When is a tracheostomy recommended?

From the Guidelines

A tracheostomy is recommended when a patient requires long-term mechanical ventilation, has upper airway obstruction, needs airway protection, or requires frequent pulmonary toilet, as it offers several advantages over prolonged endotracheal intubation, including improved patient comfort and reduced sedation requirements. The decision to perform a tracheostomy should be individualized based on the patient's condition, expected duration of ventilatory support, and overall prognosis, with the procedure typically performed by surgeons or intensivists in an operating room or at the bedside in intensive care units 1.

Key Indications for Tracheostomy

• Prolonged mechanical ventilation (typically after 7-14 days of endotracheal intubation)
• Upper airway obstruction that cannot be bypassed with other methods
• Need for airway protection due to inability to handle secretions
• Requirement for frequent pulmonary toilet
• Severe facial trauma, head and neck cancers obstructing the airway, congenital airway anomalies, severe sleep apnea unresponsive to other treatments, and neurological conditions causing chronic respiratory failure or inability to protect the airway

Procedure and Care

The procedure creates a direct opening into the trachea through the neck, bypassing the upper airway structures. Tracheostomies offer several advantages over prolonged endotracheal intubation, including improved patient comfort, reduced sedation requirements, easier secretion management, potential for speech with specialized valves, and lower risk of laryngeal and tracheal damage 1. Postprocedural care should be adapted to minimize airway procedures and aerosol-generating procedures, including reviewing humidification needs, specifying the frequency of suction, daily inner tube care, and discontinuing positive pressure ventilation, whenever possible, during disconnection from the ventilator circuit 1.

Considerations During the COVID-19 Pandemic

During the COVID-19 pandemic, tracheostomy insertion and subsequent care are aerosol-generating procedures, and positive-pressure ventilation increases the aerosolisation risk 1. Infectivity is likely to be low around the time of tracheostomy and significantly lower than the time of tracheal intubation 1. A tracheostomy may provide a more controlled situation for weaning as compared with a high-risk primary tracheal extubation, particularly if reintubation or the use of rescue therapies is a concern 1.

From the Research

Indications for Tracheostomy

• The medical indications of tracheostomy comprise the alleviation of upper airway obstruction; the prevention of laryngeal and upper airway damage due to prolonged translaryngeal intubation in patients subjected to prolonged mechanical ventilation; and the facilitation of airway access for the removal of secretions 2.
• Tracheostomy is often recommended if intubation is projected to be longer than several weeks 3.
• Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery 4.

Timing of Tracheostomy

• Tracheostomy should be performed as soon as the need for prolonged intubation is identified, but the timing should be individualized 2.
• It is reasonable to perform early tracheostomy in all patients projected to require prolonged mechanical ventilation 3.
• Based on evidence from 2 recent large randomized trials, it is reasonable to wait at least 10 d to be certain that a patient has an ongoing need for mechanical ventilation before consideration of tracheostomy 5.

Considerations for Tracheostomy

• The use of percutaneous dilatation techniques under bronchoscopic control are now increasingly popular throughout the world 2.
• Percutaneous tracheostomy with flexible bronchoscopy guidance is recommended 5.
• An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions 4.
• The efficacy of tracheostomy teams and tracheostomy hospital services with standardized protocols for tracheostomy insertion and care has been associated with improved outcomes 5.