How can tracheostomy address atelectasis (collapse of lung tissue)?

From the Guidelines

Tracheostomy is not recommended to improve cough effectiveness in patients with endotracheal tubes, including those with atelectasis, according to the ACCP evidence-based clinical practice guidelines 1. However, in certain clinical scenarios, tracheostomy may be beneficial in addressing atelectasis.

• The procedure can provide a direct airway that bypasses upper airway obstruction and facilitates secretion clearance.
• It helps resolve atelectasis by reducing anatomical dead space, decreasing the work of breathing and improving alveolar ventilation.
• Tracheostomy also provides direct access for suctioning and removal of secretions that might otherwise cause airway plugging.
• Additionally, it allows for more effective delivery of positive pressure ventilation when needed.
• For patients with chronic respiratory failure or recurrent atelectasis, a tracheostomy tube with an inner cannula that can be regularly cleaned or replaced helps prevent mucus buildup.
• The procedure is particularly beneficial for patients with neuromuscular weakness who cannot effectively cough, those with chronic aspiration, or individuals requiring prolonged mechanical ventilation.
• Clinicians should be aware of and monitor for possible complications, such as pneumonia, atelectasis, and/or respiratory failure, in patients with ineffective cough 1.
• While tracheostomy carries risks including bleeding, infection, and tracheal stenosis, its benefits in preventing and treating atelectasis often outweigh these concerns in appropriate clinical scenarios.
• It is essential to weigh the potential benefits and risks of tracheostomy on a case-by-case basis, considering the individual patient's condition and needs.

From the Research

Tracheostomy and Atelectasis

• Tracheostomy can help address atelectasis by facilitating the weaning process, reducing the patient's work of breathing, and increasing comfort 2.
• It also helps with secretions clearance, which can contribute to atelectasis, and enables earlier phonation, oral intake, and mobilization 2.
• However, the timing of tracheostomy remains a subject of debate, and a personalized approach is necessary to find the best possible compromise between avoiding unnecessary delays and minimizing the risks of performing a needless invasive procedure 2, 3.

Benefits of Tracheostomy

• Reduces sedation use and promotes earlier mobility compared to continued translaryngeal intubation 4.
• Percutaneous dilational tracheostomy is associated with a lower cost and complication profile compared to conventional surgical methods 4.
• Allows for easier management of secretions and can help prevent complications such as tracheal stenosis 5.

Considerations for Tracheostomy

• The decision to perform a tracheostomy should be based on individual patient characteristics and needs 2, 3.
• Patients with acute neurological injury or stroke may benefit from earlier tracheostomy 4.
• The use of percutaneous dilational tracheostomy with flexible bronchoscopy guidance is recommended 3.
• A step-by-step individualized approach based on available evidence can help identify the best strategy for tracheostomy use in ICU patients 2.