What are the indications for tracheostomy?

Indications for Tracheostomy

The predominant indications for tracheostomy are facilitating and weaning from prolonged mechanical ventilation, actual or anticipated upper airway obstruction, inadequate laryngeal reflexes, and the need for invasive pulmonary hygiene in patients unable to clear respiratory secretions. 1

Primary Indications

Prolonged Mechanical Ventilation

• Tracheostomy should be considered in patients requiring prolonged weaning from mechanical ventilation, particularly when ventilation is expected to be needed for more than 10-14 days 1
• For patients with acquired and potentially reversible neuromuscular disorders (e.g., Guillain-Barré syndrome), tracheostomy should be considered if weaning from invasive mechanical ventilation is not achieved after completion of immunotherapy 1
• In Guillain-Barré syndrome specifically, deficit in plantar flexion at the end of immunotherapy has a positive predictive value of 82% for prolonged mechanical ventilation, indicating need for tracheostomy 1

Upper Airway Management

• Actual or anticipated airway obstruction remains the primary surgical indication for tracheostomy 1
• Conditions warranting tracheostomy include:
  • Upper airway tumors 1
  • Bilateral vocal cord paralysis 1
  • Subglottic stenosis 1
  • Congenital airway malformations 1
  • Significant laryngeal edema or ulceration that does not improve over time 1

Secretion Management

• Tracheostomy is indicated for patients unable to clear respiratory secretions due to:
  • Inadequate laryngeal reflexes 1
  • Need for invasive pulmonary hygiene 1
  • Neurological disorders affecting airway protection 1

Chronic Respiratory Failure

• In patients with chronic respiratory failure, particularly those with neurological disorders, tracheostomy may be indicated to enable mechanical ventilation and simplify upper airway management 1
• The decision for tracheostomy in chronic respiratory failure should involve multidisciplinary discussion 1

Timing Considerations

• Tracheostomy should be delayed until at least day 10 of mechanical ventilation and only considered when patients are showing signs of clinical improvement 1, 2
• In COVID-19 patients specifically, tracheostomy should be considered 10-14 days after ICU admission (approximately 20-24 days after symptom onset) when patients are showing signs of recovery 1
• For patients with reversible conditions, daily weaning assessment should be performed, and the decision can generally be made within 7 days of intubation 3

Special Considerations

COVID-19 Specific Considerations

• Tracheostomy in COVID-19 patients should only be considered when:
  • The patient is showing signs of recovery from COVID-19-associated pneumonitis 1
  • The patient has recovered sufficiently that prone positioning is unlikely to be required 1
  • The procedure can be performed with appropriate infection control measures to protect healthcare staff 1

Pediatric Considerations

• Indications for pediatric tracheostomy include:
  • Long-term ventilatory support 1
  • Management of bronchopulmonary secretions 1
  • Fixed upper airway obstruction (subglottic stenosis, bilateral vocal cord paralysis) 1
  • Congenital airway malformations and associated syndromes 1

Contraindications and Cautions

• Tracheostomy should be avoided in patients who:
  • Are unlikely to survive their critical illness 2
  • Have severe coagulopathy that cannot be corrected 2
  • Are unstable and require high levels of ventilatory and oxygen support 1
  • Require continued prone positioning 1

Benefits of Tracheostomy

• Improved patient comfort and reduced need for sedation 3, 4
• Facilitation of weaning from mechanical ventilation 3
• Easier and safer nursing care 4
• Opportunity for oral feeding and communication 4
• Potential reduction in ventilator-associated pneumonia by preventing microaspiration 4
• Potential for earlier transfer from intensive care to lower acuity care areas 1

Tracheostomy is a common but significant procedure that requires careful consideration of timing, technique, and patient-specific factors. The decision should be based on the patient's clinical condition, expected duration of mechanical ventilation, and potential for recovery, with the goal of improving patient outcomes including mortality, morbidity, and quality of life.