What are the indications for performing a tracheostomy in patients with various medical conditions, including chronic respiratory diseases, such as Chronic Obstructive Pulmonary Disease (COPD) or pneumonia, and other underlying health conditions?

Indications for 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 due to inadequate laryngeal reflexes, and those with chronic respiratory failure requiring long-term ventilatory support. 1

Primary Indications

Prolonged Mechanical Ventilation

• Tracheostomy is indicated when mechanical ventilation is expected to exceed 10-14 days, as this represents the threshold where benefits outweigh risks of continued translaryngeal intubation 1, 2
• The procedure should be delayed until at least day 10 of mechanical ventilation and only considered when patients show signs of clinical improvement 1
• Three large randomized controlled trials failed to demonstrate mortality benefit from early tracheostomy (<7 days), supporting a more conservative timing approach 2
• Approximately 55% of patients designated for "late" tracheostomy never require the procedure, making premature intervention wasteful 3

Airway Obstruction

• Actual or anticipated airway obstruction remains the primary surgical indication for tracheostomy 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
  • Severe laryngospasm or generalized muscle rigidity (as in tetanus) 3

Secretion Management

• Tracheostomy is necessary for patients unable to clear respiratory secretions due to inadequate laryngeal reflexes 1
• This includes patients requiring invasive pulmonary hygiene 1
• Neurological disorders affecting airway protection commonly require tracheostomy for this indication 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
• For patients with acquired and potentially reversible neuromuscular disorders (e.g., Guillain-Barré syndrome), tracheostomy should be considered if weaning from invasive mechanical ventilation is not achieved after completion of immunotherapy 1
• In Guillain-Barré syndrome specifically, a deficit in plantar flexion at the end of immunotherapy has an 82% positive predictive value for prolonged mechanical ventilation 1

Timing Algorithm by Clinical Scenario

Standard ICU Patients

• Day 1-7: Assess trajectory of respiratory failure; avoid tracheostomy during this period unless urgent airway obstruction exists 1, 2
• Day 7-10: Begin planning for tracheostomy if clinical trajectory suggests ventilation will exceed 14 days total 3
• Day 10-14: Perform tracheostomy if patient shows signs of clinical improvement but continued ventilation is clearly needed 1
• After Day 14: Tracheostomy should be strongly considered if not already performed 3

Special Populations Requiring Earlier Consideration

• Acute neurological injury or stroke patients may benefit from earlier tracheostomy (within 7-10 days) 2
• Severe trauma, burn, and neurological patients with clear need for prolonged ventilation may benefit from early tracheostomy to reduce duration of mechanical ventilation and ICU stay 4
• Tetanus patients requiring deep sedation and neuromuscular blockade should have tracheostomy planned by day 7-10 3

COVID-19 Specific Timing

• Tracheostomy should be considered 10-14 days after ICU admission when patients show signs of recovery from COVID-19-associated pneumonitis 1
• The procedure should only be performed when the patient is showing signs of clinical improvement, not during the acute inflammatory phase 5, 1

Pediatric Indications

Pediatric tracheostomy indications include: 1

• Long-term ventilatory support
• Management of bronchopulmonary secretions
• Fixed upper airway obstruction
• Congenital airway malformations
• Respiratory papillomatosis

Approximately 1200 surgical tracheostomies were performed in children aged ≤16 years during 2014-2015 in England, with one-third performed in children under age one year 1

Contraindications and Situations to Avoid

Tracheostomy should be avoided in: 1

• Patients who are unstable and require high levels of ventilatory and oxygen support
• Patients who require continued prone positioning
• Patients before day 10 of mechanical ventilation unless urgent airway obstruction exists

Benefits Supporting the Indications

Understanding the benefits helps clarify when tracheostomy is appropriate:

• Reduces pharyngolaryngeal lesions and lowers risk of sinusitis compared to prolonged translaryngeal intubation 1
• Reduces sedation requirements and improves patient comfort with easier communication 1
• Facilitates nursing care and maintains swallowing function 1
• Allows simpler reinsertion in cases of accidental decannulation 1
• Enables easier weaning from mechanical ventilation 1
• Potential for earlier transfer from intensive care to lower acuity care areas 1

Critical Pitfalls to Avoid

• Do not perform tracheostomy too early (before day 7-10) unless urgent airway obstruction exists, as many patients will successfully extubate 3, 2
• Do not delay beyond 10-14 days in patients with clear need for prolonged ventilation, as this increases complications from translaryngeal intubation 1, 3
• Do not attempt primary extubation in high-risk patients (e.g., tetanus, severe neurological injury) without careful assessment of laryngeal function 3
• Do not proceed without multidisciplinary discussion involving critical care, palliative care, infectious disease, and procedural teams to determine goals of care and patient selection 5, 1

Decision-Making Process

The decision for tracheostomy requires: 5, 1

• Multidisciplinary discussion involving the primary critical care team, palliative care, infectious disease, and the procedural/airway team
• Utilization of respective expertise to determine goals of care
• Patient selection based on predicted clinical course
• Procedural considerations including technique selection (open surgical vs. percutaneous dilatational)
• Workflow optimization to ensure safety of both patient and healthcare workers