Why are patients with conditions such as respiratory failure, chronic obstructive pulmonary disease (COPD), pneumonia, spinal cord injuries, or neurological disorders like amyotrophic lateral sclerosis (ALS) typically on tracheotomies?

Why Patients Require Tracheostomy

Patients are placed on tracheostomy primarily for three core reasons: prolonged mechanical ventilation (expected >10-14 days), inability to protect their airway or clear secretions, and actual or anticipated upper airway obstruction. 1

Primary Indications

Prolonged Mechanical Ventilation

• Tracheostomy should be considered when mechanical ventilation is expected to exceed 10-14 days, as this represents the threshold where benefits outweigh risks of continued translaryngeal intubation. 1
• The procedure is specifically indicated for patients with prolonged weaning from mechanical ventilation, where liberation from the ventilator is anticipated to be difficult or extended. 2
• In intensive care settings, tracheostomy should not be performed before day 4 of mechanical ventilation (GRADE 1+ recommendation), as early placement does not reduce mortality, ventilator-associated pneumonia, or ICU length of stay. 2

Neuromuscular and Neurological Disorders

• Acquired and potentially reversible neuromuscular disorders (such as Guillain-Barré syndrome, critical illness myopathy) warrant tracheostomy when weaning fails after completion of immunotherapy. 2, 1
• For Guillain-Barré syndrome specifically, deficit in plantar flexion at the end of immunotherapy has 82% positive predictive value for prolonged mechanical ventilation, indicating need for tracheostomy. 2, 1
• Chronic respiratory failure from neurological disorders (including ALS, spinal cord injuries) may require tracheostomy to enable mechanical ventilation and simplify upper airway management, though this requires multidisciplinary discussion. 2, 1

Airway Protection and Secretion Management

• Inability to clear respiratory secretions due to inadequate laryngeal reflexes is a primary indication, particularly in patients with neurological impairment affecting cough effectiveness. 1
• Patients requiring invasive pulmonary hygiene who cannot manage secretions despite mechanical aids need tracheostomy for airway access. 1
• Actual or anticipated airway obstruction remains the primary surgical indication, including upper airway tumors, bilateral vocal cord paralysis, subglottic stenosis, and significant laryngeal edema. 1

Critical Timing Considerations

When to Delay

• Tracheostomy 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 demonstrated that early tracheostomy (before day 4-7) does not reduce mortality, ventilator-associated pneumonia, or ICU/hospital length of stay compared to delayed approach. 2, 3

When to Expedite

• Severe trauma, burn patients with cervicofacial involvement, and acute neurological injury may benefit from earlier tracheostomy, though this approaches emergency rather than planned tracheostomy. 2
• In traumatic brain injury specifically, early tracheostomy may reduce ventilator-associated pneumonia and ICU length of stay, though mortality benefit remains unclear. 4

Absolute Contraindications in ICU Setting

Tracheostomy should NOT be performed in the following high-risk situations: 2

• Hemodynamic instability
• Intracranial hypertension (ICP >15 mmHg)
• Severe hypoxemia (PaO₂/FiO₂ <100 mmHg with PEEP >10 cmH₂O)
• Uncorrected coagulopathy (platelets <50,000/mm³, INR >1.5, or PTT >2× normal)
• Patient or family refusal
• Active withdrawal of care or dying patient

Special Population Considerations

ALS and Progressive Neuromuscular Disease

• Tracheostomy does not alter the prognosis of the underlying disease—patients and families must understand it only prolongs survival while the disease continues to progress. 2
• In ALS patients undergoing tracheostomy, 70% leave hospital completely ventilator-dependent, 28% partially dependent, with only 1% achieving complete ventilator liberation. 2
• At 1-year follow-up, only 22% of ALS patients with tracheostomy remain alive, with quality of life similar to non-tracheostomized ALS patients. 2
• Multidisciplinary discussion is mandatory before proceeding, as tracheostomy can unduly prolong suffering without improving comfort. 2

COPD and Chronic Respiratory Failure

• First-line management should be noninvasive ventilation rather than tracheostomy for chronic respiratory failure decompensation. 2
• Tracheostomy in this population requires careful evaluation of whether facilitation of upper airway management will genuinely improve comfort versus prolonging suffering. 2

Pneumonia and Acute Respiratory Failure

• Patients with pneumonia requiring prolonged ventilation follow the general timing guidelines—defer tracheostomy until at least day 10-14 to ensure ongoing ventilatory support is truly needed. 1, 3
• The procedure does not prevent ventilator-associated pneumonia when performed early. 2, 3

Common Clinical Pitfalls

• Performing tracheostomy too early (before day 4-10) based on assumption of prolonged ventilation need—many patients extubate successfully when given adequate time. 2, 3
• Assuming tracheostomy improves comfort—this is insufficiently studied and not proven; some patients experience worse suffering with tracheostomy than continued translaryngeal intubation. 2
• Failing to have goals-of-care discussions before tracheostomy in progressive neurological disease—the procedure commits patients to long-term ventilator dependence without altering disease trajectory. 2
• Proceeding despite contraindications (coagulopathy, severe hypoxemia, intracranial hypertension)—this significantly increases risk of hemorrhage, hypoxemia, and neurological deterioration. 2