Tracheostomy for Ventilated Patient

Doctors struggle to accurately predict which patients will require prolonged mechanical ventilation.  Doctors need a clear understanding of the nature and typical course of chronic critical illness.

Communication about chronic critical illness should begin before its onset and, ideally, as early as the initiation of mechanical ventilation (or even at decision-making about whether to initiate ventilation).  Doctors should inform not only of the risk of death in the ICU, but also the chance the patient might survive but remain dependent on the ventilator and other intensive therapies for a prolonged period. 

These initial discussions allow a longer time for doctors to “cultivate prognostic awareness” i.e. the capacity to understand prognosis and the likely illness trajectory and help patients and families prepare psychologically and practically for further developments.

Based on the available evidence, routine placement of tracheostomy prior to day 10 of mechanical ventilation is not indicated. General consensus is that a tracheostomy should be placed after day 10 if the patient is likely to require more than a few additional days of ventilation i.e. the patient will neither be liberated from the ventilator nor die in the near future i.e. the patient is chronically critically ill.

Benefits of tracheostomy include:

Improved patient comfort

Easier oral care and suctioning

Reduced need for sedation or analgesia

Reduced accidental extubation

Improved weaning from mechanical ventilation

Easier facilitation of rehabilitation

Earlier communication and oral nutrition

Facilitated transfer to lower level of care

Early Complications:

Bleeding

Air leak causing subcutaneous emphysema, pneumothorax, pneumomediastinum

 

Damage to the swallowing tube (esophagus)

 

Injury to the nerve of the vocal cords (recurrent laryngeal nerve)

 

Tracheostomy tube can be blocked by blood clots, mucus, or pressure of the airway walls.

Late Complications:

Accidental removal of the tracheostomy tube

 

Infection in the trachea and around the tracheostomy tube

 

Trachea may be damaged by pressure from the tube resulting in bacterial infections and scar tissue formation

Delayed Complications:

Thinning of the trachea from the tube rubbing against it (tracheomalacia)