When is tracheostomy indicated in a ventilation patient?

Indications for Tracheostomy in Ventilated Patients

Tracheostomy should be considered in patients when mechanical ventilation is anticipated to be needed for more than 10-14 days, offering benefits including more ventilator-free days, shorter ICU stays, and lower incidence of ventilator-associated pneumonia. 1

Primary Indications for Tracheostomy

• Prolonged mechanical ventilation (expected duration >10-14 days) 1, 2
• Actual or anticipated airway obstruction 2
• Management of secretions in patients unable to eliminate respiratory secretions due to inadequate laryngeal reflexes 2
• Patients with chronic respiratory failure, especially those with neurological disorders 2

Timing of Tracheostomy

• Based on recent evidence, it is reasonable to wait at least 10 days to confirm an ongoing need for mechanical ventilation before considering tracheostomy 3
• Early tracheostomy (within 7 days of translaryngeal intubation) may be beneficial if mechanical ventilation is likely to be prolonged beyond 3 weeks 4
• Early tracheostomy is associated with:
  • More ventilator-free and sedation-free days 1
  • Higher successful weaning and ICU discharge rates 1
  • Lower incidence of ventilator-associated pneumonia 1, 5
  • Lower in-hospital mortality (adjusted hazard ratio 0.26) 5
  • Higher successful weaning rate (adjusted hazard ratio 2.05) 5

Benefits of Tracheostomy vs. Prolonged Intubation

• Tracheostomy is associated with:
  • Lower ICU mortality (17.1% vs 42.7% with prolonged intubation) 5
  • Lower in-hospital mortality (22.0% vs 54.1% with prolonged intubation) 5
  • Higher successful weaning rates (68.9% vs 40.4% with prolonged intubation) 5
  • Prevention of laryngeal and upper airway damage due to prolonged translaryngeal intubation 6
  • Facilitation of airway access for secretion removal 6

Technique Considerations

• Both open surgical tracheostomy (OST) and percutaneous dilatational tracheostomy (PDT) are acceptable techniques 2
• Percutaneous tracheostomy with flexible bronchoscopy guidance is recommended 3
• The procedure should be performed by a team with the fewest number of providers and the highest level of experience 7, 2
• For COVID-19 patients, tracheostomy should be performed in a negative-pressure room, preferably in the ICU 7, 2
• If negative pressure rooms are unavailable, the procedure could be performed in a normal pressure room equipped with HEPA filters with strict door policy 7

Special Considerations

• Tracheostomy is an aerosol-generating procedure and poses infection risk to healthcare workers, particularly with COVID-19 patients 7
• Patients should be maintained with a closed circuit while on mechanical ventilation with a tracheostomy tube and with in-line suction 7
• The decision to perform tracheostomy should consider patient factors, underlying disease process, patient/family preferences, and expected outcomes 1
• Percutaneous techniques under bronchoscopic control are increasingly popular worldwide 6

Potential Complications

• Immediate: bleeding and loss of airway 2
• Short-term: blockage or displacement of the tracheostomy tube 2
• Long-term: tracheomalacia, tracheal stenosis, or stoma-related problems 2

Cost-Effectiveness

• Bedside percutaneous approach may be more cost-effective than traditional surgical technique 8
• Tracheostomy teams and standardized protocols for insertion and care have been associated with improved outcomes 3