Mount Sinai Expert Guides. Группа авторов

       The bedside percutaneous dilational tracheostomy (PDT) with a minimal tracheostomy incision utilizes the Seldinger technique and gradual dilation to insert the tracheostomy.

       PDT is a safe procedure in the critical care setting and should be first choice when available. Its use is more cost‐effective and trends towards fewer complications compared with open surgical tracheostomy.

       Proper selection of the bedside candidate requires a hemodynamically stable patient with no bleeding diatheses and normal neck anatomy.

       PDT is associated with less bleeding than open tracheostomy. Patients on anticoagulation or with severe derangements of INR or platelet count may either be supplemented with the appropriate blood products or deferred until stable for the procedure.

       Bronchoscopic guidance is often used during bedside tracheostomy procedures, but is not routinely required since it has not demonstrated better outcomes. Those not routinely using a bronchoscope may reserve its use for difficult cases.

       Surgical tracheostomy has been performed since 1909.

       Percutaneous tracheostomy using the Seldinger technique allows tracheostomy placement at the bedside in the ICU.

       Tracheostomy is considered for the patient who is expected to require a prolonged course of mechanical ventilation or requires an artificial airway for obstruction or secretion clearance.

       For patients requiring mechanical ventilation for more than 2 weeks, it is believed that tracheostomy may be beneficial in avoiding continued injury to the vocal cords.

       Tracheostomy may be better tolerated and allow a reduction of sedation. As a consequence it facilitates physical therapy, nursing care, and transfer of the ventilated patient out from the ICU setting.

       Weaning from mechanical ventilation is also expedited due to the decreased work of breathing from a reduction of airway resistance and dead space.

       Other benefits include patient comfort such as the initiation of oral intake, communication, and mobility, and possibly fewer respiratory infections.

       Early tracheostomy is variably defined, and generally performed within 4 days of intubation.

       Earlier tracheostomy is considered if the likelihood of intubation is recognized to be prolonged beyond 2 weeks.

       Patient discomfort secondary to translaryngeal intubation and multiple failed extubation attempts may also support earlier tracheostomy.

       The benefits for earlier intervention are not clear. In some studies, such as in patients with traumatic brain injury or subarachnoid hemorrhage, reductions in length of stay (LOS) and pulmonary infections have been seen. However, in these neurosurgical populations, patients are often considered for earlier tracheostomy due to mental status issues and fear of weaning. A review and meta‐analysis also indicated early tracheostomy placement reduced the duration of mechanical ventilation and hospital stay.

       There is no definitive mortality benefit for early tracheostomy.

       In general, the decision for tracheostomy should begin with an evaluation of the patient within a week of intubation as to the likelihood of extubation in the upcoming week. The first week’s course is often predictive of ventilator dependency.

       Bedside approaches are performed either as open, cut‐down procedures or via PDT using the Seldinger method. The Seldinger method is essentially a blind procedure done at the bedside.

       The primary advantages to the bedside approach are the more efficient use of OR time and the consequent cost savings, which include those of patient transportation and general anesthesia.

       Further advantages of PDT include smaller incisions, decreasing the likelihood for poor wound healing, scarring, and peristomal bleeding, and reduced local site infections. The procedure can also be more timely.

       LOS in the ICU as well as time to placement of the tracheostomy is significantly shortened with PDT, suggesting further cost savings when using bedside procedures.

       Most importantly, major complications and mortality are similar between PDT and open surgical tracheostomy. This is regardless of whether the bedside procedure is PDT or open.

       Consent for procedure includes the risks of: pneumothorax (PTX), tracheo‐innominate artery fistula, airway damage and stenosis, bleeding, infection, and death.

       Mortality of this procedure is less than 1%, while major morbidity is 5–10%.

       Bleeding with