Clinical Guidelines Section.
noTRACH advises that the following guidelines should be used in determining when a tracheostomy is clinically required, and precautions that should be taken prior to being performed. Your organization may have additional requirements for clinical justification and legal risk mitigation.
noTRACH has also published advisory guidelines for malpractice risk mitigation which can be viewed HERE [LINK: www.notrach.com/article3/]
The decision to perform a tracheostomy should clearly meet the following test;
- that its clinical requirement is beyond doubt, or was the result of an emergency event, and;
- all possibilities of alternative available forms of non-invasive ventilation have failed, or were not appropriate, and ;
- the patient is fully aware of the life-altering implications involved, and the potential complications that may result.
Failure to meet this test will clearly establish that negligence has occurred.
The clinical requirement for a tracheostomy is easily established, but limited. In order to demonstrate clinical necessity, the following must be established;
- The lack of a viable airway, and/or;
- Failure of both available forms available non-invasive ventilation (mask based, and biphasic cuirass ventilation), or;
- The circumstance which would preclude either form of non-invasive ventilation from being attempted. This can include, contra-indications for use of either method of non-invasive ventilation (e.g, lack of patent or viable airway, bodily burns in the case of biphasic cuirass ventilation, facial trauma in the case of mask-based ventilation.)
In order to clearly prove that informed consent has been given, the following test should be met;
- The patient has been made aware of the complications and their prevalence, that can follow a tracheostomy e.g risk of infections, bleeding, damage to vocal cords, etc
- The aftercare requirements following the procedure
- Quality of life impact issues, e.g difficulties in talking, eating, etc
- That both alternative forms of non-invasive ventilation are available and have either failed or are contra-indicated or have been specifically declined.
Alternative Forms of Ventilation
Currently, two mainstream forms of non-invasive ventilation are available.
- NIPPV– Non-invasive Positive Pressure Ventilation
Non-invasive Positive Pressure Ventilation is very well proven and is often used as an alternative to invasive ventilation. NIPPV may be used with either a mask or mouthpiece as an interface. There is a significant body of clinical evidence that illustrates its use as a safe effective alternative to invasive ventilation – available worldwide.
BCV – Biphasic Cuirass Ventilation
Biphasic Cuirass Ventilation is also very well proven and used as an alternative form of non-invasive ventilation. BCV is used with a Cuirass, a semi-rigid plastic shell as an interface. Biphasic Cuirass Ventilation also has a significant body of evidence that illustrates its use as a safe and effective alternative to invasive ventilation – available worldwide.
Both forms of ventilation have many hundreds of clinical publications supporting their use and are used by thousands around the world. It is very well proven that where one method has failed, the other has proved effective.