What is the recommended tracheostomy (trach) approach for a patient with stroke admitted to the Intensive Care Unit (ICU)?

Percutaneous Tracheostomy is the Recommended Approach for Stroke Patients in the ICU

For stroke patients admitted to the ICU requiring tracheostomy, percutaneous dilatational tracheostomy (PDT) performed at the bedside is the preferred approach due to its shorter operative time, decreased incidence of stoma infection, and widespread availability in ICU settings. 1

Timing of Tracheostomy

• Tracheostomy should not be performed before the fourth day of mechanical ventilation 1
• For stroke patients specifically, assessment for tracheostomy should occur at the end of the first week of intensive care if extubation is not feasible 2
• While early tracheostomy (within days 1-3) may reduce sedation needs compared to standard timing (days 7-14), there is insufficient evidence to recommend a specific timing for tracheostomy in stroke patients 1, 3

Technique Selection

Percutaneous Dilatational Tracheostomy (PDT)

• First-line recommendation for most stroke patients in the ICU 1
• Advantages over surgical tracheostomy:
  • Shorter operative time
  • Decreased incidence of stoma infection and inflammation
  • Can be performed at the bedside in the ICU
  • Avoids transportation risks 1, 4
• Among PDT techniques, the single dilator technique has a higher success rate but may have more minor complications (minor bleeding, tracheal ring fractures) 1

Surgical Tracheostomy

• Reserved for cases with contraindications to PDT:
  • Unstable cervical spine
  • Anterior cervical infection
  • Previously operated/irradiated neck
  • Difficulty identifying anatomical landmarks (obesity, short neck, thyroid hypertrophy)
  • Stiff cervical spine 1

Procedural Considerations

Pre-Procedure

• Fiberoptic bronchoscopy should be performed before and during percutaneous tracheostomy to:
  • Help locate the point of incision
  • Position the endotracheal tube correctly
  • Visualize all stages of the procedure 1
• Ultrasound can identify vascular structures and select optimal puncture site 4

During Procedure

• Performed by a team with the least number of providers with highest level of experience 1
• Use techniques that minimize aerosolization 1
• Ensure waveform capnography monitoring is in place 1

Post-Procedure

• Note that percutaneous tracheostomy stomas are unlikely to be mature enough for safe tube exchange until 7-10 days 1
• Management of tube blockage/displacement in this period should focus on securing the native upper airway 1

Risk Factors and Complications

• Stroke patients requiring tracheostomy often have:

  • Higher baseline NIHSS scores
  • Higher rates of hospital-acquired pneumonia
  • Failed extubation attempts
  • Need for decompressive hemicraniectomy 5

• Common complications to monitor for:

  • Displacement (most common in ICU)
  • Blockage
  • Hemorrhage 1

Safety Measures

• Continuous waveform capnography is critical for monitoring and early detection of complications 1
• Display relevant information on bedhead signs 1
• All ICU staff caring for these patients should receive training in prevention, detection, and management of tracheostomy emergencies 1
• Implement a "red flag" system to identify potential airway issues early (see Table 3 in 1)

Special Considerations for Stroke Patients

• Stroke patients often have dysphagia and increased aspiration risk
• Reliable confirmation of swallowing ability (e.g., by endoscopy) is necessary before decannulation 2
• Early tracheostomy in stroke patients may reduce sedation needs without worsening clinical course 2, 3
• Younger stroke patients with higher NIHSS scores are more likely to require tracheostomy 5

By following these evidence-based recommendations, the care team can optimize outcomes for stroke patients requiring tracheostomy in the ICU setting while minimizing complications.