When is a tracheostomy (trach) performed?

When to Perform a Tracheostomy

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

Primary Indications

Prolonged Mechanical Ventilation

• The most common indication is anticipated need for mechanical ventilation exceeding 10-14 days 1, 2
• Tracheostomy facilitates weaning from mechanical ventilation, reduces sedation requirements, and improves patient comfort with easier communication 1
• The procedure allows for earlier transfer from intensive care to lower acuity care areas 1
• It reduces pharyngolaryngeal lesions and lowers the risk of sinusitis compared to prolonged translaryngeal intubation 1

Airway Obstruction

• Actual or anticipated airway obstruction remains the primary surgical indication 1
• Specific conditions 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

• Indicated for patients unable to clear respiratory secretions due to inadequate laryngeal reflexes 1, 2
• Necessary for patients requiring invasive pulmonary hygiene 1
• Neurological disorders affecting airway protection may require tracheostomy 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

Optimal Timing

General Timing Principles

• 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 should occur as soon as the need for prolonged intubation is identified, though predicting which patients will require prolonged ventilation remains imprecise 1, 3
• Recent high-quality randomized trials have not demonstrated mortality or morbidity benefits for early (within 7 days) versus delayed tracheostomy 1

COVID-19 Specific Timing

• In COVID-19 patients, tracheostomy should be considered 10-14 days after ICU admission when patients are showing signs of recovery from COVID-19-associated pneumonitis 1, 2
• The procedure should only be performed when the patient shows signs of recovery, not during acute deterioration 2

Contraindications

Absolute Contraindications

• Patients who are unstable requiring high levels of ventilatory and oxygen support 2
• Patients who require continued prone positioning 1

Relative Contraindications

• Active local infection at the proposed tracheostomy site 2

Pediatric Considerations

In children, the indications are similar but with specific anatomical considerations 4:

• Long-term ventilatory support 1
• Management of bronchopulmonary secretions 1
• Fixed upper airway obstruction (subglottic stenosis, bilateral vocal cord paralysis) 4
• Congenital airway malformations and associated syndromes 4
• Respiratory papillomatosis and craniofacial syndromes 4

Approximately 1200 surgical tracheostomies were performed in children aged 16 years or less during 2014-2015 in England, with one-third performed in children under age one year 4

Clinical Benefits Supporting the Decision

• Improved patient comfort and ability to communicate 1, 5
• Reduced sedation requirements 1, 5
• Easier nursing care and maintenance of swallowing 1
• Simpler reinsertion in cases of accidental decannulation 1
• Lower airway resistance compared to endotracheal tubes, potentially facilitating weaning 5
• May reduce ventilator-associated pneumonia by preventing microaspiration of secretions 5

Common Pitfalls to Avoid

• Do not perform tracheostomy too early (before day 10) as many patients may be successfully extubated, making the procedure unnecessary 1, 6
• Do not delay beyond 14 days once the need for prolonged ventilation is clearly identified 1, 3
• Avoid performing the procedure in unstable patients or those requiring maximal ventilatory support 2
• Do not proceed without multidisciplinary discussion involving critical care, palliative care, and procedural teams 4