What are the criteria for determining when a patient is optimized for tracheostomy (tracheal ostomy) placement following prolonged endotracheal intubation (ETI)?

From the Guidelines

A patient is optimized for tracheostomy placement following prolonged intubation when they are anticipated to require prolonged mechanical ventilation, as suggested by the American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors expert panel report 1. To determine the optimal timing for tracheostomy placement, consider the following factors:

• Prolonged mechanical ventilation is anticipated, as indicated by the need for ongoing respiratory support 1
• The patient has stable hemodynamics and adequate oxygenation, although specific parameters such as FiO2 and PEEP are not defined in the provided evidence
• The patient has no active coagulopathy or uncontrolled infection at the proposed tracheostomy site, and has received appropriate sedation and analgesia
• The procedure should be performed with full monitoring, including continuous pulse oximetry, capnography, and blood pressure monitoring, and with emergency airway equipment readily available It is essential to note that the timing of tracheostomy placement may vary depending on individual patient factors, and there is insufficient evidence to recommend a specific timing for tracheostomy in COVID-19 related respiratory failure 1. The procedure should be performed by a team consisting of the least number of providers with the highest level of experience, in a negative-pressure room, preferably in the ICU, with enhanced personal protective equipment (PPE) to mitigate the risk of healthcare worker related infection 1. Ultimately, the decision to proceed with tracheostomy placement should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances, and with consideration of the potential risks and benefits of the procedure 1.

From the Research

Determining Optimal Timing for Tracheostomy Placement

To determine when a patient is optimized for tracheostomy placement following prolonged intubation, several factors and studies should be considered:

• The decision for tracheostomy is often based on the projected duration of intubation, with tracheostomy recommended if intubation is expected to last several weeks 2.
• Early tracheostomy, defined as within 7-10 days of intubation, has been associated with improved outcomes, including reduced mortality, shorter ICU length of stay, and decreased duration of mechanical ventilation 3, 4.
• A systematic review and meta-analysis found that early tracheostomy modestly decreased mortality and reduced ICU length of stay and duration of mechanical ventilation compared to late tracheostomy or prolonged intubation 3.
• Another study found that tracheostomy within 7 days of intubation had better results than those performed within 14 or 21 days of intubation 4.
• The optimal timing of tracheostomy may vary depending on the patient population and individual factors, such as the underlying condition requiring intubation and the presence of comorbidities 5, 6.

Key Considerations

When evaluating a patient for tracheostomy placement, the following key considerations should be taken into account:

• The patient's projected duration of intubation and need for prolonged mechanical ventilation 2.
• The potential benefits of tracheostomy, including improved patient comfort, ability to communicate, and easier nursing care 2.
• The risks and complications associated with tracheostomy, such as bleeding, infection, and tracheal stenosis 6.
• The patient's overall clinical condition and presence of comorbidities that may impact the decision for tracheostomy 5, 6.