Why Tracheostomy is Performed in Prolonged Endotracheal Intubation
Tracheostomy should be performed in patients requiring prolonged mechanical ventilation (anticipated >10-15 days) to reduce complications from endotracheal intubation, improve patient comfort, facilitate weaning, and potentially reduce mortality and ventilator-associated pneumonia. 1, 2
Primary Indications for Tracheostomy
Prevention of Laryngotracheal Injury
- 94% of patients intubated for more than 4 days develop laryngeal injury, including edema and ulceration of the vocal folds 3
- Up to 44% develop vocal fold granulomas within 4 weeks of extubation 3
- Prolonged intubation causes pressure necrosis leading to subglottic and tracheal stenosis, resulting in long-term breathing difficulties requiring surgical intervention 1, 3
- Patients commonly experience dysphonia, dysphagia, and dyspnea on exertion as sequelae 1, 3
Clinical Benefits Over Prolonged Intubation
Mortality and Morbidity Reduction:
- A Cochrane systematic review of nearly 2,000 patients demonstrated lower mortality with early tracheostomy (number needed to treat = 11) 1, 2
- Early tracheostomy (day 3) versus late (day 15) results in more ventilator-free days, sedation-free days, and ICU-free days 1, 4
- Higher successful weaning rates (74.1% vs 55.7%) and ICU discharge rates (67.2% vs 47.5%) with early tracheostomy 4
Reduction in Ventilator-Associated Pneumonia:
- Early tracheostomy reduces VAP incidence (29.3% vs 49.2% in late tracheostomy) 4
- A large retrospective study of 125,000 tracheostomies showed decreased rates of sepsis and VAP with early timing 1, 2
Patient Comfort and Care Advantages
- Reduced sedation requirements allowing better patient awareness and communication 3, 5
- Improved patient tolerance and nursing care compared to translaryngeal intubation 5
- Reduced inspiratory load and better airway access for secretion management 5, 6
- Fewer accidental extubations compared to prolonged endotracheal intubation 1
Timing Recommendations
The American College of Chest Physicians recommends considering tracheostomy when mechanical ventilation is anticipated to exceed 10-15 days, though no specific timing can be universally mandated 1, 2
- Conventional practice performs tracheostomy 2-3 weeks after intubation in medical ICUs 1
- Wait at least 10 days to confirm ongoing ventilation needs before proceeding 6
- The decision should account for the underlying disease process, expected duration of ventilation, and patient/family preferences 1, 2
Critical Caveats
Risk Factors for Complications
- Patients with diabetes and ischemic disease have increased risk of laryngeal injury from prolonged intubation 1, 3
- Aggressive endotracheal tube cuff over-inflation significantly increases mucosal injury risk 1, 3
- Extrinsic factors (duration of intubation, tube size) and intrinsic factors (comorbidities) compound injury risk 1
Procedural Considerations
- The procedure should be performed by the most experienced team with the fewest providers 1, 7
- Both open surgical and percutaneous techniques are acceptable; choice depends on local expertise 1, 7
- Use negative pressure rooms when available to minimize aerosolization risk 1, 7