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Are emergency tracheostomies obsolete?

OCTOBER 22, 2018
Clinical Congress Daily Highlights, Monday First Edition


On Monday, a panel of surgeons debated whether emergency tracheostomies are necessary in certain settings or whether they are becoming obsolete in the face of advancing non-surgical technologies.

Gerald Fortuna, MD FACS, Barnes-Jewish Hospital, Saint Louis, MO, gave a background on the history, techniques and complications of emergency tracheostomies. He also contrasted open surgical tracheotomy with percutaneous tracheotomy, which is usually done bedside in the intensive care unit, citing two large meta-analyses that suggest that percutaneous tracheostomy is the procedure of choice in an elective setting with reduced infections, lower costs and shorter case times.

Bradley Freeman, MD, FACS, Barnes-Jewish Hospital, Saint Louis, MO, argued that there are settings where creating a surgical airway is impossible to avoid, but that refinements in approaches to translaryngeal intubation for patients with difficult airways have the potential to make use of emergency tracheostomy less common. He did offer the caveat that patients who initially avoid a tracheostomy may ultimately undergo the procedure due to considerations such as airway security.

“I will agree that there are a plethora of really interesting tools out there that have made intubations much safer and much cleaner,” said Stephanie Savage, MD, MS, FACS, Indiana University School of Medicine, Indianapolis. “But I think it’s a little premature to think that we can get away from a procedure that we’ve been relying on for over four millennia.”

Yet Aaron M. Strumwasser, MD, FACS, Los Angeles County Medical Center, argued that tracheostomy is obsolete and mentioned newer techniques such as laryngeal mask airways, King laryngeal tubes, surgical cricothyrotomy and needle cricothyrotomy. He said that across specialties and techniques, surgical airways are becoming exceedingly rare because prehospital and emergency department management of difficult airways is outstanding.

 “There is no question that emergency surgical airways are becoming much less necessary,” concluded moderator Michael Bouton, MD, FACS, Sanford Health, Fargo, ND. “At the same time, perhaps we need to renew the effort to keep these skills, because there are times when they will be necessary.”

Additional Information

The Panel Session, Emergency Airway Management 2018: Are Emergency Tracheotomies Obsolete?, was held October 22 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast, and audio information is available online at facs.org/clincon2018.

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