At what point do you consider transitioning an Intensive Care Unit (ICU) patient from a ventilator to a tracheostomy?

From the Guidelines

The decision to transition an ICU patient from endotracheal intubation to a tracheostomy should be considered after 10 to 15 days of mechanical ventilation if prolonged ventilatory support is anticipated, 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. This timeframe balances the risks of prolonged endotracheal intubation against the invasiveness of tracheostomy. The procedure offers several advantages, including:

• Improved patient comfort
• Decreased sedation requirements
• Easier oral care
• Reduced laryngeal damage
• Improved ability to communicate
• Potentially shorter ICU stays and ventilator duration However, the decision should be individualized based on the patient's overall condition, anticipated recovery trajectory, and goals of care. Some patients may not be candidates due to coagulopathy, hemodynamic instability, or anatomical considerations. The optimal timing of tracheostomy in patients with COVID-19-related respiratory failure requiring mechanical ventilation is not well established, and the decision should be based on the physician's best estimate regarding prognosis and factoring in institutional critical care resource constraints 1. A large Cochrane Database systematic review from 2015 comparing early (2-10 days after intubation) to late (> 10 days after intubation) tracheostomy in critically ill adults included eight randomized controlled trials with almost 2,000 participants, and found a lower mortality rate in the early compared with the late tracheostomy group 1. Ultimately, the timing of tracheostomy should be determined on a case-by-case basis, taking into account the individual patient's needs and circumstances, as well as the availability of resources and expertise 1.

From the Research

Timing of Tracheostomy in ICU Patients

The decision to transition an ICU patient to a tracheostomy is complex and depends on various factors, including the patient's specific characteristics and the duration of mechanical ventilation.

• According to 2, the timing of tracheostomy remains a subject of debate, and a personalized approach is necessary to find the best possible compromise between avoiding unnecessary delays and minimizing the risks of performing a needless invasive procedure.
• There is no specific timeframe mentioned in the studies for keeping an ICU patient on a ventilator before considering tracheostomy, but 3 defines prolonged mechanical ventilation as mechanical ventilation dependency ≥ 21 days.

Considerations for Tracheostomy

When considering tracheostomy, several factors should be taken into account, including:

• The patient's work of breathing and comfort, as tracheostomy can facilitate the weaning process and reduce sedation levels 2
• The patient's ability to clear secretions, as tracheostomy can facilitate disconnection from the ventilator and enable earlier phonation, oral intake, and mobilization 2
• The risk of complications, such as tracheal stenosis, associated with tracheostomy 2

Outcomes of Prolonged Mechanical Ventilation

The outcomes of patients requiring prolonged mechanical ventilation are generally poor, with:

• High mortality rates, ranging from 59% to 62% at 1 year 4
• Low rates of successful liberation from mechanical ventilation, ranging from 47% to 50% 4
• High rates of complications, such as muscle weakness, pressure ulcers, and bacterial nosocomial sepsis 3