What are the indications for a tracheostomy?

Indications for Tracheostomy

Tracheostomy should be considered primarily for patients requiring prolonged mechanical ventilation beyond 10-14 days, those with actual or anticipated upper airway obstruction, and patients unable to clear respiratory secretions due to inadequate laryngeal reflexes. 1

Primary Indications

Prolonged Mechanical Ventilation

• 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
• The procedure is indicated when ventilation is expected to be needed for more than 10-14 days, as this threshold represents the point where benefits outweigh risks. 1
• For patients with acquired and potentially reversible neuromuscular disorders (Guillain-Barré syndrome, ICU-acquired weakness), tracheostomy should be proposed if weaning from invasive mechanical ventilation is not achieved after completion of immunotherapy. 3, 1
• In Guillain-Barré syndrome specifically, deficit in plantar flexion at the end of immunotherapy has an 82% positive predictive value for prolonged mechanical ventilation, making this a key clinical predictor for tracheostomy need. 1

Airway Obstruction

• Actual or anticipated airway obstruction remains the primary surgical indication for tracheostomy. 1
• Specific conditions include upper airway tumors, bilateral vocal cord paralysis, subglottic stenosis, congenital airway malformations, and 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, 2
• Patients requiring invasive pulmonary hygiene benefit from tracheostomy placement. 1
• Neurological disorders affecting airway protection may require tracheostomy for secretion management. 1

Chronic Respiratory Failure

• In patients with chronic respiratory failure, particularly those with neurological disorders (such as amyotrophic lateral sclerosis), tracheostomy may be indicated to enable mechanical ventilation and simplify upper airway management. 3, 1
• The decision for tracheostomy in chronic respiratory failure requires multidisciplinary discussion involving pulmonology, neurology, and palliative care, as tracheostomy does not alter the prognosis of the underlying disease but may prolong suffering. 3, 1
• Patients and families must be informed that in progressive neuromuscular diseases, tracheostomy facilitates management but does not improve survival or necessarily enhance comfort. 3

Pediatric-Specific Indications

• Indications for pediatric tracheostomy include long-term ventilatory support, management of bronchopulmonary secretions, fixed upper airway obstruction, and congenital airway malformations. 1
• Respiratory papillomatosis and craniofacial syndromes are additional pediatric indications. 2

Special Considerations for COVID-19

• In COVID-19 patients, tracheostomy should be considered 10-14 days after ICU admission only when patients are showing signs of recovery from COVID-19-associated pneumonitis. 1, 2
• The procedure can be performed safely with appropriate infection control measures including negative pressure rooms and enhanced personal protective equipment. 1, 2

Absolute Contraindications

• Patients who are unstable requiring high levels of ventilatory and oxygen support should not undergo tracheostomy. 1, 2
• Patients requiring continued prone positioning are not candidates for tracheostomy. 1
• Active local infection at the proposed tracheostomy site is a relative contraindication. 2

Common Pitfalls to Avoid

• Do not perform tracheostomy before day 10 of mechanical ventilation unless there is a clear indication such as upper airway obstruction, as earlier timing has not shown mortality or morbidity benefit in recent high-quality trials. 1, 2
• Avoid tracheostomy in patients with uncertain prognosis who have not yet demonstrated clinical improvement, as this may commit patients to invasive procedures without clear benefit. 1
• In chronic progressive neuromuscular diseases, ensure thorough discussion of goals of care before proceeding, as tracheostomy may prolong dying rather than improve quality of life. 3

Benefits Supporting These Indications

• Tracheostomy enables earlier transfer from intensive care to lower acuity care areas, reducing ICU length of stay. 1
• The procedure reduces laryngeal damage compared with prolonged translaryngeal intubation, improves patient comfort, facilitates communication, and allows for oral feeding. 3
• Lower airway resistance compared to endotracheal tubes may facilitate weaning and reduce sedation requirements. 4