What are the indications for a tracheostomy?

Tracheostomy Indications

Tracheostomy should be performed in patients requiring prolonged mechanical ventilation beyond 10-14 days, those with actual or anticipated airway obstruction, patients unable to clear respiratory secretions, and those with chronic respiratory failure requiring ventilatory support. 1, 2

Primary Indications for Tracheostomy

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 timeframe balances the risks of prolonged translaryngeal intubation against the risks of tracheostomy itself. 1
• In COVID-19 patients specifically, tracheostomy should be considered 10-14 days after ICU admission when patients are showing signs of recovery from COVID-19-associated pneumonitis. 1, 2

Airway Obstruction

• Actual or anticipated airway obstruction remains the primary surgical indication for tracheostomy. 1
• Specific conditions requiring tracheostomy include:
  • Upper airway tumors 1
  • Bilateral vocal cord paralysis 1
  • Subglottic stenosis 1
  • Congenital airway malformations 1
  • 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
• The procedure is necessary for patients requiring invasive pulmonary hygiene. 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, tracheostomy enables mechanical ventilation and simplifies upper airway management. 1
• The decision should involve multidisciplinary discussion. 1

Special Population Considerations

Neuromuscular Disorders

• For patients with acquired and potentially reversible neuromuscular disorders, tracheostomy should be considered if weaning from invasive mechanical ventilation is not achieved after completion of immunotherapy. 1
• In Guillain-Barré syndrome patients, a deficit in plantar flexion at the end of immunotherapy has an 82% positive predictive value for prolonged mechanical ventilation, indicating need for tracheostomy. 1

Pediatric Patients

• Indications for pediatric tracheostomy include long-term ventilatory support, management of bronchopulmonary secretions, fixed upper airway obstruction, and congenital airway malformations. 1, 2

Absolute Contraindications

Tracheostomy should be avoided in patients who are unstable and require high levels of ventilatory and oxygen support. 1, 2

• Patients who require continued prone positioning should not undergo tracheostomy. 1
• Active local infection at the proposed tracheostomy site is a relative contraindication. 2

Benefits Supporting These Indications

The rationale for these indications is based on several advantages of tracheostomy over prolonged translaryngeal intubation:

• Reduction in pharyngolaryngeal lesions and lower risk of sinusitis 3
• Reduced sedation requirements and improved patient comfort with easier communication 3
• Facilitated care by nursing personnel and maintenance of swallowing 3
• Simpler reinsertion in cases of accidental decannulation and easier weaning from mechanical ventilation 3
• Potential for earlier transfer from intensive care to lower acuity care areas 1

Critical Timing Considerations

The timing of tracheostomy must balance the risks of prolonged intubation against procedural risks, with the 10-14 day window representing the optimal compromise based on current evidence. 1, 2

• While early tracheostomy (within 7 days) has been proposed, recent high-quality randomized trials have not demonstrated mortality or morbidity benefits for early versus delayed tracheostomy. 3
• The challenge remains predicting which patients will require prolonged ventilation, as this prediction is imprecise. 3

COVID-19 Specific Modifications

• Tracheostomy in COVID-19 patients should only be performed when showing signs of recovery from pneumonitis, with appropriate infection control measures including negative pressure rooms and enhanced PPE. 1, 2
• The procedure can be safely performed with proper precautions to protect healthcare staff. 1, 2