What are the indications for reintubation versus tracheostomy in a post-operative patient who developed atelectasis after extubation following endotracheal intubation (ETI)?

From the Guidelines

For a post-operative patient who developed atelectasis after extubation, tracheostomy is generally indicated when prolonged mechanical ventilation is anticipated, whereas reintubation is preferred for short-term ventilatory needs. The decision between reintubation and tracheostomy should be based on the expected duration of ventilatory support and patient-specific factors, as suggested by the American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors expert panel report 1.

Key Considerations

• Reintubation is suitable for patients with short-term ventilatory needs, expected to be less than 7-10 days.
• Tracheostomy is considered when prolonged mechanical ventilation is anticipated, typically more than 10-15 days, as it offers advantages such as improved patient comfort, reduced sedation requirements, and easier secretion clearance 1.
• Patient-specific factors, including neuromuscular weakness, poor neurological status, extensive pulmonary disease, or failed previous extubation attempts, should be taken into account when deciding between reintubation and tracheostomy.
• Initial management of atelectasis should include conservative measures such as chest physiotherapy, incentive spirometry, bronchodilators, and positive pressure support (CPAP or BiPAP), as recommended by the European Society for Anaesthesiology and Intensive Care and European Society of Intensive Care Medicine (ESA/ESICM) 1.

Procedure and Care

• Tracheostomy can be performed percutaneously at bedside or surgically in the operating room, depending on patient anatomy and institutional expertise.
• Patients receiving noninvasive positive pressure ventilation (NIPPV) or continuous positive airway pressure (CPAP) should be managed in a clinical area where staff are competent in these therapies, with continuous physiological monitoring and frequent arterial blood gas sampling 1.
• Goal-directed hemodynamic therapy and epidural analgesia may also be beneficial in preventing postoperative pulmonary complications, as suggested by a systematic review and meta-analysis of perioperative interventions 1.

Recent Evidence

• A recent study published in 2023 found that prophylactic use of noninvasive respiratory support, such as CPAP, may not reduce the incidence of pneumonia, endotracheal re-intubation, or death after major elective abdominal surgery 1.
• However, another study suggested that early tracheostomy (within 7-10 days) may be beneficial for patients with factors suggesting prolonged ventilation needs, such as neuromuscular weakness or poor neurological status 1.

From the Research

Indications for Reintubation versus Tracheostomy in Postoperative Patients with Atelectasis

• Reintubation may be considered in patients with severe atelectasis who require immediate relief of airway obstruction or who are unable to maintain adequate oxygenation and ventilation 2.
• Tracheostomy should be considered in patients with relapsing atelectasis or swallow disorders, as it can provide a more stable and secure airway 2.
• The decision to reintubate or perform a tracheostomy should be based on individual patient factors, such as the severity of atelectasis, underlying lung disease, and overall medical condition.

Treatment Options for Postoperative Atelectasis

• Incentive spirometry has been shown to be an effective strategy in reducing postoperative pulmonary complications, including atelectasis, and shortening hospital stay 3.
• Continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP) may be used to increase functional residual capacity and prevent atelectasis 4, 5.
• Respiratory physical therapy, including incentive spirometry, can promote rapid recovery of postoperative lung function in obese patients 6.

Factors Influencing the Development of Postoperative Atelectasis

• Smoking and American Society of Anesthesiologists (ASA) class have been identified as risk factors for the development of postoperative atelectasis 5.
• Preoperative predicted FEV1 of <80% has been shown to be a predictor of benefit from incentive spirometry in reducing postoperative pulmonary complications 3.
• Obesity has been identified as a risk factor for postoperative atelectasis, and short-term respiratory physical therapy has been shown to be effective in promoting rapid recovery of lung function in these patients 6.