pegs in these patients while minimizing aerosolization and transitioning. How do you transition them without aerosolizing the entire environment? So as Dr. Holden mentioned, there are advantages to tracheostomy and to nutrition with gastrostomy too. I will not dwell again on the tracheostomy advantages, but I will say the gastrostomy is underutilized even though we're doing it more and more, it's a wave. And the reason is it gives us secure access to the GI tract less x-rays are needed. If we can put a gastrostomy tube at the same time, decrease risk of sinusitis, we secure uninterrupted nutrition and medication and no need for retraining swallowing in these patients most of the times. So this graph that I put together just shows you that before we had vaccines and there are still a lot of patients worldwide and in the U.S. who are not vaccinated, there was a clear distinction between those who survive and those who didn't. And those who didn't, of course, it had a shorter observation period. And those who we kept going and forcing ourselves into keeping them alive tended to progress into trache and nutrition in about 0.5% of the cases. However, we were asking ourselves, are these patients so preselected that's why they survive or are we making a difference? And I'd like to make the case that we actually made a difference because we allow the immune system along with the supportive measures to help us. But you can see here that just about half a percent ended up with a tracheostomy. Once you smooth out the curves and things look prettier, you are able to convince your administrators of such a thing. Having said that, Van asked me to present to you how we had modified our standard procedure and how we do it actively. So this is a complicated graph. I'll break it down in. You have patients who have prolonged mechanical ventilation. You do an SVT trial. If they pass, they get extubated. If they get reintubated, they tend to get trach. At our institution, if they fail, then we do a tracheostomy and a PEG placement simultaneously and at the bedside by interventional pulmonologist, most of the time. If the patients progress well after the trach, they go on to trach mask. If they pass, they are liberated from mechanical ventilation and we consider that an open trach. Everything that you see in red is high aerosolizing risk. And we were not thinking about this before the peak of the epidemic of COVID. Those patients who go on to be liberated from mechanical ventilation undergo tracheostomy manometry. If they pass, they go on to spontaneous reading trials and then trach cap. If they fail, they go on to a trach tube downsizing. Why is this important? Because the manometry allows you to know if there's air going around the tube, right? And that would allow the patient to phonate and as I said, has incredible psych effect. And finally, if the patient passes the cap trial, they get decannulated. So you may say, well, this is a very complicated thing. I came to this session because I'm interested in the tracheostomy. Yes, but once you do the tracheostomy and or the PEG, is my recommendation or my suggestion, you own that airway and you should be called if there are complications. And the complications will happen in the following weeks or months following that. Now, if you tell me, hey, I work in a small hospital, I'm never gonna get a high volume. I'm gonna give you a piece of advice. Create a trach clinic, see every patient who had a trach, no matter if you did it, didn't do it, people will come to you and that will multiply not only your involvement, but the quality of care you provide to this patient. Most of this stuff I'm showing you regarding decannulation is not stuff that I am continuously following. This is the product of the work of Dr. Miguel Divo, a partner of mine in the LTAC system. And he calls me back and goes, remember this trach you did or someone else did or surgery did, the patient's not passing the captral or not passing the passive mirror. Can you see them? I suspect there's something going on in the upper airway. And I can tell you that his sensitivity for this is over 80%. When he calls, he's usually right. So in COVID, I know nobody wants to hear about COVID, but I think it's important that we understand what we learned from it. And one of the things we learned is that we could minimize the aerosolizing events. And this is what we came up with. And regarding the use of manometry, it's important that you know, once you connect, you cap the trach and you connect it on a sideboard and you should measure the inspiratory and expiratory on quiet breathing. And the numbers that you should keep in mind is zero to minus five. Any numbers that are very negative on either way should warn you that there may be an obstruction that is superior to the tracheostomy site. So what were those outcomes in those patients who had trach and PEG at our institution simultaneously? And one of the authors and people who put the most effort is here in the room, Dr. Panchalai is here. And this graph shows you the time to event curves on our population of patients. The first one is the time from tracheostomy to weaning. And that's about, as you can see, nine days. Nine days after we did the trach, the patient were weaned off ventilation. The second graph is tracheostomy to downsizing. And that's about 17 days. So for eight days, we were trying to progress on this manometry and they didn't progress. And we had to downsize them so we could do phonation. Tracheostomy to decannulation was approximately 25 days. And tracheostomy to discharge was again 25 days or so, 21 to 25. So the survival was 90%. So 10% of the patients who actually underwent trache and PEG died, which is incredible for me because some of the survivors were quadriplegic or had morbid obesity of 49 or they were 89 years old, et cetera. So I have to say the healthcare system stepped up and did an incredible job for these people. These are just a table of the stuff that I mentioned showing you the ranges, but really the outcomes were very good. Now regarding PEG placement, I emphasize the use of PEG, not only because it's a very simple procedure to train you all on and because we can provide value, value in that we can do it at the same time in that we can reduce the hospital stay, the lengths of stay in the ICU and the satisfaction, but also because it's easy to train all of you on it. And this is thoracic endoscopy. This is not something that should be limited to gastroenterology. But because I've given this talk before and I've been asked the same question over and over again, how come are you training this? Well, Dr. Over presented this in ATS a couple of years back and she compared the training that interventional fellows have in PEG placement and it actually significantly more stringent than gastroenterology, general surgery or intervention radiology with better outcomes, I should add. And we've published our outcomes and as self-critical as I am about outcomes of things we do, putting anatomic barriers into our practice is in my mind, short-sighted. Now, not only is in the decannulation process, you're gonna see the manometry and stuff, but you also see cases like this. If you see the date, it's September 15. As I'm preparing my slides for this session, I get called about this patient. You can see her spine is very lordotic. And they call me because when they did a bronchoscopy in the ICU, they think the trach is going into the esophagus. When they get in, they just see soft tissue. So I saw the CAT scan and I was like, I'm not sure there's perforation, but let's take a look. And we did a bronchoscopy and we found that the trach was against the wall. It wasn't perforating. There's no tracheoesophageal fistula, but we just needed a better trach. So in that same paper by Dr. Debo and our group, we make recommendations of what Dr. Murthy mentioned, which is choose the right trach. And if the patient has soft tissue, choose a trach that goes distal to it, whether it's horizontal or vertical. But more important, I frequently find, not this case, but I frequently find that the trach is not conforming to the tracheostomy tube at the time of the procedure. So my partner, Colleen Keats, has figured a method. If the punch dilator, the little first dilator that you use at the time of the procedure, if you have to hob it to get it inside the trachea, she immediately turns around and goes, make sure we get an extended horizontal trach. That's her rule of thumb. So I pass on that to you. Now, a little just on the late stenosis, Dr. Murthy mentioned all of them, but I wanna mention the same thing. They're suprastomal, stomal, and infrastomal, and they should be managed by interventional pulmonologist or pulmonologists who are interested in advanced airway procedures. And regarding, same thing he mentioned, the necrosis and stomal infection, what we have seen is more than it being related to suture or pressure from the plastic, we've seen it overwhelmingly on patients with liver failure. And it's because they have poor vasculature and they have all these collaterals, but it's also seen because they have poor immune response. And in patients with morbid obesity or poor spine, we can contribute, if they are morbidly obese, we sometimes can do this under rigid bronchoscopy guidance. If you put a rigid in a morbidly obese patient and you lift the trachea, it really comes to the surface and helps you. But also, from a relative contraindication, it has become one of the preferred methods for our hospital. They just call us and say, hey, I have this patient with very difficult anatomy, would you do it? Sure, happy to contribute. And the other thing we do is we can make customized tracheostomy tubes. If you reach out to companies and say, hey, do you have a program of customized trachs, because I'm having a problem with this chronic trach, they will customize it for you and you can use. We implemented this CAD system just to give them angles and we have very good results. And we try to add value by doing those things. Finally, these are the residual scars after decannulation and PEG removal in our patients. So in summary, my transition is, if you need to limit a resolidization, use the bottom graph. If you are standard, use the top one. And if you create a longitudinal clinic, you'll have the pleasure that I have of seeing my patients come to decannulation and ask me if they can take a selfie and put it online. So I'm honored to take care of these people and we'll all take your questions now. Thank you for being here.

tracheostomy

ICU

patient selection

timing

percutaneous tracheostomy

surgical tracheostomy

complications

obesity

coagulopathy