Tracheotomy is widely used in intensive care units with great disparities between medical teams in terms of frequency and modality. Indications and techniques.Group of experts from the French Intensive Care Society and the French Society of Anesthesia and Intensive Care Medicine with the participation of the French Emergency Medicine Association and the French Society of Otorhinolaryngology have released Latest Guidelines about Tracheotomy in the intensive care unit.The aim of these guidelines is to define the indications, contraindications, modalities, and monitoring of tracheotomy in light of the current literature data.
Topics of the guidelines: summary of the results
The experts have addressed tracheotomy only in the setting of planned tracheotomy in adults in intensive care.Five topics were defined:
- Indications and contraindications for tracheotomy in intensive care,
- Tracheotomy techniques in intensive care
- Modalities of tracheotomy in intensive care
- Management of patients undergoing tracheotomy in intensive care
- Decannulation in intensive care.
The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols.
Key Recommendations :
a)Indications and contraindications for tracheotomy in intensive care
- The experts suggest that tracheotomy be proposed in cases of prolonged weaning from mechanical ventilation and of acquired and potentially reversible neuromuscular disorder.
- The experts suggest that the indication for tracheotomy in patients with chronic respiratory failure should be the subject of multidisciplinary discussion.
- Tracheotomy in intensive care should not be performed before the fourth day of mechanical ventilation.(GRADE 1+/STRONG agreement)
- The experts suggest that tracheotomy (percutaneous or surgical) should not be performed in intensive care in situations at high risk of complications.
b) Tracheotomy techniques in intensive care
- Percutaneous tracheotomy is the standard method in intensive care patients.
- The experts suggest that medical and surgical teams should discuss and decide upon the tracheotomy technique to be used when there is a risk of complications.
- Percutaneous dilatational tracheotomy should probably be preferred as the standard method in intensive care patients.
c) Conditions necessary for tracheotomy in intensive care
- Fiberoptic bronchoscopy should probably be performed before and during percutaneous tracheotomy.
- A laryngeal mask airway should probably not be used during percutaneous tracheotomy in intensive care.
- Cervical ultrasound should probably be performed with percutaneous tracheotomy in intensive care.
- The experts suggest that antibiotic prophylaxis should not be prescribed for tracheotomy.
- The experts suggest that a standardized procedure be implemented in intensive care units that perform the percutaneous tracheotomy.
Proposal for a protocol associated with guideline 3.5 (Expert opinion)
d) Tracheotomy monitoring and maintenance in intensive care
- The experts suggest that intensive care units should have a tracheotomy management protocol.
Proposed care protocol associated with guideline
2.The experts recommend airway humidification in patients with a tracheotomy in intensive care.
3.The experts suggest that tracheotomy tubes should not be routinely changed in intensive care.
e) Tracheotomy decannulation
- The experts suggest that a multidisciplinary decannulation protocol should be available in intensive care units.
- The tracheotomy tube cuff should probably be deflated when the patient is breathing spontaneously.
Proposed endoscopic protocol associated with guideline (according to Warnecke et al. Crit Care Med 2013 (106))
3.A pharyngolaryngeal examination should probably be performed at or following decannulation.
For more details click on the link: Annals of Intensive Care20188:37 https://doi.org/10.1186/s13613-018-0381-y
This article is being published jointly in Anaesthesia Critical Care & Pain Medicine and Annals of Intensive Care. The manuscript validated by the board of the SRLF (12/13/2016) and the SFAR (12/15/2016).
Dr. Kamal Kant Kohli
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