When Tracheostomy is Necessary
Tracheostomy should be performed when prolonged mechanical ventilation (beyond 4 days) is anticipated, when there is acute upper airway obstruction that cannot be managed with endotracheal intubation, or when chronic airway management is needed for neuromuscular disorders or upper airway pathology. 1
Primary Indications for Tracheostomy
1. Prolonged Mechanical Ventilation
- Tracheostomy should not be performed before the fourth day of mechanical ventilation in ICU patients, as early tracheostomy (before day 4) does not reduce mortality, ventilator-associated pneumonia, or duration of mechanical ventilation 1
- Consider tracheostomy when the need for mechanical ventilation is expected to exceed 14 days, though accurate prediction by day 3 remains challenging 2
- The procedure facilitates weaning by reducing work of breathing, increasing patient comfort, allowing sedation reduction, and enabling earlier mobilization and phonation 3
2. Acute Upper Airway Obstruction
- Elective surgical tracheostomy is indicated when airway patency may be compromised for a considerable period due to pre-existing airway problems, tumor, swelling, edema, or bleeding 1
- The decision is informed by: (1) extent of airway compromise at end of surgery, (2) likelihood of postoperative airway deterioration, (3) ability to rescue the airway, and (4) expected duration of significant airway compromise 1
- Specific scenarios include major head and neck surgery (e.g., free flap reconstruction), cervicofacial burns with inhalation injury, and cervicofacial trauma 1, 4
3. Neuromuscular Disorders
- Tracheostomy should be proposed for acquired and potentially reversible neuromuscular disorders (e.g., Guillain-Barré syndrome, ICU-acquired weakness) requiring prolonged airway support 1
- For chronic respiratory failure from neurological conditions, multidisciplinary discussion is mandatory before proceeding, as tracheostomy does not alter disease prognosis and may prolong suffering 1
- In amyotrophic lateral sclerosis (ALS), 70% of patients remain ventilator-dependent after tracheostomy, with only 22% alive at 1 year—ethical considerations must be thoroughly discussed with patient and family 1
4. Chronic Upper Airway Management
- Tracheostomy is indicated for management of chronic upper airway obstructive conditions when long-term airway access is required 5
- It reduces risk of glottic damage compared to prolonged translaryngeal intubation, particularly important with laryngeal edema or slow resolution of airway problems 1
Absolute Contraindications
Tracheostomy should NOT be performed in the following high-risk situations: 1
- Hemodynamic instability requiring vasopressor support
- Intracranial hypertension (ICP > 15 mmHg)
- Severe hypoxemia (PaO₂/FiO₂ < 100 mmHg with PEEP > 10 cmH₂O)
- Uncorrected coagulopathy (platelets < 50,000/mm³, INR > 1.5, or PTT > 2× normal)
- Patient or family refusal
- Active withdrawal of care or dying patient
Technical Approach
- Percutaneous tracheostomy is the standard method in ICU patients (GRADE 1+ recommendation), associated with shorter operative time and decreased stoma infection compared to surgical technique 1
- The procedure should be performed by experienced physicians only, as complications can be serious 6
- Placement should be between the second and third tracheal rings to avoid tracheo-innominate fistula, subglottic stenosis, and cricoid cartilage injury 7
Common Pitfalls to Avoid
- Do not perform tracheostomy too early (before day 4) as it provides no mortality benefit and exposes patients to unnecessary procedural risks 1
- Do not proceed without correcting coagulopathy, as hemorrhage is a potentially life-threatening complication occurring in up to 5% of cases 1
- Avoid placement through the first tracheal ring or cricothyroid membrane, which guarantees subglottic complications and cricoid injury 7
- Do not perform the procedure in patients with severe hypoxemia or hemodynamic instability, as these conditions significantly increase risk of catastrophic complications 1