Tracheostomy in the ICU: Wound Care & Percutaneous Tracheostomy

1. Overview and Indications

2. Timing of Tracheostomy

• Early tracheostomy (within 4-7 days): associated with shorter ICU stay and fewer ventilator days, but no consistent mortality benefit
• The largest RCT (>900 patients across 72 UK ICUs) found no mortality difference between early (<4 days) and late (>10 days) tracheostomy at 30-day to 2-year follow-up
• Notably, over 50% of patients randomized to late tracheostomy were eventually liberated from ventilation without needing the procedure
• In COVID-19, retrospective data and meta-analysis suggest tracheostomy after 10-14 days of mechanical ventilation is associated with lower MV duration and ICU stay without increased mortality

3. Tracheostomy Tube Components

1. Outer cannula - the permanent portion; should not be removed routinely. Has flanges with eyelets for securing the tube to the neck
2. Obturator - rounded insert used only during tube insertion to guide placement; removed immediately once tube is seated
3. Inner cannula - removable lining that can be cleaned or replaced; has the 15-mm adapter for Ambu bag or ventilator connection. The inner cannula MUST be in place to ventilate the patient

• Cuffed tubes: used for mechanical ventilation and aspiration risk; high-volume, low-pressure cuffs reduce mucosal injury
• Uncuffed / metal tubes: for patients with adequate ventilatory effort who are alert and low aspiration risk; can speak if air bypasses the tube

4. Tracheostomy Wound Care in the ICU

4.1 Stoma Site Care

• Change contaminated tube ties regularly; soiled ties harbor bacteria and promote skin maceration
• Clean tube flanges regularly with saline or chlorhexidine-soaked gauze
• Use pre-cut tracheostomy gauze dressings under the flanges - do NOT use hand-cut gauze, as loose fibers cause inflammatory reactions at the stomal site
• Clean the peri-stomal skin gently; watch for skin breakdown, granulation tissue, and early infection signs (erythema, purulent discharge, odor)

4.2 Inner Cannula Care

• The inner cannula should remain in place at all times and removed only for daily cleaning
• A clogged inner cannula is the most common cause of respiratory distress in tracheostomy patients
• Cleaning technique:
  • Soak in half-strength hydrogen peroxide solution for 10-15 minutes
  • Remove encrustations with a soft-bristle tracheostomy brush
  • Rinse all equipment with sterile saline before reinsertion to prevent tracheal mucosal damage
• In mechanically ventilated patients, use a disposable single-use inner cannula system if available to reduce infection risk

4.3 Cuff Pressure Management

• Cuff pressure should ideally be maintained below 25 mmHg (some sources cite 20-25 cmH2O)
• Overinflation is common and dangerous - can cause:
  • Tracheomalacia
  • Tracheal stenosis
  • Tracheoesophageal fistula
  • Tracheo-innominate artery fistula (if very high pressure over innominate artery)
• Use a handheld pressure manometer to regularly check and document cuff pressure
• If an air leak persists at or above maximum recommended cuff pressure, suspect tube dislodgement and evaluate urgently

4.4 Humidification

• Adequate humidification is essential - inadequate humidification causes:
  • Tube obstruction from thick secretions
  • Sputum retention
  • Keratinization or ulceration of tracheal mucosa
  • Lung atelectasis
• Ambulatory/low-flow O2 patients: use a heat-moisture exchanger (HME) on the tracheostomy opening
• Long-term ventilated or high-flow O2 patients: require regular saline nebulizer treatments via in-line humidification system

4.5 Tracheal Suctioning

• Preoxygenate with 100% FiO2 for 30-60 seconds before suctioning
• Suction catheter size (French) = 2 × (tracheostomy tube size - 2)
• Catheter diameter must be no larger than half the inner diameter of the tracheostomy tube
• Insert catheter 10-15 cm only (shallow to premeasured technique preferred)
• Apply suction while withdrawing the catheter; rotate gently
• Suction duration should not exceed 10-15 seconds per pass
• Vacuum pressure: max 150 mmHg in adults (80 mmHg in infants)
• Routine saline instillation is NOT recommended
• Use aseptic technique throughout

• Hypoxemia
• Dysrhythmias (vagal/sympathetic stimulation)
• Atelectasis
• Mucosal injury and tracheitis
• Raised ICP (especially in TBI patients)

5. Tube Exchange

• Have the current size and 1-2 smaller sizes ready (in case of difficult re-insertion)
• Patient in semi-recumbent position with neck slightly extended - do NOT flex the neck
• Check cuff integrity before insertion
• Apply water-based lubricant to the replacement tube
• Continuous pulse oximetry and cardiac monitoring throughout
• First tube change after surgical tracheostomy: wait 4-5 days for tract maturity; PDT tracts may take slightly longer (7+ days)

6. Percutaneous Dilatational Tracheostomy (PDT)

6.1 Background and Adoption

• PDT was first described by Ciaglia et al. in 1985 and has since become the standard bedside technique in many ICUs
• It is widely used for elective tracheostomy in critically ill adults
• Can be safely performed in patients of higher obesity classes
• Periprocedural mortality in randomized studies: <0.2%; major complication rate in large series: 0.15%

6.2 Pre-procedure Evaluation

• Review history, respiratory status, neck anatomy
• Palpate thyroid cartilage, cricoid cartilage, and 1st-3rd tracheal rings
• Ultrasound assessment of the neck - strongly recommended to:
  • Identify vessels in the cannulation pathway
  • Detect enlarged thyroid lobes
  • Reduce the number of needle passes (especially in obese patients)
• Review existing CT imaging for vascular anatomy (high-riding innominate artery, aberrant vessels)
• Lab work: platelet count, PT, PTT, BUN
  • Ideal: PT/PTT <1.5 times control, platelets >50,000/mm³
  • Uremic patients: pre-treat with DDAVP

6.3 Staffing Requirements

• Anesthesiologist or airway-trained physician at the head of the bed: manages ETT, performs bronchoscopy, administers anesthesia
• Sedation + analgesia + short-acting paralysis preferred to minimize coughing and optimize first-attempt success
• Nurse familiar with the procedure for monitoring and supply management

6.4 Step-by-Step Technique (Ciaglia Single-Dilator Method)

1. Positioning: shoulder roll placed, neck slightly extended
2. Prep: sterile field, FiO2 increased to 100%
3. Landmarks: identify entry point between 1st/2nd or 2nd/3rd tracheal rings (cricothyroid membrane involvement risks tracheal stenosis; too inferior risks tracheo-innominate fistula)
4. Infiltrate: up to 10 cc of 1.5% lidocaine with epinephrine (primarily for vasoconstrictive effect)
5. Incision: 1-1.5 cm horizontal or vertical skin incision through skin and subcutaneous fascia; bluntly dissect to palpate tracheal rings
6. Bronchoscope positioning: scope advanced to distal ETT end to transilluminate through anterior neck; ETT cuff deflated and withdrawn under bronchoscopic vision
7. Needle insertion: 14-gauge needle inserted under direct bronchoscopic visualization in the midline, avoiding posterior tracheal membrane; air aspiration confirms tracheal lumen entry
8. Guidewire: J-tipped guidewire advanced toward carina using Seldinger technique
9. Dilation: short 14-French dilating catheter first, then single tapered dilator over the wire
10. Tube insertion: tracheostomy tube loaded over obturator, passed over wire into trachea; cuff inflated once confirmed in lumen
11. Confirmation: bronchoscopy through ETT to confirm position; ETT removed once tracheostomy tube confirmed

6.5 PDT vs. Surgical Tracheostomy - Comparison

• A meta-analysis of 17 RCTs (1,212 patients) showed PDT was associated with fewer infections and less bleeding vs. surgical tracheostomy
• An earlier meta-analysis of 65 trials showed posterior tracheal wall injury was slightly more common with PDT (50 vs. 6 per 10,000), but the absolute rates are very small
• Evidence-based guidelines do not recommend one technique over the other for reducing mortality or overall complications

6.6 Role of Bronchoscopic and Ultrasound Guidance

• Bronchoscopic guidance: ensures midline needle entry, prevents posterior membrane injury, reduces accidental paratracheal placement
• Ultrasound guidance: increasingly preferred for preprocedural anatomy mapping; 2025 meta-analysis (PMID 40281422) and 2026 systematic review (PMID 41987801) confirm US-guided PDT reduces complications vs. landmark-only techniques, particularly vascular injury

6.7 Special Populations

• Obesity: PDT can be performed safely; ultrasound pre-assessment is especially helpful; dedicated bedside series of >3,000 cases confirmed safety across higher BMI classes
• ECMO patients: tracheostomy can be safely performed at bedside with meticulous hemostatic technique; overall complication rates are higher (mainly bleeding), but PDT and open techniques have similar complication rates in this group
• COVID-19: aerosol-generating procedure requiring full airborne + droplet PPE; timing after 10-14 days recommended

7. Complications of Tracheostomy

Early (<7 days)

• Hemorrhage (anterior jugular veins, thyroid isthmus)
• False passage / paratracheal placement
• Subcutaneous emphysema
• Pneumothorax / pneumomediastinum
• Accidental decannulation
• Tube obstruction
• Hypoxia during procedure

Late (weeks to months)

• Tracheal stenosis: most important long-term complication; symptomatic stenosis in ~6% of PDT patients; subclinical stenosis in up to 40% - usually subglottic
• Tracheo-innominate artery fistula: life-threatening; caused by tube placed too inferiorly or high-riding innominate artery
• Tracheoesophageal fistula: from cuff overinflation or posterior wall erosion
• Tracheomalacia
• Stomal infection
• Granulation tissue formation
• Difficult decannulation

Summary

• Sabiston Textbook of Surgery, pp. 960-961
• Roberts and Hedges' Clinical Procedures in Emergency Medicine, pp. 203-207
• Current Surgical Therapy 14e, pp. 1594-1596
• Wen D et al. (2025). Ultrasound vs. landmark-guided PDT meta-analysis - BMC Anesthesiol (PMID 40281422)
• Ren B et al. (2026). US-guided vs. bronchoscopy-guided PDT RCT meta-analysis - Front Med (PMID 41987801)

Bronchopulmonary Segments: Anatomy, Anaesthetic & Surgical Importance

1. Definition (Gray's Anatomy for Students)

"A bronchopulmonary segment is the area of lung supplied by a segmental bronchus and its accompanying pulmonary artery branch."

"A bronchopulmonary segment is the smallest functionally independent region of a lung and the smallest area of lung that can be isolated and removed without affecting adjacent regions."

• Segmental bronchus + pulmonary artery branch = intrasegmental (run together in the centre of the segment)
• Pulmonary vein tributaries = intersegmental (run in the connective tissue planes between segments and demarcate segment boundaries)

2. The Bronchial Tree - Overview

• Right main bronchus: wider, shorter, and more vertical (~25° from midline) - hence more direct continuation of the trachea
• Left main bronchus: narrower, longer (~5 cm before division), and more horizontal (~45° from midline)
• Lobar bronchi divide into segmental (third-order) bronchi - one per bronchopulmonary segment

3. Number of Bronchopulmonary Segments

4. Complete Segment Listing

RIGHT LUNG (10 segments)

LEFT LUNG (8 segments, American; 10 British)

5. Diagrams

6. Segmental Bronchoscopic Landmarks (Clock-face positions)

• Upper lobe: Apical (B1) at 4 o'clock | Anterior (B2) at 12 o'clock | Posterior (B3) at 8 o'clock
• Middle lobe: Lateral (B4) at 3-6 o'clock | Medial (B5) at 9-12 o'clock
• Lower lobe: Superior (B6) at 5 o'clock (just past middle lobe orifice) | Medial basal (B7) at 9 o'clock | Anterior basal (B8) at 1 o'clock | Lateral basal (B9) at 3 o'clock | Posterior basal (B10) at 6 o'clock

• Upper division orifice at 8 o'clock → apicoposterior (B1+3) and anterior (B2)
• Lingular orifice at 2 o'clock → superior lingular (B4) at 10 o'clock | inferior lingular (B5) at 2 o'clock
• Lower lobe: Superior (B6) at 6 o'clock | Anteromedial basal (B8+7) at 12 o'clock | Lateral basal (B9) at 9 o'clock | Posterior basal (B10) at 5 o'clock

7. Anaesthetic Importance

7.1 Right vs. Left Main Bronchus - Critical Differences

7.2 Unintentional Endobronchial Intubation

• ETT advancing too far → right main bronchus intubation preferentially (because of its steeper angle)
• Right upper lobe collapse is the classic consequence (right upper lobe bronchus is occluded by ETT tip)
• Monitor: unilateral breath sounds, SpO2 fall, increased peak airway pressure

7.3 One-Lung Ventilation (OLV) and DLT

• Anatomical knowledge of segmental bronchi is essential for fiberoptic bronchoscopy confirmation of DLT position
• After DLT insertion, fiberoptic bronchoscope is passed through:
  • Tracheal lumen → should see carina, blue bronchial cuff just below, and open right or left bronchus
  • Bronchial lumen → should see segmental orifices of the respective lobe

• Right-sided DLT: the bronchial cuff has a special slot/doughnut design to avoid occluding the right upper lobe bronchus (which arises 1-2.5 cm from carina)
• Left-sided DLT is used for ~99% of thoracic cases including right-sided surgery

7.4 Aspiration Pneumonia and Dependent Segments

• The right lower lobe posterior basal (S10) and right upper lobe posterior (S2) are classically the most common sites of aspiration pneumonia in supine patients
• Knowledge critical for: aspiration risk in anaesthesia, ICU positioning, bronchoscopic lavage targeting

7.5 Postural Drainage - Physiotherapy in ICU

7.6 Foreign Body Aspiration

• Adults (upright): foreign bodies typically lodge in right lower lobe bronchi (especially posterior basal, S10) - due to the more vertical right main bronchus
• Children (supine): right and left sides equally affected in some series
• Rigid bronchoscopy is the treatment - knowledge of segment anatomy guides retrieval

7.7 Lung Abscess

• Most common in dependent segments
• Supine: superior segments of lower lobes (S6) and posterior segments of upper lobes (S2) - especially the right side
• Right side predominance - due to wider, more vertical right main bronchus

7.8 Segmentectomy and Surgical Resection

• A bronchopulmonary segment is the smallest surgically resectable unit of lung tissue
• Segmentectomy (vs. lobectomy) is used for:
  • Small peripheral tumours (<2 cm, stage IA)
  • Poor pulmonary reserve (FEV1 <40% predicted)
  • Metastasectomy
• Pulmonary veins being intersegmental means they must be ligated carefully during segmentectomy to avoid injuring adjacent segments
• The right middle lobe (lingula on the left) has a long, narrow bronchus making it susceptible to middle lobe syndrome (recurrent collapse/atelectasis)

7.9 Bronchoscopy and Targeted BAL

• Each segment's bronchial orifice is identifiable bronchoscopically by clock-face position (see Section 6 above)
• Targeted bronchoalveolar lavage (BAL), bronchial washing, or endobronchial biopsy can be directed to specific segments
• Critical in ICU for ventilator-associated pneumonia (VAP) diagnosis - mini-BAL or protected specimen brushing directed at consolidating segment

7.10 Selective Lobar Blockade

• Bronchial blockers (e.g., Arndt, Cohen, EZ-Blocker) can be guided into specific segmental bronchi under FOB to achieve selective lobar or segmental collapse while ventilating other lobes
• Particularly useful in patients with pre-existing contralateral lung disease or in pediatric thoracic cases where DLT is not feasible

8. Surgical Importance Summary

9. Viva Questions for MD Anaesthesia

• Gray's Anatomy for Students, pp. 208-210 (Figs 3.47, 3.48, 3.49)
• Color Atlas of Human Anatomy Vol. 2 - Internal Organs, pp. 214-216 (Fig. 3.16)
• Fischer's Mastery of Surgery 8th Edition, pp. 2058-2059
• Barash, Cullen & Stoelting's Clinical Anaesthesia 9th Edition, pp. 3177-3182