it's also hard to find a lot of RCT evidence for trachs decreasing mortality
Trach cancellations?
- Thread starter anbuitachi
- Start date
it's also hard to find a lot of RCT evidence for trachs decreasing mortality
D
deleted171991
It' easy.
Intubation means sedation, which means pressors, which means central/arterial lines. It also means increased IV fluids and fluid overload (long-term), which are definitely associated with increased mortality (zero doubt and tons of evidence about that).
I am aware of the anecdotal reasons for suspicions of an outcome difference. I'm just saying it's not exactly something we have a lot of evidence to support making a big mortality difference. I'm not aware of any study looking at patients with an infectious lung process on a vent at 21 days and being randomized to be trached or not. Anecdotally the difference in mortality I see is the families pushing for trach that want to do everything and letting a patient hang on for months vs the families that are willing to shift to comfort care.
D
deleted171991
You can have all the studies you want, and still they won't apply to many patients. 100% "evidence-based" medicine (especially since most studies are JUNK, including RCTs) is bad medicine. That's why protocols fail.
The correct question to ask is: Will a trach probably change the outcome in THIS particular patient? If the trach is the difference between being awake or not, NPO or not, on pressors or not, then the answer is a clear and resounding YES.
Let me make it clearer: if I ever need to be intubated for Covid, I'd rather be trach'd instead. Intubation beyond a few days can be really bad for people, when in the wrong hands.
Last edited by a moderator:
- Joined
- Sep 17, 2016
- Messages
- 778
- Reaction score
- 1,251
Do you have a trial or meta-analysis that shows trachs improve mortality? In my mind, they definitely help wean sedation (thus fluids and pressors), make pulm hygiene easier and may reduce vent async, help placement to LTAC. Trach does not necessarily reduce time to weaning off vent support or reduce VAP (I feel trials are inconsistent for these outcomes).
Edit: I just now see your discussion with @Mman ; I agree with your point on fluids, pressors, lines
- Joined
- Sep 17, 2016
- Messages
- 778
- Reaction score
- 1,251
I’ve never given paralytics in ICU for agitation. If the pt is that awake/agitated, I would be concerned about awareness (though low risk given ICU pts tend not to remember anything), but also, would be worried pt is contributing a lot to their own TVs and minute ventilation so paralysis may reduce lung compliance. Rock and a hard place...
D
deleted171991
As with anything, individual patients should be trached when it's clearly better than the alternative. Not because of some stupid protocol or "evidence", unless it's beyond doubt. There are a lot of grey areas, as in this epidemic. That's why the opinion of an experienced intensivist (in general, not me) should matter more than what a surgeon or anesthesiologist thinks.
Most "evidence" in medicine is junk. I don't care about meta-analyses and other artificial statistical constructs, created to invent statistical difference and professional careers out of thin air. Medicine is not an exact science, humans are not robots; the more one combines approximative techniques, the more (humongous) error gets introduced. One could be happy if individual RCTs are well-done and keep giving the same result, again and again, as in experimental physics. That's the closest I personally get to evidence.
P.S. I rarely trach people. I also don't intubate them, or do ANY other procedures, unless the alternative would be worse. First do no harm.
Last edited by a moderator:
I am old school and recall sinusitis as a potential issue with longer-term intubation. Is that still an issue - I'm not hearing much although I don't do ICU any more. Better pulmonary hygiene - is that real ? You suction a little deeper than via an ETT perhaps..right ? I would personally not wanna be trached. I know the resistance to spontaneous breathing is lower but like somebody said here it doesn't clearly shorten weaning..
Sent from my SM-F900U1 using Tapatalk
Sent from my SM-F900U1 using Tapatalk
D
deleted171991
Absolutely true, because of the NGTs, and underdiagnosed.
Let me tell you the greatest difference between trach and ETT: sedation (and all the badness that flows from it). That one thing can make a world of difference after a couple of weeks. I hate exposing my patients to procedures (#1 thing patients remember from the ICU is pain), but, in Covid, where people usually stay intubated for weeks, I would trach almost everybody from the beginning if I could.
If I get Covid, I may ask them to trach me and keep me awake, instead of intubating and sedating me. I don't want IV fluids, I want only the IV meds that benefit from being given IV, I don't want gastric tubes, I don't want Foley etc. The care of a trach'd patient is easier, except if it's fresh.
Last edited by a moderator:
- Joined
- May 24, 2006
- Messages
- 6,750
- Reaction score
- 6,259
So what would be the alternative, because those sedation drugs are too much. I rarely paralyzed anyone in fellowship, but in Covid heaven, those patients seem to require a lot of sedation. So we paralyzed. And they weren't exactly overtly agitated, they were many who were more or so dyssynchronous with the vent with high peak pressures and since their V/Q mismatch was so severe. We had to do it in order to properly enhance O2/CO2 exchange and flip them. CO2s in the 90's -100's was common in these patients. I saw much more ventilation than severe oxygenation problems. The vents were also old school and we were figuring out as we went. Looked like giant 02 pulse oximeters.
We certainly did not see VS that showed that they were aware and were using propofol and Fentanyl plus roc or cis depending on renal failure, or interaction with doxycycline. Certainly not versed and not at that high rate.
It certainly was a different world. Not the norm for sure.
D
deleted171991
A trach is typically easier to tolerate (and maintain) than an ETT, especially after it's not fresh anymore (after about a week).
Advantages and disadvantages of tracheostomy
In short, the advantages of tracheostomy can be summarised by saying that it helps you wean the patient from the ventilator, largely by being more comfortable and therefore better tolerated. Disadvantages are largely related to the risk of the procedure, which are topics for another chapter.
derangedphysiology.com
Last edited by a moderator:
D
deleted171991
Same for parachutes.
Sometimes, a trach is the obvious right thing to do, for everybody. Like a parachute. No debates. Other times, it's clearly just some protocolized knee-jerk thing ("all patients need a trach after X days").
Many other times, it's just an expert opinion, like everything else in critical care, possibly based on some weak study. That's when the intensivist's opinion should matter a lot. In the end, he's the one asking for a better tool to fix the patient, and he's not supposed to take that decision (or any other procedure) lightly.
Last edited by a moderator:
- Joined
- Aug 12, 2004
- Messages
- 3,049
- Reaction score
- 6,409
do you really think you'll ever see a study where a patient is randomized to trach or not after 21 days riding a vent? I dunno, maybe we will. I guess it's not such a massive stretch. I don't think one needs to take that many patients to the ICU to understand that it's not just a disease process requiring prolonged intubation that is harmful to patients, but also simply the presence of the ETT and everything that tends to come along with it (sedation, pressors, lines, fluids).
- Joined
- Sep 17, 2016
- Messages
- 778
- Reaction score
- 1,251
PSV mode sometimes help with asynchronous vents, or going up on flow or TVs. That has worked for me in the past. But I see what you‘re saying. Maybe a barbituate?
Also, when I see max dose dexmedetomidin, I just stop it. 99% of the time, it is not doing ANYTHING, hence why the nurse maxed it out. You get all of the side effect with no sedation.
D
deleted171991
Or early APRV?
- Joined
- May 24, 2006
- Messages
- 6,750
- Reaction score
- 6,259
Did that too. On the ones who weren’t too sick. Kept them on PSV to prep for extubation.
But the ones who aren’t ventilating with pHs in the 6s aren’t gonna survive on PSV.
We get a N-95 as we walk in the hospital and so I just leave it on. Like it was said here, I don't walk around in a PAPR u put it on and then take it off at some point so where would u be keeping your own N-95 - so that's why.
Sent from my SM-F900U1 using Tapatalk
Sent from my SM-F900U1 using Tapatalk
If you look at all the Chinese C19 intubation pics they always wear a complete hood. The fact we don't have those is a supply problem that I don't want my survival to depend on. Recall with the PAPRs most of us in the US have there is an incomplete neck cover. Splashes but mostly your own touches cause contact contamination. It makes no sense to have your entire body covered but your neck uncovered. As per Tran's SARS review paper- which as mentioned here may still all b junk but it's what everyone is going by, we have nothing much else - intubation carries the highest risk of contracting C-19.
A. splashes, B. aerosol, C. airborne particles.
1. N-95 just sits there from the moment u enter the hospital and u take it off in the car when going home. If u trust the PAPR 100% u can keep it in your pocket if it bothers u. It's not 100% anyway.
2. PAPR - its air motor has a filter for the virus.
3. Stryker ortho hoodie protects your neck from splashes/touches, not restrictive/bothersome. If not soiled u can let it sit and reuse like the N-95.
You can tape a towel around your neck but that's makeshift that's gona become undone when u need it the least, make u feel hot and it won't be clear which is the contaminated surface and which is not. A splash can get in between the layers of your towel.
If you use the Stryker hoodie without a PAPR u must wear a N-95 as the Stryker doesn't filter the virus at all.
Sent from my SM-F900U1 using Tapatalk
A. splashes, B. aerosol, C. airborne particles.
1. N-95 just sits there from the moment u enter the hospital and u take it off in the car when going home. If u trust the PAPR 100% u can keep it in your pocket if it bothers u. It's not 100% anyway.
2. PAPR - its air motor has a filter for the virus.
3. Stryker ortho hoodie protects your neck from splashes/touches, not restrictive/bothersome. If not soiled u can let it sit and reuse like the N-95.
You can tape a towel around your neck but that's makeshift that's gona become undone when u need it the least, make u feel hot and it won't be clear which is the contaminated surface and which is not. A splash can get in between the layers of your towel.
If you use the Stryker hoodie without a PAPR u must wear a N-95 as the Stryker doesn't filter the virus at all.
Sent from my SM-F900U1 using Tapatalk
- Joined
- Dec 31, 2018
- Messages
- 241
- Reaction score
- 399
Our group met with the surgeons and this is what we agreed on:
GUIDELINES FOR TRACHEOTOMY
IN THE COVID PATIENT
PREOPERATIVE PHASE
Determine Candidacy for Tracheotomy:
Tracheotomy may be considered in patients intubated more than 21 days who are without significant comorbidities and have a good prognosis.
A multidisciplinary discussion should be held between the primary team, procedure team, palliative care team, and family to establish the goals of care, overall prognosis, and expected benefits of tracheotomy. DNR status should be determined. The Ethics Committee can be consulted as needed.
Tracheotomy in the COVID patient is high risk for aerosolization. It requires numerous providers to work in close proximity to one another and the patient.
We must balance the competing interests of providing high-quality patient care while simultaneously protecting personnel. It is reasonable to consider patient benefit against the risk to the surgical team.
The decision to proceed is customized for the individual patient on a case by case basis. Prohibiting factors may include:
Hemodyamic status +/- pressors/inotropes
Coagulation status
Risk of instability during transport or surgery
Tracheotomy before 21 days should not be routinely performed but may be considered in patients with increased requirement for pulmonary toilet, high levels of sedation or known difficult airway.
Summary: Tracheotomy is indicated if it is necessary for continued care, typically when an ETT and weaning difficulty are the rate limiting step to improvement. Tracheotomy is not indicated in patients who require a high level of hemodynamic support.
Preoperative Testing:
A sputum sample, obtained by closed endotracheal suctioning, is sent on Ventilator Day 14 to ensure the result is available by Ventilator Day 21. The result reflects patient clearance of the virus and guides use of resources. A positive result does not mandate case cancellation.
Coagulation Status:
This should be carefully assessed, well in advance, to facilitate hemostasis and minimize electrosurgery. Anticoagulants may be held, dose and timing adjusted, or transitioned between drug class. Testing may help with decision making.
OR Team Members Meet:
As soon as practical, members of the surgical, anesthesia and nursing teams should meet to discuss the case with an emphasis on personal protection and fire prevention.
The anesthesia team should be prepared to reintubate from above.
Replacement endotracheal and tracheotomy tubes should be available. Provide size options for the same.
During any part of the operation there must be a plan to manage:
Cuff rupture
Desaturation
Cardiac arrest
Fire
INTRAOPERATIVE PHASE
High Risk For Fire:
All tracheotomies are high risk for fire. Abide by all fire prevention and management strategies.
Open Tracheotomy is Indicated:
The open approach, compared to percutaneous, will decrease aerosol generation and is preferred.
Location: The procedure should be performed in an operating room, not bedside. Negative pressure is preferred. Neutral pressure is the next best choice.
PPE:
Tracheotomy has been shown to be an aerosol generating procedure. Proper use, donning and doffing of PPE for each person in the room is essential. Minimize aerosolization during the procedure.
The surgeon and first assistant are closest to the smoke plume and open trachea. Their PPE will include one of the following:
PAPR Hood, Blower and Filter
Orthopedic Hood with N95 mask, without blower
Note: The risk of PAPR exhaust contaminating a surgical field, that is presumed already to be contaminated, does not outweigh the benefit of protecting the surgeon and first assistant from aerosolization.
Verbal Communication is Critical:
Personnel will be wearing extra layers of PPE.
Eliminate music and unnecessary conversation. Minimize ambient noise.
Speak clearly and with sufficient volume. Acknowledge when you are spoken to. Use concise phrasing.
The surgeon and anesthesiologist must maintain instantaneous verbal communication after skin incision. The interaction is carefully choreographed.
The surgeon can direct that ventilation be held or resumed. If held, the anesthesiologist will not deliver any form of positive pressure to the breathing circuit.
The surgeon directs when the
ETT is advanced or withdrawn, and the distance
ETT cuff deflated or inflated
Procedure:
The patient should be fully paralyzed at all times, guarantee zero patient movement.
Minimize use of electrosurgery.
FI02 should be at the lowest level to maintain adequate oxygenation.
A non-fenestrated cuffed tracheotomy tube with a disposable inner cannula should be used.
The ETT cuff should be advanced distal to the tracheotomy site to the level of the carina.
Cuffs, when inflated, should be snug, but not overdistended.
Holding ventilation means that the ETT remains attached to the anesthesia breathing circuit, ventilator is set to manual, adjustable pressure limiting valve is wide open and PEEP is allowed to dissipate.
Ventilation is held if the ETT cuff is deflated or ruptured.
When the tube position is adjusted, ventilation should be held before the cuff is deflated until it is fully reinflated.
Ventilation should be held prior to incision of the trachea.
If ventilation needs to be resumed via the ETT after the trachea is incised, the cuff should be inflated.
Ventilation is held as the ETT is withdrawn in preparation for tracheotomy tube insertion.
If cuff position could not be previously confirmed via palpation, ventilation should be held and the cuff fully deflated while the trachea is incised. The cuff position can then be adjusted through the tracheal opening before reinflation.
Traction sutures into the trachea are recommended.
Insertion of the tracheotomy tube should be accurate and quick to minimize open airway time. The cuff should be immediately inflated and tracheotomy tube connected to a closed circuit, after which ventilation may resume.
Tube placement should be confirmed with end tidal CO2 and appropriately secured.
POSTOPERATIVE PHASE
INFECTION RISK CONTINUES:
Remember, the tracheostomy is a higher risk for aerosolization than an ETT.
PPE should be worn.
A viral filter should be used in the ventilator circuit.
Closed in-line suctions should be used
Disposable inner cannulas should be disposed of and replaced per the manufacturer’s guidelines. They should not be cleaned and replaced.
Avoid trach collars, unnecessary suctioning and pulmonary lavage.
If the tracheostomy tube is dislodged, call surgery, call anesthesia for reintubation, call for help. Ensure adequate PPE before room entry.
Changing the inner cannula or tracheostomy tube is a high risk procedure. This should be deferred until the patient is no longer infectious. Guidance may be obtained from the Infectious Disease Team.
References:
Chao, TN, Braslow, BM, Martin, ND, et al. Tracheotomy in ventilated patients with COVID 19. ANNALS OF SURGERY. 2020.
Tay, JK, Li-Chung Khoo, M, Woei,SL. Surgical Considerations for Tracheostomy During the COVID 19 Pandemic. JAMA Otolaryngology. 2020.
GUIDELINES FOR TRACHEOTOMY
IN THE COVID PATIENT
PREOPERATIVE PHASE
Determine Candidacy for Tracheotomy:
Tracheotomy may be considered in patients intubated more than 21 days who are without significant comorbidities and have a good prognosis.
A multidisciplinary discussion should be held between the primary team, procedure team, palliative care team, and family to establish the goals of care, overall prognosis, and expected benefits of tracheotomy. DNR status should be determined. The Ethics Committee can be consulted as needed.
Tracheotomy in the COVID patient is high risk for aerosolization. It requires numerous providers to work in close proximity to one another and the patient.
We must balance the competing interests of providing high-quality patient care while simultaneously protecting personnel. It is reasonable to consider patient benefit against the risk to the surgical team.
The decision to proceed is customized for the individual patient on a case by case basis. Prohibiting factors may include:
Hemodyamic status +/- pressors/inotropes
Coagulation status
Risk of instability during transport or surgery
Tracheotomy before 21 days should not be routinely performed but may be considered in patients with increased requirement for pulmonary toilet, high levels of sedation or known difficult airway.
Summary: Tracheotomy is indicated if it is necessary for continued care, typically when an ETT and weaning difficulty are the rate limiting step to improvement. Tracheotomy is not indicated in patients who require a high level of hemodynamic support.
Preoperative Testing:
A sputum sample, obtained by closed endotracheal suctioning, is sent on Ventilator Day 14 to ensure the result is available by Ventilator Day 21. The result reflects patient clearance of the virus and guides use of resources. A positive result does not mandate case cancellation.
Coagulation Status:
This should be carefully assessed, well in advance, to facilitate hemostasis and minimize electrosurgery. Anticoagulants may be held, dose and timing adjusted, or transitioned between drug class. Testing may help with decision making.
OR Team Members Meet:
As soon as practical, members of the surgical, anesthesia and nursing teams should meet to discuss the case with an emphasis on personal protection and fire prevention.
The anesthesia team should be prepared to reintubate from above.
Replacement endotracheal and tracheotomy tubes should be available. Provide size options for the same.
During any part of the operation there must be a plan to manage:
Cuff rupture
Desaturation
Cardiac arrest
Fire
INTRAOPERATIVE PHASE
High Risk For Fire:
All tracheotomies are high risk for fire. Abide by all fire prevention and management strategies.
Open Tracheotomy is Indicated:
The open approach, compared to percutaneous, will decrease aerosol generation and is preferred.
Location: The procedure should be performed in an operating room, not bedside. Negative pressure is preferred. Neutral pressure is the next best choice.
PPE:
Tracheotomy has been shown to be an aerosol generating procedure. Proper use, donning and doffing of PPE for each person in the room is essential. Minimize aerosolization during the procedure.
The surgeon and first assistant are closest to the smoke plume and open trachea. Their PPE will include one of the following:
PAPR Hood, Blower and Filter
Orthopedic Hood with N95 mask, without blower
Note: The risk of PAPR exhaust contaminating a surgical field, that is presumed already to be contaminated, does not outweigh the benefit of protecting the surgeon and first assistant from aerosolization.
Verbal Communication is Critical:
Personnel will be wearing extra layers of PPE.
Eliminate music and unnecessary conversation. Minimize ambient noise.
Speak clearly and with sufficient volume. Acknowledge when you are spoken to. Use concise phrasing.
The surgeon and anesthesiologist must maintain instantaneous verbal communication after skin incision. The interaction is carefully choreographed.
The surgeon can direct that ventilation be held or resumed. If held, the anesthesiologist will not deliver any form of positive pressure to the breathing circuit.
The surgeon directs when the
ETT is advanced or withdrawn, and the distance
ETT cuff deflated or inflated
Procedure:
The patient should be fully paralyzed at all times, guarantee zero patient movement.
Minimize use of electrosurgery.
FI02 should be at the lowest level to maintain adequate oxygenation.
A non-fenestrated cuffed tracheotomy tube with a disposable inner cannula should be used.
The ETT cuff should be advanced distal to the tracheotomy site to the level of the carina.
Cuffs, when inflated, should be snug, but not overdistended.
Holding ventilation means that the ETT remains attached to the anesthesia breathing circuit, ventilator is set to manual, adjustable pressure limiting valve is wide open and PEEP is allowed to dissipate.
Ventilation is held if the ETT cuff is deflated or ruptured.
When the tube position is adjusted, ventilation should be held before the cuff is deflated until it is fully reinflated.
Ventilation should be held prior to incision of the trachea.
If ventilation needs to be resumed via the ETT after the trachea is incised, the cuff should be inflated.
Ventilation is held as the ETT is withdrawn in preparation for tracheotomy tube insertion.
If cuff position could not be previously confirmed via palpation, ventilation should be held and the cuff fully deflated while the trachea is incised. The cuff position can then be adjusted through the tracheal opening before reinflation.
Traction sutures into the trachea are recommended.
Insertion of the tracheotomy tube should be accurate and quick to minimize open airway time. The cuff should be immediately inflated and tracheotomy tube connected to a closed circuit, after which ventilation may resume.
Tube placement should be confirmed with end tidal CO2 and appropriately secured.
POSTOPERATIVE PHASE
INFECTION RISK CONTINUES:
Remember, the tracheostomy is a higher risk for aerosolization than an ETT.
PPE should be worn.
A viral filter should be used in the ventilator circuit.
Closed in-line suctions should be used
Disposable inner cannulas should be disposed of and replaced per the manufacturer’s guidelines. They should not be cleaned and replaced.
Avoid trach collars, unnecessary suctioning and pulmonary lavage.
If the tracheostomy tube is dislodged, call surgery, call anesthesia for reintubation, call for help. Ensure adequate PPE before room entry.
Changing the inner cannula or tracheostomy tube is a high risk procedure. This should be deferred until the patient is no longer infectious. Guidance may be obtained from the Infectious Disease Team.
References:
Chao, TN, Braslow, BM, Martin, ND, et al. Tracheotomy in ventilated patients with COVID 19. ANNALS OF SURGERY. 2020.
Tay, JK, Li-Chung Khoo, M, Woei,SL. Surgical Considerations for Tracheostomy During the COVID 19 Pandemic. JAMA Otolaryngology. 2020.
D
deleted875186
Without any significant comirbidities?! Just do the trach. I agree we need palliative care involved on all these cases, but who are you to refuse a trach. Many of these people can recover. Probably not the 90 yo with multiple medical problems, but a lot of the younger folks.
the younger healthier folks generally extubate without needing a trach
- Joined
- Feb 28, 2009
- Messages
- 205
- Reaction score
- 206
agree 100%. Perc trach seems to be the better/less COVID spewing option.
With regard to why trach, have seen a number of the patients who end up requiring prolonged intubation also have physical traits (obesity involving neck and face, OSA, etc) that lend themselves to failed extubation, especially in a weakened state. I would bet we'd have a much faster/easier/safer wean if the trach rate went up.
As an aside, trach (often) isn't forever. Dead is forever. Every intubated/immobile day is probably an independent risk factor for not surviving this. (especially with the hypercoagulable state these patients are finding themselves in).
D
deleted875186
One of my pet peeves. Anesthesia providers don’t suction the oropharynx before these cases. and they wonder why there are so many secretions when the person gets back from their trach.
- Joined
- Oct 26, 2008
- Messages
- 7,466
- Reaction score
- 4,146
"The ETT cuff should be advanced distal to the tracheotomy site to the level of the carina."
How do we know if its at the level of the carina when we advance..?
How do we know if its at the level of the carina when we advance..?
D
deleted875186
Look at the X Ray from the ICU, note the distance to the carina, once the surgeon is down to trachea and ready to enter the airway, advance the tube that many centimeters. Keep ventilating, after the surgeon has entered the airway if the patient desats you can retract the tube under direct visualization until the cuff is right below where the trach site will be.
