When is a tracheostomy indicated and what are the considerations for the procedure?

Tracheostomy: Indications and Procedural Considerations

Primary Indications

Tracheostomy should be considered when mechanical ventilation is anticipated to exceed 10-15 days, with the primary goal of facilitating weaning from prolonged ventilation while reducing complications of translaryngeal intubation. 1

Core Indications:

• Prolonged mechanical ventilation (anticipated >10-14 days) remains the predominant indication 1, 2
• Actual or anticipated airway obstruction is the primary surgical indication 1, 2
• Inadequate laryngeal reflexes requiring invasive pulmonary hygiene in patients unable to clear respiratory secretions 1, 2
• Upper airway pathology including tumors, bilateral vocal cord paralysis, subglottic stenosis, or significant laryngeal edema not improving over time 2

Optimal Timing

Wait at least 10 days after intubation before performing tracheostomy, and only proceed when patients show signs of clinical improvement. 1

Timing Algorithm:

• Day 0-10: Continue translaryngeal intubation with daily weaning assessments 1
• Day 10+: Consider tracheostomy if:
  • Patient shows clinical improvement 1
  • Prolonged ventilation (>14 days total) is anticipated 1, 2
  • Patient no longer requires prone positioning 1
  • Weaning from mechanical ventilation has not been achieved 2

Evidence on Early vs. Late Timing:

The 2016 BTS/ICS guidelines found that early tracheostomy (within 7 days) does not reduce mortality, duration of mechanical ventilation, or ventilator-associated pneumonia incidence 1. Large multicenter trials demonstrated that 55% of patients randomized to late tracheostomy never required the procedure at all 1. This supports a conservative approach, waiting at least 10 days to avoid unnecessary procedures in patients who may recover without tracheostomy. 1

Benefits of Tracheostomy

Tracheostomy provides a closed system for controlled weaning that allows reduced sedation, improved patient comfort, and potential for earlier ICU transfer. 1

Documented Benefits:

• Reduced sedation requirements and ability to manage patients with minimal or no sedation 1
• Shorter ICU length of stay and ventilator-free days in selected patients 1
• Lower risk of failed extubation compared to high-risk primary extubation attempts 1
• Easier transfer to lower acuity care areas while maintaining ventilatory support 1, 2
• Potentially reduced incidence of hospital-acquired pneumonia compared to prolonged translaryngeal intubation 1

Procedural Technique Selection

Either percutaneous dilatational tracheostomy (PDT) or open surgical tracheostomy (OST) can be performed safely; the choice depends on patient factors and institutional expertise. 1

Technique Considerations:

• PDT with bronchoscopic guidance is recommended when anatomically feasible 1
• OST is preferred when anatomical concerns exist or PDT is contraindicated 1
• Bedside ICU placement is preferred over operating room to minimize transport risks 1

Safety Considerations

Infection Control (Particularly Relevant for COVID-19 and Infectious Respiratory Diseases):

• Enhanced PPE is mandatory as tracheostomy is an aerosol-generating procedure 1
• Negative-pressure room preferred in ICU setting; if unavailable, use normal pressure room with HEPA filters and strict door policy 1
• Minimize number of providers to most experienced team members only 1
• Maintain closed circuit with in-line suction after tracheostomy placement 1

Patient Selection Contraindications:

• Unstable patients requiring high levels of ventilatory and oxygen support 2
• Patients requiring continued prone positioning 1, 2
• Patients likely to wean within 10 days based on daily assessments 1

Special Populations

COVID-19 Patients:

In COVID-19 patients, delay tracheostomy until 10-14 days after ICU admission (approximately 20-24 days after symptom onset) and only when showing recovery from pneumonitis. 1, 2

The viral load and infectivity are significantly reduced by this timepoint, particularly when antiviral antibodies are present 1. Clinical improvement must be evident before proceeding 1.

Neuromuscular Disease:

In progressive neuromuscular disorders, tracheostomy carries risk of permanence and requires multidisciplinary discussion including home ventilation specialists before proceeding. 1, 2 Consider NIV-supported extubation as an alternative to avoid tracheostomy when possible 1.

Critical Decision-Making Framework

Multidisciplinary Approach Required:

Before proceeding, convene a team including 1, 3:

• Primary critical care team
• Palliative care consultation
• Infectious disease (if applicable)
• Procedural/airway team
• Patient/family for goals of care discussion

Key Questions to Answer:

1. Is mechanical ventilation truly anticipated to exceed 10-14 days? 1, 2
2. Is the patient showing clinical improvement? 1
3. Is prone positioning no longer required? 1, 2
4. What are the patient's goals of care? 1, 3
5. Are there anatomical or coagulation concerns affecting technique selection? 1

Common Pitfalls to Avoid

• Performing tracheostomy too early (before day 10) leads to unnecessary procedures in patients who would have successfully weaned 1
• Attempting high-risk primary extubation instead of elective tracheostomy in patients with poor extubation predictors 1
• Inadequate infection control precautions during aerosol-generating procedures 1
• Proceeding without multidisciplinary discussion of goals of care and prognosis 1, 3