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
  • Randomized SETPOINT2 Trial of Early Tracheostomy in Severe Acute Ischemic/Hemorrhagic Cerebrovascular Accident (CVA) (JAMA, 2022) [MEDLINE]: n = 366
    • Tracheostomy (Predominantly Percutaneously) was Performed in 95.2% of the Early Tracheostomy Group at a Median of 4 Days After Intubation (Interquartile Range: 3-4 Days) and in 67% of the Control Group at a Median of 11 Days After Intubation (Interquartile Range: 10-12 Days)
    • The Proportion without Severe Disability (Modified Rankin Scale Score: 0-4) at 6 Months was Not Significantly Different in the Early Tracheostomy vs the Control Group (43.5% vs 47.1%; Difference: −3.6%; 95% CI: −14.3% to 7.2%]; Adjusted Odds Ratio 0.93; 95% CI: 0.60-1.42]; P = 0.73)
    • Of the Serious Adverse Events (Related to Tracheostomy), Rates were 5.0% in the Early Tracheostomy Group vs 3.4% in the Control Group
    • Conclusion
      • In Patients with Severe Ischemic/Hemorrhagic Stroke Requiring Invasive Mechanical Ventilation, a Early Tracheostomy Did Not Significantly Improve the Survival Rate without Severe Disability at 6 Months, as Compared to Standard Approach to Tracheostomy
      • However, the Wide Confidence Intervals Around the Effect Estimate May Include a Clinically Important Difference (Therefore, a Clinically Relevant Benefit or Harm from Early Tracheostomy Cannot Be Excluded)

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
  • Multicenter Retrospective Cohort Study of Timing of Tracheostomy in Critically Ill, Mechanically Ventilated Patients (J Intensive Care, 2022) [MEDLINE]: n = 1,538 (from 46 ICU’s)
    • Quartiles for Timing of Tracheostomy Placement
      • Quartile 1: ≤ 6 days
      • Quartile 2: 7-10 days
      • Quartile 3: 11-14 days
      • Quartile 4: > 14 days
    • Hospital Mortality was Significantly Higher in Quartile 2 (Adjusted Odds Ratio 1.52, 95% CI: 1.08-2.13), Quartile 3 (Adjusted Odds Ratio 1.82, 95% CI: 1.28-2.59), and Quartile 4 (Adjusted Odds Ratio 2.26, 95% CI: 1.61-3.16) (p for Trend < 0.001), as Compared to Quartile 1
    • A Similar Trend was Observed in the Subgroup Analyses of Patients with Impaired Consciousness (Glasgow Coma Scale Score < 8) and Respiratory Failure (pO2:FiO2 Ratio ≤ 300) at ICU Admission (p for Trend = 0.081 and 0.001, Respectively)
    • Authors Concluded that the Timing of Tracheostomy was Significantly and Independently Associated with Hospital Mortality Rate in a Stepwise Manner

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)

Ultrasound-Guided Percutaneous Dilational Tracheostomy

Surgical Tracheostomy

Common Brands/Models of Tracheostomy Tubes

Tracheostomy Sizing Comparison (Common Tracheostomy Tubes)

Shiley (Medtronic Covidien)

Portex (Smiths Medical)

Passy-Muir Valve

Use of the Passy-Muir Valve

Tracheostomy Configurations

Tracheostomy Tube Change

Routine Tracheostomy Tube Change

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

Tracheostomy Tube Weaning and Decannulation

Airway Evaluation by Bronchoscopy (see Bronchoscopy)

Methods of Tracheostomy Weaning

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

Decannulation Failure


Adverse Effects/Complications of Tracheostomy

Acute or Early Adverse Effects/Complications

Pulmonary Adverse Effects/Complications (Hours-Days)

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

Pulmonary Adverse Effects/Complications


References

General

Indications

Technique

Decannulation

Adverse Effects/Complications