Tracheostomy

Indications for Tracheostomy

Respiratory Failure with Need for Prolonged Mechanical Ventilation (see Respiratory Failure and Invasive Mechanical Ventilation-General)

Tracheostomy is Generally Performed in Patients Who Require >3 wks of Mechanical Ventilator Support

  • The 3 Week Cutoff Has Been Derived from Historical Data Related to the Adverse Effects of Prolonged Endotracheal Tube Cuff Pressure on the Tracheal Wall Associated with High-Pressure Cuffs
    • However, Current Generation Endotracheal Tubes Have Low-Pressure Cuffs and This Data Likely No Longer Applies
  • Studies of Duration of Mechanical Ventilation Before Tracheostomy
    • In a Spanish International Study of Medical-Surgical ICU Patients, Tracheostomy was Performed After a Median of 11 Days (Am J Respir Crit Care Med, 2000) [MEDLINE]: n = 1,638
    • In the Project Impact Database Study of Impact of Timing of Tracheostomy and Duration of Mechanical Ventilation, Tracheostomy was Performed After a Median of 9 Days (Crit Care Med, 2005) [MEDLINE]
  • The Decision to Proceed with Tracheostomy Placement Should Be Individualized for Each Patient

General Advantages of Tracheostomy Over Endotracheal Intubation (see Endotracheal Intubation)

  • Decreases the Need for Sedation
  • Decreases the Work of Breathing
  • Improves the Ease of Suctioning to Facilitate Secretion Clearance
  • Improves Patient Comfort
  • Improves Patient Communication
  • Increases the Ease of Replacement (Once a Tracheostomy Tract has Formed)
  • Has No Clear Impact on the Mortality Rate
  • Has No Clear Impact on the Ventilator-Associated Pneumonia (VAP) Rate (see Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia)

Clinical Efficacy-Improved Respiratory Mechanics Associated with Tracheostomy (as Compared to Endotracheal Intubation)

  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Am J Respir Crit Care Med, 1999) [MEDLINE]
    • Tracheostomy Decreased the Work of Breathing, Pressure-Time Index of the Respiratory Muscles, and PEEP/Auto-PEEP (as Compared to Endotracheal Tube)
  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Arch Surg, 1999) [MEDLINE]
    • Tracheostomy Decreased the Work of Breathing, Due to the Short, Rigid Nature of the Tube (as Compared to the Longer, Thermolabile Endotracheal Tube): effect is more pronounced at higher respiratory rates
  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Anaesth Intensive Care, 1999) [MEDLINE]
    • Tracheostomy Decreased Peak Inspiratory Pressure, But Changed Respiratory Mechanics Very Little
    • Patients Who Had Better Underlying Mechanics (Higher Cstatic, Lower PEEP) Had Better Chances of Weaning from Mechanical Ventilation After Tracheostomy
  • Study of the Effects of Tracheostomy Dead Space (J Trauma, 2001) [MEDLINE]
    • Tracheostomy Minimally Improved Respiratory Mechanics
    • Post-Tracheostomy Change in Physiologic Dead Space Did Not Predict Outcome of Weaning from Mechanical Ventilation
    • Tracheostomy Improved Pulmonary Toilet, Initiation of the Removal of Mechanical Ventilation, and Control of the Upper Airway
  • Study of the Effects of Tracheostomy on Respiratory Mechanics (Eur Respir J, 2002) [MEDLINE]
    • Tracheostomy Decreased Inspiratory Resistive Work, Intrinsic PEEPi, Inspiratory Pressure-Time Product (and its Resistive and Elastic Components)
  • Observational Study of the Effects of Tracheostomy on Respiratory Mechanics in Difficult to Wean Mechanically Ventilated Patients (PLoS One, 2015) [MEDLINE]
    • Tracheostomy Improved Weaning Parameters (Rapid Shallow Breathing Index, etc) in Difficult to Wean Mechanically Ventilated Patients Who Weaned from the Ventilator
    • However, Tracheostomy Only Improved Airway Resistance in Mechanically Ventilated Patients Who Failed to Wean from the Ventilator

Clinical Efficacy-Patient Comfort (as Compared to Endotracheal Intubation)

  • Observational Study of the Effect of Tracheostomy on Sedation Requirements (Crit Care Med, 2005) [MEDLINE]
    • Tracheostomy Decreased the Intravenous Sedation and Analgesic Requirement, Spent Less Time Heavily Sedated, and Achieved Autonomy Earlier in the Hospital Course

Clinical Efficacy-Need for Sedation (as Compared to Endotracheal Intubation)

  • Observational Study of the Effect of Tracheostomy on Sedation Requirements (Crit Care Med, 2005) [MEDLINE]
    • Tracheostomy Decreased the Intravenous Sedation and Analgesic Requirement, Spent Less Time Heavily Sedated, and Achieved Autonomy Earlier in the Hospital Course

Clinical Efficacy-Mortality Rate (as Compared to Endotracheal Intubation)

  • Study of Outcome of Tracheostomy in the Intensive Care Unit (Crit Care Med, 1999) ([MEDLINE]
    • Tracheostomy Patients Had a Lower Hospital Mortality Rate than Non-Tracheostomy Patients (13.7% vs 26.4%)
    • Tracheostomy Patients Had a Longer Duration of Mechanical Ventilation and Hospital Length of Stay, as Compared to Non-Tracheostomy Patients
  • Retrospective Study of the Outcome After Respiratory Failure and Tracheostomy Placement (Chest, 2004) [MEDLINE]
    • Overall Survival and Functional Status are Poor for Patients with Respiratory Failure and Tracheostomy
    • Survival is Highest in Patients Who are Weaned from Mechanical Ventilation and Have Tracheostomy Removed
  • Spanish Cohort Study of the Effect of Tracheostomy (Crit Care Med, 2005) [MEDLINE]
    • Tracheostomy Improved ICU Mortality Rate, But Increased the Length of Stay in the ICU
    • Tracheostomy Did Not Impact the Hospital Mortality Rate
  • Project Impact Database Study of Impact of Timing of Tracheostomy and Duration of Mechanical Ventilation (Crit Care Med, 2005) [MEDLINE]
    • Tracheostomy Patients Had a Lower Mortality Rate than Non-Tracheostomy Patients (78.1% vs 71.1%)
    • Tracheostomy Timing is Significantly Associated with Duration of Mechanical Ventilation, ICU Length of Stay, and Hospital Length of Stay
  • Study of Effect of Early Tracheostomy (Within 12 Days) on Outcome (Crit Care Med, 2007) [MEDLINE]
    • Tracheostomy Decreased the ICU and In-Hospital Mortality Rates
  • Multicenter Prospective Cohort Study of the Effect of Tracheostomy on Outcome (Crit Care Med, 2007) [MEDLINE]
    • Tracheostomy Did Not Improve ICU Mortality Rate or Ventilator-Associated Pneumonia Rate
    • No Difference in ICU Mortality When Tracheostomy was Performed Early vs Late
    • Post-ICU Mortality Rate was Higher in Patients Who Underwent Tracheostomy (Particularly in Those in Whom Tracheostomy was Left in Place)
      • This May Be Related to Comorbidities in this Patient Population, Rather than an Adverse Effect of Tracheostomy Itself

Clinical Efficacy-Timing of Tracheostomy Placement in Respiratory Failure

  • Study of Outcome of Tracheostomy in the Intensive Care Unit (Crit Care Med, 1999) ([MEDLINE]
    • Tracheostomy Patients Had a Lower Hospital Mortality Rate than Non-Tracheostomy Patients (13.7% vs 26.4%)
    • Tracheostomy Patients Had a Longer Duration of Mechanical Ventilation and Hospital Length of Stay, as Compared to Non-Tracheostomy Patients
  • Randomized Trial of Early Tracheostomy in Medical ICU Patients (Crit Care Med, 2004) [MEDLINE]
    • Early Tracheostomy (Within 48 hrs), as Compared to Late Tracheostomy (at 14-16 Days), was Associated with Decreased Mortality, Decreased VAP Rate, Decreased Rate of Accidental Extubation, Decreased ICU Length of Stay, Decreased Duration of Mechanical Ventilation, and Decreased Upper Airway Mucosal Trauma
  • Prospective ICU Database Study of Early vs Late Tracheostomy In Trauma Patients (Crit Care, 2004) [MEDLINE]
    • Early Tracheostomy (within 7 Days of Start of Mechanical Ventilation) was Associated with Shorter Duration of Mechanical Ventilation and Shorter ICU Length of Stay, But Did Not Impact the ICU or Hospital Mortality Rate
  • Retrospective Review of Early vs Late Tracheostomy in a Surgical ICU Population (Am J Surg, 2005) [MEDLINE]: n = 185
    • Early Tracheostomy (Within 7 Days of ICU Admission) was Associated with Decreased Incidence of VAP, Decreased Ventilator Time, and Decreased ICU Length of Stay in a Surgical ICU Population
  • Systematic Review Studying the Impact of the Timing of Tracheostomy in Adults Supported on Mechanical Ventilation (BMJ, 2005) [MEDLINE]: n= 406 (from 5 studies)
    • Performance of Early Tracheostomy Did Not Impact the Mortality Rate or Risk of Pneumonia
    • Performance of Early Tracheostomy Decreased the Duration of Mechanical Ventilation (8.5 Days Less; 95% Confidence Interval: -15.3 to -1.7 Days) and Duration of ICU Stay (15.3 Days Less; 95% Confidence Interval: -24.6 to -6.1 Days)
  • Project Impact Database Study of Impact of Timing of Tracheostomy and Duration of Mechanical Ventilation (Crit Care Med, 2005) [MEDLINE]
    • Tracheostomy Patients Had a Lower Mortality Rate than Non-Tracheostomy Patients (78.1% vs 71.1%)
    • Tracheostomy Timing is Significantly Associated with Duration of Mechanical Ventilation, ICU Length of Stay, and Hospital Length of Stay
  • Study of Effect of Early Tracheostomy (Within 12 Days) on Outcome (Crit Care Med, 2007) [MEDLINE]
    • Tracheostomy Decreased the ICU and In-Hospital Mortality Rates
  • Retrospective Review of Early vs Late Tracheostomy in Patients with Severe Traumatic Brain Injury (Surg Infect-Larchmt, 2007) [MEDLINE]: n = 55
    • Early Tracheostomy (5.5 +/-1.8 Days), as Compared to Late Tracheostomy (11.0 +/- 4.3 Days) Decreased ICU Length of Stay, But Did Not Decrease Ventilator Days, Incidence of Pneumonia Prior to Tracheostomy, Hospital Cost, Hospital Length of Stay, or Mortality Rate
  • Multicenter Prospective Cohort Study of the Effect of Tracheostomy on Outcome (Crit Care Med, 2007) [MEDLINE]
    • Tracheostomy Did Not Improve ICU Mortality Rate or Ventilator-Associated Pneumonia Rate
    • No Difference in ICU Mortality When Tracheostomy was Performed Early vs Late
    • Post-ICU Mortality Rate was Higher in Patients Who Underwent Tracheostomy (Particularly in Those in Whom Tracheostomy was Left in Place): this may be related to comorbidities in this patient population, rather than an adverse effect of the tracheostomy itself
  • Systematic Review and Meta-Analysis of Effect of Early Tracheostomy on VAP Rates (Chest, 2011) [MEDLINE]
    • Early Tracheostomy Did Not Impact VAP Rates, Duration of Mechanical Ventilation, or Mortality Rate
  • Study of Early Tracheostomy in Cardiothoracic Surgery Population (Ann Intern Med 2011) [MEDLINE]
    • Early Tracheostomy Did Not Decrease Length of Hospital Stay, Mortality Rate, Infectious Complication Rate, Long-Term Health-Related Quality of Life in Patients Who Required Long-Term Mechanical Ventilation After Cardiothoracic Surgery
    • Early Tracheostomy was Well-Tolerated and Associated with Decreased Sedation Use, Better Comfort, and Earlier Resumption of Autonomy
  • Italian Multicenter, Randomized, Controlled Trial of Early vs Late Tracheostomy (JAMA, 2010) [MEDLINE]
    • Early Tracheostomy Did Not Decrease the Risk of VAP or Mortality Rate
    • Critique of Trial: 31% of early group and 43% of late group did not ultimately undergo tracheostomy placement
  • Cochrane Database Systematic Review of Early vs Late Tracheostomy (Cochrane Database Syst Rev, 2012) [MEDLINE]
    • Evidence is Low Quality, But No Data Indicate Benefit to Early vs Late Tracheostomy
  • United Kingdom TracMan Multicenter, Randomized Trial of Early vs Late Tracheostomy (JAMA, 2013) [MEDLINE]
    • Early Tracheostomy (Within 4 Days of Intubation) Did Not Improve 30-Day All-Cause Mortality, 2-Year Mortality, or Length of ICU Stay
    • Over 50% of the Patients Randomized to the Late Tracheostomy Arm Did Not Ultimately Receive the Intervention
      • Suggests that Postponing Tracheostomy Allows a Subset of Patients to Avoid Tracheostomy Completely
    • The Ability of Clinicians to Predict Which Patients Would Require Extended Mechanical Ventilation Support was Limited
  • Meta-Analysis of Timing of Tracheostomy (Crit Care, 2015) [MEDLINE]
    • Early Tracheostomy is Associated with Higher Tracheostomy Rates, Increased Ventilator-Free Days, Decreased ICU Length of Stay, Decreased Need for Sedation, and Decreased Mortality Rate
  • Meta-Analysis of Early vs Late Tracheostomy (Br J Anaesth, 2015) [MEDLINE]
    • Early Tracheostomy (Within 10 Days) was Not Associated with Decreased Mortality Rate, ICU Length of Stay, Duration of Mechanical Ventilation, or Incidence of VAP
    • Early Tracheostomy was Associated with Increased Number of Procedures and Shorter Duration of Sedation
  • Retrospective Cohort Study of Clinical Variations in Tracheostomy Use (Crit Care Med, 2016) [MEDLINE]
    • Early Tracheostomy is Potentially Overused in Mechanically Ventilated Trauma Patients (21.9-81.9%), as Compared to Pneumonia/Sepsis Patients (14.9-38.3%)
      • Nearly 50% of All Tracheostomies in the Trauma Population were Performed within the First 7 Days of Mechanical Ventilation, with Large Unexplained Variation from Hospital to Hospital and No Impact on the Mortality Rate

Upper Airway Obstruction (see Obstructive Lung Disease)

Rationale

  • Tracheostomy is Utilized to Manage Prolonged Upper Airway Compromise (Due to Tumors, Laryngeal Edema, etc)

Clinical Efficacy

  • Study of the Effects of Tracheostomy on Dead Space (J Trauma, 2001) [MEDLINE]
    • Tracheostomy Minimally Improved Respiratory Mechanics
    • Post-Tracheostomy Change in Physiologic Dead Space Did Not Predict Outcome of Weaning from Mechanical Ventilation
    • Tracheostomy Improved Pulmonary Toilet, Initiation of the Removal of Mechanical Ventilation, and Control of the Upper Airway

Technique

Tracheostomy Placement Techniques

Percutaneous Dilational Tracheostomy (Bronchoscopically-Guided)

  • Procedural Aspects of Percutaneous Dilational Tracheostomy
    • Percutaneous Dilational Tracheostomy is Placed Between the First and Second Tracheal Rings
    • Routine Postprocedural Chest X-Ray Following Percutaneous Dilational Tracheostomy is Unnecessary in the Absence of Clinical Deterioration or the Anticipation of Postprocedural Complications (Chest, 2003) [MEDLINE]
  • Commercially-Available Percutaneous Dilational Tracheostomy Kits
    • Blue Rhino Kit
    • Cook Critical Care Kit
  • Relative Contraindications to Percutaneous Dilational Tracheostomy
    • Age <15 y/o
    • High Levels of Ventilator Support Required
      • High Level of Positive End-Expiratory Pressure (PEEP)
        • In Some Cases, PEEP-Dependent Patients May Not Be Able to Tolerate the Loss of PEEP During the Procedure
        • However, Bronchoscopically-Guided Percutaneous Dilational Tracheostomy is Probably Safe Even in Patients Requiring PEEP ≥10 cm H2O (Intensive Care Med, 2003) [MEDLINE]
      • Inability to Tolerate Periods of Respiratory Acidosis During Percutaneous Dilational Tracheostomy
        • Induction of Respiratory Acidosis May Be a Contraindication to Percutaneous Dilational Tracheostomy in Patients with Increased Intracranial Pressure (Associated with Traumatic Brain Injury, etc) (see Increased Intracranial Pressure)
        • Intraprocedural Respiratory Acidosis Appears to Be More Significant During Percutaneous Dilational Tracheostomy than During Surgical Tracheostomy (Intensive Care Med, 1997) [MEDLINE]
    • Inability to Extend Neck (Due to Cervical Fusion, Rheumatoid Arthritis, Cervical Spine Instability, etc)
    • Neck Hematoma/Tumor/Surgery/Thyromegaly (with Anatomic Distortion)
    • Neck Infection
    • Obesity/Short Neck
      • Morbid Obesity is Associated with Increased Risk of Life-Threatening Complications with Surgical Tracheostomy (Crit Care, 2007) [MEDLINE]
      • Tracheostomy Complication Rates are Higher in Obese Patients (Laryngoscope, 2015) [MEDLINE]: n= 151
        • Complication Rates are Particularly Higher in Obese Patients with BMI ≥35
        • Complication Rates are Particularly Higher in Obese Patients the Intraoperative and Early Postoperative Periods
        • Procedure Duration Has Also Been Noted to Be Longer in Obese Patients
    • Tracheomalacia (see Tracheobronchomalacia)
    • Uncorrectable Coagulopathy (see Coagulopathy)
      • Risk of Acute Bleeding with Percutaneous Dilational Tracheostomy was Independent of Coagulation Variables Tested (Anaesthesia, 2007) [MEDLINE]
      • Risk of Chronic Bleeding with Percutaneous Dilational Tracheostomy was Most Associated with PTT >50 sec, Platelet Count <50k, and in the Presence of ≥2 Abnormal Coagulation Variables, But Not with the Use of Heparin Prophylaxis (Anaesthesia, 2007) [MEDLINE]
  • Advantages of Percutaneous Dilational Tracheostomy (as Compared to Surgical Tracheostomy)
    • Can Be Performed at the Bedside
    • Comparable Rates of Tracheal Stenosis
      • In Trauma Population, Percutaneous Dilational Tracheostomy Had a Similar Rate of Tracheal Stenosis, as Compared to Surgical Tracheostomy (Am J Surg, 2014) [MEDLINE]
      • Systematic Review/Meta-Analysis Reported that Percutaneous Dilational Tracheostomy Had Comparable Rates of Tracheal Stenosis, as Compared to Surgical Tracheostomy (Crit Care Med, 2016) [MEDLINE]
    • Decreased Cost
      • Cost of ICU Stay with Percutaneous Dilational Tracheostomy was Lower than with Surgical Tracheostomy ($123k vs $156k) in Neurologic Critical Care Populations (Neurocrit Care, 2009) [MEDLINE]
    • Decreased Duration of Mechanical Ventilation
      • Percutaneous Dilational Tracheostomy Had Shorter Duration of Mechanical Ventilation, as Compared to Surgical Tracheostomy (19 Days vs 24 Days) in Neurologic Critical Care Populations (Neurocrit Care, 2009) [MEDLINE]
    • Decreased Risk of Stomal Site Infection
      • Systematic Review/Meta-Analysis Demonstrated a Decreased Rate of Stomal Infection with Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy Performed in the Operating Room (Crit Care, 2006) [MEDLINE]
      • Systematic Review/Meta-Analysis Reported that Percutaneous Dilational Tracheostomy Had a Lower Rate of Stomal Infection, as Compared to Surgical Tracheostomy (Crit Care Med, 2016) [MEDLINE]
      • Cochrane Database Systematic Review Demonstrated a Decreased Risk of Stomal Infection With Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy (Moderate Quality Evidence) (Cochrane Database Syst Rev, 2016) [MEDLINE]
    • Decreased Risk of Stomal Site Scarring
      • Systematic Review/Meta-Analysis Reported that Percutaneous Dilational Tracheostomy Had Comparable Rate of Stomal Scarring, as Compared to Surgical Tracheostomy (Crit Care Med, 2016) [MEDLINE]
      • Cochrane Database Systematic Review Demonstrated a Decreased Risk of Stomal Scarring With Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy (Low Quality Evidence) (Cochrane Database Syst Rev, 2016) [MEDLINE]
    • Generally Performed Sooner (Since Operating Room Time is Not Required to Be Scheduled)
      • Percutaneous Dilational Tracheostomy was Performed Sooner (Ventilator Day 8), as Compared to Surgical Tracheostomy (Ventilator Day 12) in Neurologic Critical Care Populations (Neurocrit Care, 2009) [MEDLINE]
    • High Level of Safety
      • Percutaneous Dilational Tracheostomy was Associated with Increased Risk of Perioperative Complications and Increased Perioperative Mortality Rate, as Compared to Surgical Tracheostomy (Crit Care Med, 1999) [MEDLINE]
      • Overall Complication Rates of Percutaneous Dilational Tracheostomy were Similar to Surgical Tracheostomy (Odds Ratio 0.732; 95% CI 0.05-9.37) with Similar Mortality Rates (Chest, 2000) [MEDLINE]
      • Systematic Review/Meta-Analysis Demonstrated a Decreased Clinically Relevant Bleeding and Mortality with Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy Performed in the Operating Room (Crit Care, 2006) [MEDLINE]
      • Spanish Study Reported Overall Complication Rate of 4% (intraprocedural: 2.1%, early postprocedural: 0.75%, and late postprocedural: 1.1%)(Anaesthesia, 2008) [MEDLINE]
        • Approximately 85% of Procedures were Performed by Residents Supervised by Critical Care Staff
        • Highest Complication Rates Occurred in Cases Performed by Residents During Their First 5 Attempts (9.2%), as Compared to Their Later Attempts (2.6%)
        • No Deaths Attributable to Tracheostomy Were Reported
      • Complication Rates of Percutaneous Dilational Tracheostomy were Similar to Surgical Tracheostomy (8% vs 9%) in Neurologic Critical Care Populations (Neurocrit Care, 2009) [MEDLINE]
      • In Trauma Population, Percutaneous Dilational Tracheostomy Had a Lower Mortality Rate, as Compared to Surgical Tracheostomy (Am J Surg, 2014) [MEDLINE]
      • When Performing Percutaneous Dilational Tracheostomy, the Use of a Multidisciplinary Bedside Checklist was Associated with Decreased Procedural Complications (J Trauma Acute Care Surg, 2015) [MEDLINE]
      • Systematic Review/Meta-Analysis Reported that Percutaneous Dilational Tracheostomy Had Comparable Rate of Major Bleeding, as Compared to Surgical Tracheostomy (Crit Care Med, 2016) [MEDLINE]
      • Cochrane Database Systematic Review Demonstrated Similar Major Bleeding and Mortality Rates With Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy (Low Quality Evidence) (Cochrane Database Syst Rev, 2016) [MEDLINE]
    • Shorter Operative Time
      • Percutaneous Dilational Tracheostomy Took 9.84 min Less to Perform than Surgical Tracheostomy (Chest, 2000) [MEDLINE]
  • Disadvantages of Percutaneous Dilational Tracheostomy (as Compared to Surgical Tracheostomy)
    • Risk of Anterior Tracheal Injury (Chest, 1999) [MEDLINE]
    • Risk of Posterior Tracheal Wall Perforation
      • Approximately 12.5% Rate of Posterior Tracheal Wall Injury Has Been Reported in Some Cadaver/Animal Studies (Associated with Poor Stabilization of Guidewire and Guiding Catheter) (Chest, 1999) [MEDLINE]
    • Tracheal Ring Fracture
      • With Percutaneous Dilational Tracheostomy, Conical Dilation Technique Appears to Result in a Greater Risk of Tracheal Ring Fractures than the Stepwise Dilation Technique (Intensive Care Med, 2002) [MEDLINE]

Ultrasound-Guided Percutaneous Dilational Tracheostomy

  • Clinical Efficacy
    • TRACHUS Trial Demonstrated that Ultrasound-Guided Percutaneous Dilational Tracheostomy was Non-Inferior to Bronchoscopy-Guided Percutaneous Dilational Tracheostomy (Intensive Care Med, 2016) [MEDLINE]

Surgical Tracheostomy

  • Site of Procedure
    • Bedside
    • Operating Room
  • Cautions
    • Obesity (see Obesity)
      • Morbid Obesity is Associated with Increased Risk of Life-Threatening Complications with Surgical Tracheostomy (Crit Care, 2007) [MEDLINE]
      • Tracheostomy Complication Rates are Higher in Obese Patients (Laryngoscope, 2015) [MEDLINE]: n= 151
        • Complication Rates are Particularly Higher in Obese Patients with BMI ≥35
        • Complication Rates are Particularly Higher in Obese Patients the Intraoperative and Early Postoperative Periods
        • Procedure Duration Has Also Been Noted to Be Longer in Obese Patients
  • Relative Contraindications
    • High Levels of Ventilator Support Required
      • High Level of Positive End-Expiratory Pressure (PEEP): in some cases, PEEP-dependent patients may not be able to tolerate the loss of PEEP during the procedure
      • Inability to Tolerate Periods of Respiratory Acidosis During Procedure
        • Intraprocedural Respiratory Acidosis Appears to Be More Significant During Percutaneous Dilational Tracheostomy than During Surgical Tracheostomy (Intensive Care Med, 1997) [MEDLINE]
    • Uncorrectable Coagulopathy (see Coagulopathy)
      • Bleeding and Stomal Infection Rates for Bedside Tracheostomy are Comparable to Operating Room Tracheostomy (Otolaryngol Head Neck Surg, 1993) [MEDLINE]

Common Brands/Models of Tracheostomy Tubes

Tracheostomy Sizing Comparison (Common Tracheostomy Tubes)

Shiley (Medtronic Covidien)

  • Shiley Tracheostomy Tube with Disposable Inner Cannula (DCT)
    • Sizes: 4, 6, 8, and 10
    • Cuff: cuffed or cuffless
  • Shiley Flexible Adult Tracheostomy Tube with Disposable or Reusable Inner Cannula
    • Sizes: 4, 5, 6, 7, 8, 9, and 10
    • Cuff: cuffed or cuffless
  • Shiley XLT Extended Length Tracheostomy Tube with Disposable Inner Cannula: longer length tracheostomy tube
    • Sizes: 5, 6, 7, and 8
    • Cuff: cuffed or cuffless

Portex (Smiths Medical)

  • Bivona Adult TTS Adjustable Neck Flange Hyperflex Tracheostomy Tube: adjustable length tracheostomy tube
    • Sizes
      • Size 6: 6 mm inner diameter, 9.2 mm outer diameter, maximum usable length 110 mm
      • Size 7: 7 mm inner diameter, 10.6 mm outer diameter, maximum usable length 120 mm
      • Size 8: 8 mm inner diameter, 11.7 mm outer diameter, maximum usable length 130 mm
      • Size 9: 9 mm inner diameter, 12.9 mm outer diameter, maximum usable length 140 mm
    • Cuff: cuffed
  • Portex Cuffed Blue Line Ultra Suctionaid Tracheostomy Tube: with subglottic suction port
    • Sizes: 6, 7, 8, and 9
    • Cuff: cuffed

Passy-Muir Valve

Use of the Passy-Muir Valve

  • Passy-Muir Valve is a One-Way Low-Resistance Valve Which Requires Deflation of the Tracheostomy Tube Cuff and Permits Inspiration, But Not Exhalation, Via the Tracheostomy Tube: exhalation is directed through the glottis/vocal cords, allowing phonation
    • Use of Passy-Muir Valve with Patient with Tracheostomy, But Not on Mechanical Ventilation
      • Since Mechanical Ventilation is Not Required and Tidal Volume Leak is Not an Issue, this is Tolerated in Almost All Patients (Assuming that the Non-Fenestrated Tracheostomy Size is Small Enough, Relative the Size of the Patient’s Trachea, to Allow Adequate Airflow in the Patient)
    • Use of Passy-Muir Valve with Patient with Tracheostomy and on Mechanical Ventilation
      • Since Mechanical Ventilation is Required and Tidal Volume Leak May Be an Issue, Patient Selection is Critical to Determine if the Patient Will Tolerate Trials
      • Due to Tracheostomy Tube Cuff Deflation in Patients Requiring Ventilator Support, Passy-Muir Valve Use Requires an Approximate 50% Increase in Ventilator Tidal Volume (on Volume-Cycled Ventilation) to Maintain Adequate Ventilation (Crit Care Med, 1993) [MEDLINE]
      • Alternatively, if the Patient is Able to Tolerate Pressure Support Ventilation, this Ventilation Approach May Be Utilized (Especially in Patients with Neuromuscular Disease) (Am J Respir Crit Care Med, 2003) [MEDLINE] (Chest, 2003) [MEDLINE]
  • Requirements for Passy-Muir Valve Use
    • Ability to Clear Secretions
    • Ability to Tolerate Tracheostomy Cuff Deflation
    • Adequate Gas Exchange
    • Hemodynamic Stability
    • Normal Mental Status
  • Advantages of the Passy-Muir Valve
    • Allows Laryngeal Airflow, Facilitating Recovery of Laryngeal Reflex Activity, Phonation, and Cough
    • Decreases Aspiration During Eating
      • Passy-Muir Valve Restores More Normal Subglottic and Glottic Airflow During Exhalation
    • Decreases Bronchial and Pharyngeal Secretions
      • Since Air Escaping through the Mouth and Nose Contributes to Evaporation of Secretions
    • Facilitates Secretion Clearance
      • Since Airflow is Directed Toward the Larynx
    • Improves Cough Effectiveness
      • Due to Restoration of Glottic Function
    • Reestablishes the Ability to Smell
    • Well-Tolerated
      • Can Even Be Used in Patients with Neuromuscular Disease
  • Adverse Effects/Complications of the Passy-Muir Valve
    • Inappropriate Use of Excessively Large Tracheostomy, Which Impedes Expiratory Airflow Through the Trachea
      • Tracheostomy Downsizing (If Tolerated) is the Usual Solution in These Cases
    • Accidental Use of the Passy-Muir Valve with Tracheostomy Cuff Still Inflated, Which Results in Completely Obstructed Expiratory Airflow

Tracheostomy Configurations

Tracheostomy Tube Change

Routine Tracheostomy Tube Change

  • The Tracheostomy Tube is Typically First Changed 7-14 Days After the Initial Tracheostomy Placement (Once the Tract Has Formed)
    • The First Tracheostomy Tube Change Should Be Performed in a Controlled Environment with Emergency Resources Available, in Case the Tracheostomy Cannot Be Safely Replaced and Endotracheal Intubation is Required (Respir Care, 2010) [MEDLINE]
    • Otolaryngologic Consensus Guidelines Suggest Changing the Tracheostomy Tube at 3-7 Days if Placed Operatively or at 10-14 Days if Placed Via a Percutaneous Dilational Method (Otolaryngol Head Neck Surg, 2013) [MEDLINE]
  • Subsequently, the Tracheostomy Tube Should Be Changed Every 60-90 Days

Recommended Tracheostomy Tube Changes to Address Specific Clinical Issues (Respir Care, 2010) [MEDLINE]

  • Patient Discomfort
    • Tracheostomy Tube Downsizing
  • Tracheostomy Malpositioning
    • Tracheostomy Tube Downsizing
    • Change to Longer Tracheostomy Tube
  • Patient-Ventilator Dyssynchrony
    • Change to Different Tracheostomy Tube
  • Tracheostomy Tube Cuff Leak: may occur in the setting of tracheomalacia
    • Change to Different Tracheostomy Tube
  • Tracheostomy Tube Fracture/Cuff Rupture
    • Change to New Tracheostomy Tube (of Same Size/Brand)
  • Need for Mechanical Ventilation
    • If Fenestrated or Uncuffed Tracheostomy is Being Used, Change to Cuffed, Non-Fenestrated Tracheostomy to Allow Mechanical Ventilation
  • Need for Bronchoscopy (see Bronchoscopy)
    • Bronchoscopy Generally Requires Tracheostomy Tube with Inner Diameter of ≥7.0-7.5 mm
    • Change to Larger Tracheostomy Tube (if Possible)

Tracheostomy Tube Weaning and Decannulation

Airway Evaluation by Bronchoscopy (see Bronchoscopy)

  • May Be Required in Some Cases to Evaluate for Tracheal Granulation Tissue or Other Airway Abnormalities Prior to Tracheostomy Decannulation (Chest, 1993) [MEDLINE]: while they may be present, these abnormalities are often not clinically significant
  • An Unsuccessful Initial Capping Trial May Predict a Subset of Patients Who Require Bronchoscopic Evaluation Prior to Consideration of Decannulation (Crit Care Med, 1997) [MEDLINE]

Methods of Tracheostomy Weaning

  • Progressive Tracheostomy Downsizing
    • Using a Decisional Flow Chart (with Progression to 6 mm Tracheostomy or Portex Minitrach for at Least 1 wk Prior to Decannulation), Success Rate (without Major Clinical Complications) was 80% (Intensive Care Med, 2003) [MEDLINE]
  • Progressive Trials of Fenestrated Tracheostomy Capping with Cuff Deflated (Until Tolerated for 12-48 hrs)
    • Consensus Guidelines Suggest Progressive Capping Trials Prior to Decannulation (with Downsizing When a Large Tracheostomy is Being Used) (Otolaryngol Head Neck Surg, 2013) [MEDLINE]
    • Observe Patient for Stridor and Absence of Effective Cough to Determine Success of the Capping Trial
  • Passy-Muir Valve Trials: may be used instead of capping
    • Passy-Muir Valves Do Not Impact Time to Decannulation, as Compared to Capping Trials
  • Single-Stage Tracheostomy Decannulation Protocol with Bronchoscopy (Laryngoscope, 2016) [MEDLINE]
    • Indications for Single-Stage Tracheostomy Decannulation
      • Absence of Active Infection
      • Absence of Dyspnea
      • Absence of Requirement for Ventilatory Support
      • Normal or Adequate Spirometry
      • Normal Bronchoscopy
      • Presence of Leak Around Tracheostomy Tube Cuff
      • Stable Arterial Blood Gas (ABG)
      • Stable Hemodynamic Status
    • Use of Tracheostomy Button (Tracheostomy Retainer): device which maintains the tracheostomy tract and which may be particularly useful in patients with borderline respiratory status during a prolonged period of clinical observation
      • Button May Be Particularly Useful in Patients Who Have Undergone Percutaneous Dilational Tracheostomy, as the Tracheal Stoma Tends to Close Rapidly in These Patients (Respiration, 2012) [MEDLINE]

Indications for Tracheostomy Decannulation (Respir Care, 2010) [MEDLINE]

  • Absence of Upper Airway Obstruction
  • Ability to Manage Secretions
  • Ability to Tolerate Tracheostomy Occlusion
  • Adequate Mental Status
  • Adequate Oxygenation and Ventilation
  • Effective Cough
    • In Neuromuscular Disease, Peak Cough Flow >160 mL/min Predicts Successful Decannulation
  • Resolution of Condition Which Originally Necessitated Mechanical Ventilation/Tracheostomy
  • Swallowing Function

Decannulation Failure

  • Acceptable Decannulation Failure Rate: 2-5% (Respir Care, 2009) [MEDLINE]
  • Onset of Decannulation Failure
    • Immediately after Decannulation
      • If Unstable: endotracheal intubation
      • If Stable: tracheostomy tube replacement
    • Failure after 48-96 hrs
      • If Tracheostomy Stoma Remains Open: tracheostomy tube replacement
      • If Tracheostomy is Stoma Closed: endotracheal intubation
  • Predictors of Failure to Tolerate Tracheostomy Decannulation
    • Advanced Age
    • Renal Failure
    • Severe Illness
    • Short Duration of Spontaneous Breathing Prior to Decannulation
    • Use of Tracheostomy Button
  • Options for Patients Who Cannot Tolerate Decannulation
    • Long-Term Tracheostomy Tube with Inner Cannula
    • Noninvasive Positive-Pressure Ventilation (NIPPV) with a Capped Tracheostomy Tube
    • Placement of an Airway Stent for Tracheomalacia
    • Sleep-Apnea Tube
    • Surgical Treatment for Tracheal Obstruction
    • Vocal Cord Surgery

Adverse Effects/Complications of Tracheostomy

Acute or Early Adverse Effects/Complications

Pulmonary Adverse Effects/Complications (Hours-Days)

  • Aspiration
    • Epidemiology
      • Aspiration of Oropharyngeal Secretions Commonly Occurs with Both Endotracheal Tubes and Tracheostomy Tubes (see Endotracheal Intubation)
      • Presence of Gag Reflex Does Not Confer Protection Against Aspiration with Endotracheal Intubation or Tracheostomy (Crit Care Med, 1990) [MEDLINE]
      • Aspiration is Not Increased with Occlusion of the Tracheostomy with a Cap/Finger for Phonation (Ear Nose Throat J, 2006) [MEDLINE]
    • Physiologic Mechanisms
      • Delayed Triggering of the Swallowing Response (Crit Care Med, 1990) [MEDLINE] (Br J Anaesth, 2012) [MEDLINE]
        • Swallowing Dysfunction (Particularly Disorder of the Pharyngeal Phase) and Aspiration are Common with Tracheostomy (Chest, 1994) [MEDLINE]: increasing age increases the risk of aspiration and aspiration is frequently silent
        • Increasing Tracheostomy Cuff Pressure Worsens Swallowing Dysfunction (as Measured by Submental Electromyogram and Amplitude of Laryngeal Acceleration) (Br J Anaesth, 2012) [MEDLINE]
        • Tracheostomy Removal Does Not Appear to Immediately Improve Swallowing Dysfunction (Dysphagia, 2012) [MEDLINE]
      • Pharyngeal Pooling of Secretions Above the Airway Cuff (Crit Care Med, 1990) [MEDLINE]
        • Risk of Aspiration is Correlated with the Amount of Oropharyngeal Secretions
    • Diagnosis
      • Methods to Detect Aspiration
        • Direct Visualization: considered the gold standard method to detect aspiration in tracheostomized patients
        • Glucose Oxidase Testing of Tracheal Secretions: glucose oxidase testing is easier to perform and has higher sensitivity for aspiration than methylene blue dye testing (Chest, 1993) [MEDLINE]
        • Dye Added to Tube Feedings (Evans Blue, Methylene Blue): detection of dye in tracheal aspirate indicates aspiration (Ear Nose Throat J, 2006) [MEDLINE] (J Cardiothorac Vasc Anesth, 2017) [MEDLINE]
    • Clinical
      • Fiberoptic Study of Swallowing Function in Patients with Tracheostomy (Chest, 2002) [MEDLINE]
        • Approximately 33% of Patients Manifested Aspiration
        • When Aspiration Occurred, 82% of These Cases were Silent Aspiration
        • Swallowing Success Occurred Most Frequently in Patients <70 y/o with Improving Respiratory and Medical Status
        • The Optimal Timing for Successful Swallowing Outcome was Approximately 3 wks Post-Tracheostomy in Patients >70 yo/ and 1 wk in Patients <70 y/o
  • Barotrauma
    • Physiology
      • Inadvertent Extraluminal Positioning of the Tracheostomy Fenestration During Tracheostomy Placement: for this reason, fenestrated tracheostomies are typically not selected for initial percutaneous tracheostomy placement
      • Laceration of the Posterior Tracheal Wall
    • Clinical
  • Decreased Phonation/Impaired Ability to Communicate
    • Epidemiology
      • Lack of Verbal Communication Can Be Very Frustrating for Patients Requiring Prolonged Mechanical Ventilatory Support with Either Endotracheal Intubation of Tracheostomy (Chest, 1990) [MEDLINE]
    • Clinical
      • Decreased Phonation May Be Prolonged (or Indefinite in Some Cases)
    • Prevention
      • Early Passy-Muir Valve Trials with Speech Pathology: although Passy-Muir speech valves have historically been used in tracheostomized patients (with a deflated cuff) after they have weaned from the ventilator (for at least some part of the day), data suggest that speech valve trials can be started even in mechanically ventilated tracheostomized patients and may shorten the time to phonation (Crit Care Med, 2016) [MEDLINE]
    • Treatment
      • Passy-Muir Valve: one-way valve device which requires tracheostomy cuff deflation
      • Use of Voice Tracheostomy Tube in Patients with Low PEEP Requirement (Chest, 2004) [MEDLINE]: utilizes slits to expand with positive-pressure inspiration and deflate during expiration, allowing phonation
      • Use of Communicating Tracheostomy Device (Portex Talk Tube, Communitrach I): these devices use a small diameter tube which expels gas above the tracheostomy tube cuff when the proximal end has been manually occluded (however, these devices require the use of manual occlusion and the patient frequently will be able to speak only in short sentences)
  • Hemorrhage from Tracheostomy Site
    • Physiology
      • Hemorrhage from the Tracheostomy Site May Result in Significant Blood Clots in the Airways with Consequent Difficulty Ventilating the Patient
    • Clinical
      • Hemoptysis (see Hemoptysis)
      • Increased Peak Inspiratory Pressure (PIP) on the Ventilator
    • Treatment
      • Control of Hemorrhage
      • Removal of Airway Clots: cryoprobe removal of clots may be required in cases where clots are difficult to evacuate
      • Tracheostomy Removal and Endotracheal Reintubation: may be required in cases with significant hemorrhage, as reintubation allows clot to form above the endotracheal tube cuff (tamponading the bleeding site) and prevents further soiling of the airways with blood
  • Stomal Site Infection
    • Epidemiology
      • Percutaneous Dilational Tracheostomy Has Been Demonstrated to Have a Lower Rate of Stomal Site Infection than Surgical Tracheostomy
        • Systematic Review/Meta-Analysis Demonstrated a Decreased Rate of Stomal Infection with Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy Performed in the Operating Room (Crit Care, 2006) [MEDLINE]
        • Systematic Review/Meta-Analysis Reported that Percutaneous Dilational Tracheostomy Had a Lower Rate of Stomal Infection, as Compared to Surgical Tracheostomy (Crit Care Med, 2016) [MEDLINE]
        • Cochrane Database Systematic Review Demonstrated a Decreased Risk of Stomal Infection With Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy (Moderate Quality Evidence) (Cochrane Database Syst Rev, 2016) [MEDLINE]
  • Tracheal Ring Fracture
    • Epidemiology
      • With Percutaneous Dilational Tracheostomy, Conical Dilation Technique Appears to Result in a Greater Risk of Tracheal Ring Fractures than the Stepwise Dilation Technique (Intensive Care Med, 2002) [MEDLINE]
    • Clinical
      • Subclinical Tracheal Deformity/Low-Grade Tracheal Stenosis
  • Tracheostomy Dislodgment
    • Epidemiology
      • Uncommon when Vigilant Postoperative Management is Utilized in the Intensive Care Unit
    • Clinical
      • Inability to Ventilate
        • Attempting to Ventilate Via a Dislodged Tracheostomy (with a Bag-Valve-Mask or Ventilator) Can Result in Pneumomediastinum (and Resultant Pneumothorax)
        • Inability to Ventilate May Require Emergent Removal of the Tracheostomy and Endotracheal Reintubation
    • Prevention
      • Strict Precautions Should Be Employed Regarding Patient Movement/Repositioning in the Days Following Tracheostomy Placement to Prevent Dislodgment
      • Tracheal Ring Sutures: unclear if the use of tracheal ring sutures at the time of tracheostomy placement decreases the risk of tracheostomy dislodgement (or improves the ability to replace a dislodged tracheostomy, if it occurs)
  • Tracheostomy Obstruction
    • Epidemiology
      • Partial Tracheostomy Obstruction by the Posterior Tracheal Membrane Can Occur with Percutaneous Tracheostomy: has been reported with use of the Portex Per-Fit tracheostomy tube (Chest, 2002) [MEDLINE]
      • Periodic Swelling of the Posterior Tracheal Wall with Intermittent Tracheostomy Obstruction Has Been Reported (Chest, 2003) [MEDLINE]
      • Tracheostomy Malpositioning (with >50% Obstruction of the Tracheostomy Lumen by Tissue) Has Been Reported in Up to 10% of Cases (Chest, 2008) [MEDLINE]: reported in 40/430 patients in this retrospective study performed in a acute care facility specializing in ventilator weaning
        • While Thoracic/General Surgeons were Equally Likely to Have Malpositioned Tracheostomies, Other Subspecialty Surgeons were More Likely to Have Malpositioned Tracheostomies (Odds Ratio: 6.42)
        • Malpositioned Tracheostomy was Associated with Prolonged Mechanical Ventilation
        • Malpositioned Tracheostomy was Not Associated with Increased Hospital Length of Stay or Mortality Rate
    • Physiology
      • Tracheostomy Obstruction by the Posterior Tracheal Membrane
    • Diagnostic
    • Clinical
      • Inability to Ventilate Patient
      • Failure to Wean from Mechanical Ventilation
  • Ventilator-Associated Pneumonia (VAP) (see Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia)
    • Epidemiology
      • Data are Inconclusive as to the Impact of Tracheostomy on the Risk of VAP
        • Tracheostomy (6-Fold Increased Risk), Multiple Central Venous Catheter Insertions, Use of Antacids, and Reintubation were Associated with an Increased Risk of VAP (Chest, 2001) [MEDLINE]
        • In Medical ICU Population, Early Tracheostomy (Within 48 hrs) was Associated with Decreased Mortality, Decreased VAP Rate, Decreased Rate of Accidental Extubation, Decreased ICU Length of Stay, Decreased Duration of Mechanical Ventilation, and Decreased Upper Airway Mucosal Trauma (Crit Care Med, 2004) [MEDLINE]
        • In a Surgical ICU Population, Tracheostomy Performed within 7 Days of ICU Admission was Associated with Decreased Incidence of VAP, Decreased Ventilator Time, and Decreased ICU Length of Stay (Am J Surg, 2005) [MEDLINE]: n = 185
        • Systematic Review of Mechanically Ventilated Patients Indicated that Early Tracheostomy Did Not Impact the Mortality Rate or Risk of Pneumonia, But Decreased the Duration of Mechanical Ventilation and Duration of ICU Stay (BMJ, 2005) [MEDLINE]
        • In Non-Trauma, Non-Immunocompromised Patients, Tracheostomy was Associated with a Lower Risk of VAP (Eur Respir J, 2007) [MEDLINE]
        • In Patients with Severe Traumatic Brain Injury, Early Tracheostomy (5.5 +/-1.8 Days), as Compared to Late Tracheostomy (11.0 +/- 4.3 Days) Decreased ICU Length of Stay, But Did Not Decrease Ventilator Days, Incidence of Pneumonia Prior to Tracheostomy, Hospital Cost, Hospital Length of Stay, or Mortality Rate (Surg Infect-Larchmt, 2007) [MEDLINE]
        • In Multicenter Prospective Cohort Study, Tracheostomy Did Not Improve the ICU Mortality Rate or Ventilator-Associated Pneumonia Rate (Crit Care Med, 2007) [MEDLINE]
        • In Multicenter, Randomized Italian Trial, Early Tracheostomy (Mean: 7 Days) Did Not Decrease the Risk of VAP or Mortality Rate (JAMA, 2010) [MEDLINE]
        • Early Tracheostomy (Within 10 Days) was Not Associated with Decreased Mortality Rate, ICU Length of Stay, Duration of Mechanical Ventilation, or Incidence of VAP, But was Associated with and Increased Number of Procedures and Shorter Duration of Sedation (Br J Anaesth, 2015) [MEDLINE]
      • Risk Factors Associated with Early Post-Tracheostomy VAP (Occurring ≤5 Days of Tracheostomy Placement) (Chest, 2000) [MEDLINE]: in this retrospective study, incidence of VAP was 26%, VAP occurred at mean of 9 days post-tracheostomy placement, and overall mortality rate was 33% (VAP increased mortality rate to 54%)
        • Endotracheal Aspirate with Significant Bacterial Colonization (>100k cfu/mL): the responsible VAP pathogen was present in the endotracheal aspirate on the day of tracheostomy
        • Fever (≥38.3 C) on Day of Tracheostomy Placement
        • Requirement for Sedation >24 hrs Post-Tracheostomy
      • Risk Factors Associated with Late Post-Tracheostomy VAP (Occurring >5 Days of Tracheostomy Placement) (Chest, 2000) [MEDLINE]: in this retrospective study, incidence of VAP was 26%, VAP occurred at mean of 9 days post-tracheostomy placement, and overall mortality rate was 33% (VAP increased mortality rate to 54%)
        • Duration of Sedation Prior to Tracheostomy
        • Fever (≥38.3 C) on Day of Tracheostomy Placement
      • Risk Factors Not Associated with Post-Tracheostomy VAP (Early or Late) (Chest, 2000) [MEDLINE]: in this retrospective study, incidence of VAP was 26%, VAP occurred at mean of 9 days post-tracheostomy placement, and overall mortality rate was 33% (VAP increased mortality rate to 54%)
        • Arterial pO2/FIO2 Ratio
        • Duration of Antimicrobial Administration
        • Duration of Mechanical Ventilation Prior to Tracheostomy
        • Intensive Care Unit Admitting Diagnosis
        • Indication for Tracheostomy
        • Prior Nosocomial Pneumonia
        • Use of Steroids on the Day of Tracheostomy
    • Physiologic Mechanisms Which May Contribute to Lower Airway Infection
      • Aspiration of Oropharyngeal Secretions
      • Bypass of Upper Airway Filtration Mechanism
      • Contaminated Equipment/Solutions Used for Respiratory Care
      • Impaired Tracheal Mucociliary Clearance
      • Ineffective Cough Clearance of Secretions
      • Tracheal Wall Mucosal Damage Due to Tracheostomy or Suction Trauma

Chronic or Late Adverse Effects/Complications (Weeks-Months)

Pulmonary Adverse Effects/Complications

  • Aspiration
    • Epidemiology
      • Aspiration of Oropharyngeal Secretions Commonly Occurs with Both Endotracheal Tubes and Tracheostomy Tubes (see Endotracheal Intubation)
      • Presence of Gag Reflex Does Not Confer Protection Against Aspiration with Endotracheal Intubation or Tracheostomy (Crit Care Med, 1990) [MEDLINE]
      • Aspiration is Not Increased with Occlusion of the Tracheostomy with a Cap/Finger for Phonation (Ear Nose Throat J, 2006) [MEDLINE]
    • Physiologic Mechanisms
      • Delayed Triggering of the Swallowing Response (Crit Care Med, 1990) [MEDLINE] (Br J Anaesth, 2012) [MEDLINE]
        • Swallowing Dysfunction (Particularly Disorder of the Pharyngeal Phase) and Aspiration are Common with Tracheostomy (Chest, 1994) [MEDLINE]: increasing age increases the risk of aspiration and aspiration is frequently silent
        • Increasing Tracheostomy Cuff Pressure Worsens Swallowing Dysfunction (as Measured by Submental Electromyogram and Amplitude of Laryngeal Acceleration) (Br J Anaesth, 2012) [MEDLINE]
        • Tracheostomy Removal Does Not Appear to Immediately Improve Swallowing Dysfunction (Dysphagia, 2012) [MEDLINE]
      • Pharyngeal Pooling of Secretions Above the Airway Cuff (Crit Care Med, 1990) [MEDLINE]
        • Risk of Aspiration is Correlated with the Amount of Oropharyngeal Secretions
    • Diagnosis
      • Methods to Detect Aspiration
        • Direct Visualization: considered the gold standard method to detect aspiration in tracheostomized patients
        • Glucose Oxidase Testing of Tracheal Secretions: glucose oxidase testing is easier to perform and has higher sensitivity for aspiration than methylene blue dye testing (Chest, 1993) [MEDLINE]
        • Dye Added to Tube Feedings (Evans Blue, Methylene Blue): detection of dye in tracheal aspirate indicates aspiration (Ear Nose Throat J, 2006) [MEDLINE] (J Cardiothorac Vasc Anesth, 2017) [MEDLINE]
    • Clinical
      • Fiberoptic Study of Swallowing Function in Patients with Tracheostomy (Chest, 2002) [MEDLINE]
        • Approximately 33% of Patients Manifested Aspiration
        • When Aspiration Occurred, 82% of These Cases were Silent Aspiration
        • Swallowing Success Occurred Most Frequently in Patients <70 y/o with Improving Respiratory and Medical Status
        • The Optimal Timing for Successful Swallowing Outcome was Approximately 3 wks Post-Tracheostomy in Patients >70 yo/ and 1 wk in Patients <70 y/o, Suggesting that the Probability of Aspiration Likely Decreases Over Time
  • Decreased Phonation/Impaired Ability to Communicate
    • Epidemiology
      • Lack of Verbal Communication Can Be Very Frustrating for Patients Requiring Prolonged Mechanical Ventilatory Support with Either Endotracheal Intubation of Tracheostomy (Chest, 1990) [MEDLINE]
    • Clinical
      • Decreased Phonation May Be Prolonged (or Indefinite in Some Cases)
    • Prevention
      • Early Passy-Muir Valve Trials with Speech Pathology: although Passy-Muir speech valves have historically been used in tracheostomized patients (with a deflated cuff) after they have weaned from the ventilator (for at least some part of the day), data suggest that speech valve trials can be started even in mechanically ventilated tracheostomized patients and may shorten the time to phonation (Crit Care Med, 2016) [MEDLINE]
    • Treatment
      • Passy-Muir Valve: one-way valve device which requires tracheostomy cuff deflation
      • Use of Voice Tracheostomy Tube in Patients with Low PEEP Requirement (Chest, 2004) [MEDLINE]: utilizes slits to expand with positive-pressure inspiration and deflate during expiration, allowing phonation
      • Use of Communicating Tracheostomy Device (Portex Talk Tube, Communitrach I): these devices use a small diameter tube which expels gas above the tracheostomy tube cuff when the proximal end has been manually occluded (however, these devices require the use of manual occlusion and the patient frequently will be able to speak only in short sentences)
  • Stomal Site Infection
    • Epidemiology
      • Percutaneous Dilational Tracheostomy Has Been Demonstrated to Have a Lower Rate of Stomal Site Infection than Surgical Tracheostomy
        • Systematic Review/Meta-Analysis Demonstrated a Decreased Rate of Stomal Infection with Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy Performed in the Operating Room (Crit Care, 2006) [MEDLINE]
        • Systematic Review/Meta-Analysis Reported that Percutaneous Dilational Tracheostomy Had a Lower Rate of Stomal Infection, as Compared to Surgical Tracheostomy (Crit Care Med, 2016) [MEDLINE]
        • Cochrane Database Systematic Review Demonstrated a Decreased Risk of Stomal Infecti
  • Stomal Site Scarring
    • Epidemiology
      • Percutaneous Dilational Tracheostomy Has Been Demonstrated to Have a Lower Rate of Stomal Scarring than Surgical Tracheostomy
        • Systematic Review/Meta-Analysis Reported that Percutaneous Dilational Tracheostomy Had Comparable Rate of Stomal Scarring, as Compared to Surgical Tracheostomy (Crit Care Med, 2016) [MEDLINE]
        • Cochrane Database Systematic Review Demonstrated a Decreased Risk of Stomal Scarring With Percutaneous Dilational Tracheostomy, as Compared to Surgical Tracheostomy (Low Quality Evidence) (Cochrane Database Syst Rev, 2016) [MEDLINE]
  • Tracheal Ring Fracture
    • Epidemiology
      • With Percutaneous Dilational Tracheostomy, Conical Dilation Technique Appears to Result in a Greater Risk of Tracheal Ring Fractures than the Stepwise Dilation Technique (Intensive Care Med, 2002) [MEDLINE]
    • Clinical
      • Subclinical Tracheal Deformity/Low-Grade Tracheal Stenosis
  • Tracheal Stenosis (see Tracheal Stenosis)
    • Epidemiology
      • Tracheal Stenosis Below the Glottis But Above the Tracheal Stoma Has Been Reported Following Percutaneous Tracheostomy (Crit Care Med, 2003) [MEDLINE]
      • Studies Report that Tracheal Stenosis Occurred a Mean of 54.5 Days After Tracheostomy Placement with 85% of Cases Demonstrating Stenosis Located Around the Tracheal Stoma (BMC Pulm Med, 2008) [MEDLINE]
        • In Contrast, Patients with Tracheal Stenosis Due to Endotracheal Intubation Predominantly Manifest Web-Like Stenosis at the Cuff Site
      • Incidence of Post-Tracheostomy Tracheal Stenosis is Approximately 2.6% (Otolaryngol Head Neck Surg, 2018) [MEDLINE]
      • Risk Factors for Post-Tracheostomy Tracheal Stenosis (Otolaryngol Head Neck Surg, 2018) [MEDLINE]
        • Endotracheal Tube Cuff Pressure ≥30 mm H2O
        • Failure to Create a Bjork Flap
        • Insertion of an Initial Tracheostomy Tube Size >6
        • Obesity (see Obesity)
        • Percutaneous Tracheostomy Insertion Technique
        • Tracheostomy After 10 Days of Endotracheal Intubation
    • Physiology
      • Development of Granulation Tissue
    • Clinical
      • Failure to Wean from Mechanical Ventilation
      • High Peak Airway Pressure (PIP)
    • Treatment
      • Placement of Longer Tracheostomy Tube with Orifice Beyond the Site of Tracheal Stenosis
      • Rigid Bronchoscopy with Nd:YAG Laser Treatment and Mechanical/Balloon Dilatation: preferred treatment (BMC Pulm Med, 2008) [MEDLINE]
      • Tracheal Stent Placement (see Airway Stent)
      • Surgery: required only in a small percentage of cases (BMC Pulm Med, 2008) [MEDLINE]
  • Tracheoarterial Fistula (see Tracheoinnominate Artery Fistula])
    • Epidemiology
      • This Complication Occurred More Commonly in the Past, Associated with a Low-Positioned Tracheostomy Tube (Ann Surg, 1976) [MEDLINE]
      • Current Incidence: <1% of cases (Chest, 2005) [MEDLINE]
    • Physiology
      • Usually a Tracheoinnominate Artery Fistula
      • Erosion of the Tracheostomy Tube Tip or Cuff into the Anterior Wall of the Trachea, Resulting in a Fistula into the Innominate Artery as it Passes Anterior to the Trachea
    • Diagnostic
      • Bronchoscopy (see Bronchoscopy): may be useful in cases which are not massive
      • CT Angiogram: may be useful in cases which are not massive
    • Clinical
      • Hemoptysis (see Hemoptysis): may be preceded by a “sentinel bleed” and may be massive
    • Treatment
      • Temporizing Measures: overinflate the tracheostomy tube/endotracheal tube cuff (to compress the innominate artery), remove tracheostomy and place an oral endotracheal tube (with cuff distal to the site of the fistula), or insert a finger into the tracheostomy stoma and advance distally in the trachea with compression anteriorly toward the sternum (“little Dutch boy maneuver”)
      • Prompt Surgical Intervention is Required
    • Prognosis
      • Mortality Rate: 86% (Clin Chest Med, 1991) [MEDLINE]
  • Tracheoesophageal Fistula (see Tracheoesophageal Fistula,)
    • Epidemiology
      • Most Cases of Tracheoesophageal Fistula are Due to Endotracheal Intubation, Rather than Tracheostomy (see Endotracheal Intubation)
      • Risk Factors (J Anaesthesiol Clin Pharmacol, 2012) [MEDLINE]
        • Corticosteroids (see Corticosteroids): possible risk factor
        • Diabetes Mellitus (see Diabetes Mellitus): possible risk factor
        • Excessive Motion of the Tracheostomy Tube/Endotracheal Tube
        • High Airway Pressures
        • High Cuff Pressure in the Tracheostomy Tube/Endotracheal Tube Cuff: predominant risk factor
        • Infection: possible risk factor
        • Nasogastric Tube (see Nasogastric-Orogastric Tube): possible risk factor
        • Prolonged Duration of Mechanical Ventilation
    • Diagnostic
    • Physiology
      • Erosion of Tracheostomy Tube or Cuff into the Posterior Tracheal Wall, Fistulizing into the Esophagus
    • Clinical
    • Treatment
      • Avoidance of Enteral Nutrition
      • Elevation of the Head of the Bed
      • Frequent Suctioning
      • Positioning of the Endotracheal Tube Cuff Distal to the Site of the Fistula
      • Stenting: may be used for palliation or temporary medical management until closure can be accomplished
      • Closure
        • Endoscopic Closure
        • Surgical Correction: definitive cure (since spontaneous closure is rare), although operative mortality is approximately 11%
  • Tracheomalacia (see Tracheobronchomalacia)
    • Physiology
      • Damage to Tracheal Cartilage at Stoma/Cuff/Distal Tube Sites Due to Pressure Necrosis, Impaired Blood Flow, Recurrent Infection, Mucosal Friction, or Mucosal Inflammation
    • Clinical
      • Usually Segmental Tracheomalacia (with Maximum Length of 3 cm)
    • Clinical
      • Failure to Wean from Mechanical Ventilation
  • Ventilator-Associated Pneumonia (VAP) (see Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia)
    • Epidemiology
      • Data are Inconclusive as to the Impact of Tracheostomy on the Risk of VAP
        • Tracheostomy (6-Fold Increased Risk), Multiple Central Venous Catheter Insertions, Use of Antacids, and Reintubation were Associated with an Increased Risk of VAP (Chest, 2001) [MEDLINE]
        • In Medical ICU Population, Early Tracheostomy (Within 48 hrs) was Associated with Decreased Mortality, Decreased VAP Rate, Decreased Rate of Accidental Extubation, Decreased ICU Length of Stay, Decreased Duration of Mechanical Ventilation, and Decreased Upper Airway Mucosal Trauma (Crit Care Med, 2004) [MEDLINE]
        • In a Surgical ICU Population, Tracheostomy Performed within 7 Days of ICU Admission was Associated with Decreased Incidence of VAP, Decreased Ventilator Time, and Decreased ICU Length of Stay (Am J Surg, 2005) [MEDLINE]: n = 185
        • Systematic Review of Mechanically Ventilated Patients Indicated that Early Tracheostomy Did Not Impact the Mortality Rate or Risk of Pneumonia, But Decreased the Duration of Mechanical Ventilation and Duration of ICU Stay (BMJ, 2005) [MEDLINE]
        • In Non-Trauma, Non-Immunocompromised Patients, Tracheostomy was Associated with a Lower Risk of VAP (Eur Respir J, 2007) [MEDLINE]
        • In Patients with Severe Traumatic Brain Injury, Early Tracheostomy (5.5 +/-1.8 Days), as Compared to Late Tracheostomy (11.0 +/- 4.3 Days) Decreased ICU Length of Stay, But Did Not Decrease Ventilator Days, Incidence of Pneumonia Prior to Tracheostomy, Hospital Cost, Hospital Length of Stay, or Mortality Rate (Surg Infect-Larchmt, 2007) [MEDLINE]
        • In Multicenter Prospective Cohort Study, Tracheostomy Did Not Improve the ICU Mortality Rate or Ventilator-Associated Pneumonia Rate (Crit Care Med, 2007) [MEDLINE]
        • In Multicenter, Randomized Italian Trial, Early Tracheostomy (Mean: 7 Days) Did Not Decrease the Risk of VAP or Mortality Rate (JAMA, 2010) [MEDLINE]
        • Early Tracheostomy (Within 10 Days) was Not Associated with Decreased Mortality Rate, ICU Length of Stay, Duration of Mechanical Ventilation, or Incidence of VAP, But was Associated with and Increased Number of Procedures and Shorter Duration of Sedation (Br J Anaesth, 2015) [MEDLINE]
      • Risk Factors Associated with Early Post-Tracheostomy VAP (Occurring ≤5 Days of Tracheostomy Placement) (Chest, 2000) [MEDLINE]: in this retrospective study, incidence of VAP was 26%, VAP occurred at mean of 9 days post-tracheostomy placement, and overall mortality rate was 33% (VAP increased mortality rate to 54%)
        • Endotracheal Aspirate with Significant Bacterial Colonization (>100k cfu/mL): the responsible VAP pathogen was present in the endotracheal aspirate on the day of tracheostomy
        • Fever (≥38.3 C) on Day of Tracheostomy Placement
        • Requirement for Sedation >24 hrs Post-Tracheostomy
      • Risk Factors Associated with Late Post-Tracheostomy VAP (Occurring >5 Days of Tracheostomy Placement) (Chest, 2000) [MEDLINE]: in this retrospective study, incidence of VAP was 26%, VAP occurred at mean of 9 days post-tracheostomy placement, and overall mortality rate was 33% (VAP increased mortality rate to 54%)
        • Duration of Sedation Prior to Tracheostomy
        • Fever (≥38.3 C) on Day of Tracheostomy Placement
      • Risk Factors Not Associated with Post-Tracheostomy VAP (Early or Late) (Chest, 2000) [MEDLINE]: in this retrospective study, incidence of VAP was 26%, VAP occurred at mean of 9 days post-tracheostomy placement, and overall mortality rate was 33% (VAP increased mortality rate to 54%)
        • Arterial pO2/FIO2 Ratio
        • Duration of Antimicrobial Administration
        • Duration of Mechanical Ventilation Prior to Tracheostomy
        • Intensive Care Unit Admitting Diagnosis
        • Indication for Tracheostomy
        • Prior Nosocomial Pneumonia
        • Use of Steroids on the Day of Tracheostomy
    • Physiologic Mechanisms Which May Contribute to Lower Airway Infection
      • Aspiration of Oropharyngeal Secretions
      • Bypass of Upper Airway Filtration Mechanism
      • Contaminated Equipment/Solutions Used for Respiratory Care
      • Impaired Tracheal Mucociliary Clearance
      • Ineffective Cough Clearance of Secretions
      • Tracheal Wall Mucosal Damage Due to Tracheostomy or Suction Trauma

References

General

  • Verbal communication of ventilator-dependent patients. Crit Care Med 1993; 21:512-517
  • Scintigraphic quantification of aspiration reduction with the Passy-Muir valve. Laryngoscope 1996; 106:231-234

Indications

  • Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med. 1999;159(2):383 [MEDLINE]
  • Changes in respiratory mechanics after tracheostomy. Arch Surg. 1999;134(1):59 [MEDLINE]
  • Pulmonary mechanics in patients with prolonged mechanical ventilation requiring tracheostomy. Anaesth Intensive Care. 1999;27(6):581 [MEDLINE]
  • Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med. 1999;27(9):1714 [MEDLINE]
  • How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med. 2000;161(5):1450 [MEDLINE]
  • The role of dead space ventilation in predicting outcome of successful weaning from mechanical ventilation. J Trauma. 2001;51(5):843 [MEDLINE]
  • Effects of tracheotomy on respiratory mechanics in spontaneously breathing patients. Eur Respir J. 2002;20(1):112 [MEDLINE]
  • Hospital and long-term outcome after tracheostomy for respiratory failure. Chest. 2004;125(1):220 [MEDLINE]
  • Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med. 2005;33(11):2527 [MEDLINE]
  • Outcome of mechanically ventilated patients who require a tracheostomy. Crit Care Med. 2005;33(2):290 [MEDLINE]
  • Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005;330:1243 [MEDLINE]
  • Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med. 2005;33(11):2513 [MEDLINE]
  • Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med. 2005;33(11):2527 [MEDLINE]
  • Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med. 2007;35(3):802 [MEDLINE]
  • Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med. 2007;35(1):132 [MEDLINE]
  • Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010;303(15):1483 [MEDLINE]
  • The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Chest 2011;140(6):1456–1465 [MEDLINE]
  • Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial. Ann Intern Med 2011;154:373–383 [MEDLINE]
  • Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2012 [MEDLINE]
  • Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121 [MEDLINE]
  • Effect of Tracheostomy on Weaning Parameters in Difficult-to-Wean Mechanically Ventilated Patients: A Prospective Observational Study. PLoS One. 2015;10(9):e0138294 [MEDLINE]
  • Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials. Br J Anaesth. 2015;114(3):396 [MEDLINE]
  • Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials. Crit Care. 2015;19:424 [MEDLINE]
  • Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study. Crit Care Med. 2016 Aug;44(8):1506-14 [MEDLINE]

Technique

  • Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med. 1991;19(8):1018 [MEDLINE]
  • The safety and efficacy of bedside tracheotomy. Otolaryngol Head Neck Surg. 1993;109(4):707 [MEDLINE]
  • Comparison between conventional cap and one-way valve in the decannulation of patients with long-term tracheostomies. Respir Care. 1993; 38:1161
  • The technique of weaning from tracheostomy. Criteria for weaning; practical measures to prevent failure. J Crit Illn. 1995;10(10):729 [MEDLINE]
  • Some important details in the technique of percutaneous dilatational tracheostomy via the modified Seldinger technique. Chest. 1996;110(3):762 [MEDLINE]
  • Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy. Intensive Care Med. 1997;23(8):859 [MEDLINE]
  • Tracheostomy tube occlusion protocol predicts significant tracheal obstruction to air flow in patients requiring prolonged mechanical ventilation. Crit Care Med. 1997;25(3):413 [MEDLINE]
  • Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy. A clinical randomised study. Acta Anaesthesiol Scand. 1998;42(5):545 [MEDLINE]
  • Posterior tracheal wall perforation during percutaneous dilational tracheostomy: an investigation into its mechanism and prevention. Chest. 1999;115(5):1383 [MEDLINE]
  • Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med. 1999;27(8):1617 [MEDLINE]
  • A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000;118(5):1412 [MEDLINE]
  • Complications of bronchoscopically guided percutaneous dilational tracheostomy: beyond the learning curve. Intensive Care Med. 2002;28(1):59 [MEDLINE]
  • Safety of percutaneous dilational tracheostomy in patients ventilated with high positive end-expiratory pressure (PEEP). Intensive Care Med. 2003;29(6):944 [MEDLINE]
  • The utility of chest radiographs following percutaneous dilatational tracheostomy. Chest. 2003;123(5):1603 [MEDLINE]
  • Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome. Intensive Care Med. 2003;29(5):845 [MEDLINE]
  • Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up. Crit Care Med. 2006;34(8):2145 [MEDLINE]
  • Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55 [MEDLINE]
  • A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients. Crit Care. 2007;11(1):R3 [MEDLINE]
  • Risk factors associated with bleeding during and after percutaneous dilational tracheostomy. Anaesthesia. 2007;62(4):342 [MEDLINE]
  • Safety and complications of percutaneous tracheostomy in a cohort of 800 mixed ICU patients. Anaesthesia. 2008;63(11):1198 [MEDLINE]
  • Safety and feasibility of percutaneous tracheostomy performed by neurointensivists. Neurocrit Care. 2009;10(3):264 [MEDLINE]
  • When to change a tracheostomy tube. Respir Care. 2010 Aug;55(8):1069-75 [MEDLINE]
  • Tracheostomy decannulation. Respir Care. 2010 Aug;55(8):1076-81 [MEDLINE]
  • Predictors of successful decannulation using a tracheostomy retainer in patients with prolonged weaning and persisting respiratory failure. Respiration. 2012;84(6):469-76 [MEDLINE]
  • Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013 Jan;148(1):6-20 [MEDLINE]
  • Advantages of US in percutaneous dilatational tracheostomy: randomized controlled trial and review of the literature. Radiology. 2014 Dec;273(3):927-36 [MEDLINE]
  • Incidence of overall complications and symptomatic tracheal stenosis is equivalent following open and percutaneous tracheostomy in the trauma patient. Am J Surg. 2014;208(5):770 [MEDLINE]
  • The impact of obesity on adult tracheostomy complication rate. Laryngoscope. 2015 Jan;125(1):105-10 [MEDLINE]
  • The impact of a multidisciplinary safety checklist on adverse procedural events during bedside bronchoscopy-guided percutaneous tracheostomy. J Trauma Acute Care Surg. 2015 Jul;79(1):111-6 [MEDLINE]
  • Long-Term Outcome Following Tracheostomy in Critical Care: A Systematic Review. Crit Care Med. 2016 Mar;44(3):617-28 [MEDLINE]
  • Ultrasound-guided percutaneous dilational tracheostomy versus bronchoscopy-guided percutaneous dilational tracheostomy in critically ill patients (TRACHUS): a randomized noninferiority controlled trial. Intensive Care Med. 2016 Mar;42(3):342-51 [MEDLINE]
  • Use of Bronchoscopy in Percutaneous Dilational Tracheostomy. JAMA Otolaryngol Head Neck Surg. 2016 Feb;142(2):143-9[MEDLINE]
  • Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev. 2016;7:CD008045 [MEDLINE]
  • Feasibility of a single-stage tracheostomy decannulation protocol with endoscopy in adult patients. Laryngoscope. 2016;126(9):2057 [MEDLINE]

Decannulation

  • A North American survey of respiratory therapist and physician tracheostomy decannulation practices. Respir Care 2009;54(12):1658-166 [MEDLINE]
  • Tracheostomy decannulation. Respir Care. 2010 Aug;55(8):1076-81 [MEDLINE]

Adverse Effects/Complications

  • Ulcerative tracheo-oesophageal fistula during treatment by tracheostomy and intermittent positive pressure ventilation. Thorax. 1972;27(3):338 [MEDLINE]
  • Tracheo-innominate artery erosion: Successful surgical management of a devastating complication. Ann Surg. 1976;184(2):194 [MEDLINE]
  • Tracheostomy and its complications. A retrospective study of 794 tracheostomized patients. Ann Chir Gynaecol. 1981;70(3):96 [MEDLINE]
  • Tracheoesophageal fistula formation in intubated patients. Risk factors and treatment with high-frequency jet ventilation. Chest. 1990;98(1):161 [MEDLINE]
  • Importance of verbal communication for the ventilator-dependent patient. Chest. 1990;98(4):792 [MEDLINE]
  • Swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes. Crit Care Med. 1990;18(12):1328 [MEDLINE]
  • Late complications of tracheotomy. Clin Chest Med. 1991 Sep;12(3):597-609 [MEDLINE]
  • Comparison of blue dye visualization and glucose oxidase test strip methods for detecting pulmonary aspiration of enteral feedings in intubated adults. Chest. 1993;103(1):117 [MEDLINE]
  • Verbal communication of ventilator-dependent patients. Crit Care Med. 1993;21(4):512 [MEDLINE]
  • Increased frequency of obstructive airway abnormalities with long-term tracheostomy. Chest. 1993;104(1):136 [MEDLINE]
  • Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest. 1994;105(2):563 [MEDLINE]
  • Management of acquired tracheoesophageal fistula. Chest Surg Clin N Am. 1996 Nov;6(4):819-36 [MEDLINE]
  • Predisposing factors for nosocomial pneumonia in patients receiving mechanical ventilation and requiring tracheotomy. Chest. 2000;118(3):767 [MEDLINE]
  • The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest. 2001;120(2):555 [MEDLINE]
  • Percutaneous tracheostomy tube obstruction: warning. Chest. 2002;122(4):1377 [MEDLINE]
  • Complications of bronchoscopically guided percutaneous dilational tracheostomy: beyond the learning curve. Intensive Care Med. 2002;28(1):59 [MEDLINE]
  • Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheotomy. Chest. 2002;122(5):1721 [MEDLINE]
  • Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication. Chest. 2003;123(5):1595 [MEDLINE]
  • Tracheoesophageal fistula. Chest Surg Clin N Am. 2003 May;13(2):271-89 [MEDLINE]
  • Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. Am J Respir Crit Care Med. 2003;167(2):114 [MEDLINE]
  • Clinical ventilator adjustments that improve speech. Chest. 2003;124(4):1512 [MEDLINE]
  • Tracheal stenosis and obliteration above the tracheostoma after percutaneous dilational tracheostomy. Crit Care Med. 2003;31(5):1574 [MEDLINE]
  • Tracheostomy tube enabling speech during mechanical ventilation. Chest. 2004;125(3):1046 [MEDLINE]
  • A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004;32(8):1689 [MEDLINE]
  • Emphysema and pneumothorax after percutaneous tracheostomy: case reports and an anatomic study. Chest. 2004;125(5):1805 [MEDLINE]
  • Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review. Crit Care. 2004;8(5):R347 [MEDLINE]
  • The incidence of tracheoarterial fistula in patients with chronic tracheostomy tubes: a retrospective study of 544 patients in a long-term care facility. Chest. 2005;128(6):3906 [MEDLINE]
  • Early tracheostomy versus late tracheostomy in the surgical intensive care unit. Am J Surg. 2005;189(3):293 [MEDLINE]
  • Secretions, occlusion status, and swallowing in patients with a tracheotomy tube: a descriptive study. Ear Nose Throat J. 2006;85(12):831 [MEDLINE]
  • A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients. Crit Care. 2007;11(1):R3 [MEDLINE]
  • Review of tracheo-esophageal fistula associated with endotracheal intubation. J Surg Educ. 2007 Jul-Aug;64(4):237-40 [MEDLINE]
  • Relationship between tracheotomy and ventilator-associated pneumonia: a case control study. Eur Respir J. 2007;30(2):314 [MEDLINE]
  • Early versus late tracheostomy in patients with severe traumatic head injury. Surg Infect (Larchmt). 2007;8(3):343 [MEDLINE]
  • Effect of positive expiratory pressure and type of tracheal cuff on the incidence of aspiration in mechanically ventilated patients in an intensive care unit. Crit Care Med. 2008;36(2):409 [MEDLINE]
  • Tracheostomy tube malposition in patients admitted to a respiratory acute care unit following prolonged ventilation. Chest. 2008;134(2):288 [MEDLINE]
  • Post tracheostomy and post intubation tracheal stenosis: report of 31 cases and review of the literature. BMC Pulm Med. 2008 [MEDLINE]
  • Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed tracheostomy tube. Respir Care. 2010 Dec;55(12):1661-70 [MEDLINE]
  • A clinical audit of the management of patients with a tracheostomy in an Australian tertiary hospital intensive care unit: Focus on speech-language pathology. Int J Speech Lang Pathol. 2011 Dec;13(6):518-2 [MEDLINE]
  • Posttracheostomy tracheoesophageal fistula. J Anaesthesiol Clin Pharmacol. 2012 Jan;28(1):140-1 [MEDLINE]
  • Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. Br J Anaesth. 2012 Oct;109(4):578-83 [MEDLINE]
  • Does removal of tracheostomy affect dysphagia? A kinematic analysis. Dysphagia. 2012 Dec;27(4):498-503 [MEDLINE]
  • Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience. Ann Thorac Surg. 2013 Apr;95(4):1141-6 [MEDLINE]
  • Optimizing Communication in Mechanically Ventilated Patients. J Med Speech Lang Pathol. 2014;21(4):309-31 [MEDLINE]
  • Causes and consequences of adult laryngotracheal stenosis. Laryngoscope. 2015 May;125(5):1137-43 [MEDLINE]
  • The impact of obesity on adult tracheostomy complication rate. Laryngoscope. 2015 Jan;125(1):105-10 [MEDLINE]
  • Endoscopic closure of acquired oesophagorespiratory fistulas with cardiac septal defect occluders or vascular plugs. Respir Med. 2015 Aug;109(8):1069-78 [MEDLINE]
  • Split latissimus dorsi muscle flap repair of acquired, nonmalignant, intrathoracic tracheoesophageal and bronchoesophageal fistulas. Heart Lung Circ. 2015 Jun;24(6):e75-8 [MEDLINE]
  • Return of Voice for Ventilated Tracheostomy Patients in ICU: A Randomized Controlled Trial of Early-Targeted Intervention. Crit Care Med. 2016 Jun;44(6):1075-81 [MEDLINE]
  • Surgical Management of Benign Acquired Tracheoesophageal Fistulas: A Ten-Year Experience. Ann Thorac Surg. 2016;102(4):1081 [MEDLINE]
  • Treatment of large persistent tracheoesophageal peristomal fistulas using silicon rings. Braz J Otorhinolaryngol. 2016 Jul [MEDLINE]
  • A New Modified Evans Blue Dye Test as Screening Test for Aspiration in Tracheostomized Patients. J Cardiothorac Vasc Anesth. 2017;31(2):441 [MEDLINE]
  • Risk Factors for Posttracheostomy Tracheal Stenosis. Otolaryngol Head Neck Surg. 2018 Aug 21:194599818794456 [MEDLINE]