Emergency Percutaneous Tracheostomy: Virtuosity versus Advisability

Airway management in the ICU poses important challenges to intensivists.Indeed, it differs significantly from tracheal intubation (TI) carried out for routine surgical procedures in the operating room (OR), where elective intubations are usually performed on stable patients with good physiological reserve and a low complication rate [1].These observations are in stark contrast to the high occurrence of failed airways and major complications, such as severe hypoxemia and cardiac arrest, during airway instrumentation in the ICU [2-3].

Not only may these patients have an inadequate response to pre-oxygenation, but emergent airway instrumentation in the hands of inexperienced physicians can lead to multiple intubation attempts, esophageal intubation, episodes of severe hypoxemia, and possibly, cardiac arrest [4-5].In this issue of Internet Journal of Emergency and Intensive Care Medicine, Nfonoyim et al. [6] reported the use of percutaneous tracheotomy (PT) to solve four scenarios of failed intubation in the ICU setting.The take home message made by the authors is that PT is an optimal solution to solve the scenario of failed TI; however, the point is not whether PT is feasible in an emergency situation, but rather, if that is the most appropriate strategy to manage the airway in an emergency.These cases actually demonstrate poor anticipation of potential airway difficulties and inadequate planning, which is not uncommon and well described in the literature [7].

Additionally, it is questionable to perform an emergency PT on a patient after multiple attempts of intubation without attempting to oxygenate the patient using an alternative device, such as a supraglottic airway (SGA).A pre-planned strategy or strategies is central to managing airway problems and the American Society of Anesthesiologists (ASA) algorithm for management of the difficult airway is also applicable to critically ill patients [8].Maintaining adequate oxygenation and ventilation should be the main goal during airway management.Use of a SGA to initially secure the airway, followed by the performance of a surgical or percutaneous tracheostomy may be more appropriate for the failure to intubate situation.Despite the wave of enthusiasm accompanying PT in the last two decades, there is no strong evidence that it can be used effectively in an emergency.

In a recent study, Davidson et al. [9] concluded that in the severely hypoxic or hemodynamically unstable patient, such as those reported in this article, cricothyrotomy is the preferred route for an emergency percutaneous airway, due to the shorter duration required for its completion and greater safety.Additionally, anatomical landmarks are usually more easily located for the performance of a cricothyrotomy.Nonetheless, the recent NAP4 report regarding airway management in the UK demonstrated that invasive airways often result in a high incidence of unsuccessful airway access and major complications [10].

There are several considerations regarding whether or not PT is a suitable technique in the emergent setting.It is often difficult to predict the need for a long cannula in cases of a deep trachea or complications, such as tracheal bleeding, cannula malposition, cannula dislodgement, and tracheal damage or airway loss with hypoxia, which may require an open invasive technique. The authors believe that the use of PT without bronchoscopic guidance, or ultrasound airway visualization, especially in challenging anatomy or airway situations (such as emergency airway access) is not advised because of the risk of airway failure or structural disruption [11].ENT surgeons share similar concerns regarding emergency airway access in terms of long term tracheal complications; however prospective, well conducted studies are not available and are necessary to support this clinical perspective.

Thus, we do not recommend TI as an emergency procedure, despite successful anecdotal cases.The feasibility of a surgical technique, even in the hands of skilled intensivists, and the choice of airway management (e.g. PT) in the four cases presented is concerning.Education in hospital airway management has been directed to reduce the need for emergency airway rescue, particularly invasive techniques [12].While education and simulation should improve physician skills and management of emergency airway invasive techniques, performance of a safe and effective cricothyrotomy should be considered over PT.

In conclusion, emergency airway management in the ICU setting requires a clear airway management strategy, including back-up plans in case of failure, limiting the number of intubation attempts, and effective pre-oxygenation and positioning.Availability of alternative intubation techniques (e.g. videolaryngoscopy) should help reduce the risk of the “can’t intubate, can’t ventilate” scenario in critically ill patients.It must be kept in mind that the priority isn’t necessarily access to the trachea at the speed of light, but rather, achievement of adequate oxygenation using a well-planned and effective strategy which has a high success rate and, at the same time, a low complication rate.