- •
Tracheostomy has several advantages compared with endotracheal intubation, including facilitation in weaning from mechanical ventilation, comfort, and ability to eat and speak.
- •
Percutaneous tracheostomy, especially with the Ciaglia dilatational technique, is becoming the standard of care and can be performed at bedside. The technique can lead to decreased health resource use and is associated with less stomal infection and bleeding compared with surgical tracheostomy.
- •
Bronchoscopy and ultrasound
The Changing Role for Tracheostomy in Patients Requiring Mechanical Ventilation
Section snippets
Key points
Advantages of tracheostomy compared with endotracheal tubes
Tracheostomy has several advantages over endotracheal intubation.
- 1.
Improved respiratory physiology
Tracheostomy tube bypasses the upper airway and can reduce the dead space by up to 100 mL compared with an unintubated patient.4 However, the difference in dead space between tracheostomy and endotracheal tubes of the same diameter is only 10 to 20 mL.5
Davis and colleagues5 compared tracheostomy and endotracheal tubes of similar internal diameter and found that tracheostomy tubes reduce the work of
Tracheostomy techniques
Tracheostomy can be performed with either a percutaneous or open surgical approach. Although the first report of percutaneous tracheostomy (PT) dates back to 1957,15 it became popular when the Seldinger technique with dilatation was first described by Ciaglia and colleagues in 1985.16 The technique was modified in 1998 when a series of graduated dilators was replaced with a single tapered dilator.17 Since its introduction, this technique has gained increasing popularity compared with surgical
Efficacy and Safety Comparison
In a recent meta-analysis by Putensen and colleagues29 following the Cochrane Collaboration guidelines, PT was compared with ST in 14 randomized, controlled trials, including 973 patients. PT was faster (median time reduction, 13 minutes; 95% confidence interval, −19.3 to −6.7 minutes; P<.0001). PT was associated with decreased risk of stomal inflammation, infection, and bleeding (odds ratios, 0.38, 0.22, and 0.39, respectively, all statistically significant). However, PT was associated with
Timing of tracheostomy
Tracheostomies are performed in most institutions within 2 weeks of prolonged mechanical ventilation.18, 31 There is a long-standing controversy about the ideal time for tracheostomy. Many studies looked into early tracheostomy's role in decreasing ventilator-associated pneumonias, early weaning from the ventilator, decreased sedation, and shorter ICU and hospital stay with conflicting results.14, 32, 33, 34 A large, multicenter, randomized, controlled trial was conducted by Young and
Obese
Obesity is considered a risk factor for increased complications for many surgical procedures including tracheostomy.35 However, Romero and colleagues36 found that the complication rate was similar in obese versus nonobese patients (8% vs 7.5%; P = 1) in their prospective study of PT in 120 patients. Preoperative US and bronchoscopy were used for the procedures. Extra long tracheostomy tubes are frequently used for obese patients to ensure optimal positioning in the trachea.
Unstable or Fractured Cervical Spine
PT is increasingly
Complications of tracheostomy
Early and late complications of tracheostomy are summarized in Box 1.40
Long-term tracheostomy management
- •
Initial tracheostomy tube change is performed 7 days after the percutaneous tube placement, to allow a mature tract to form.49 Replacement of a tube before this time can lead to insertion into a false tract, especially in obese patients. The inner cannulas are changed daily to prevent mucus plugging. Subsequent tracheostomy changes are done every 2 to 4 weeks to decrease granulation tissue formation.50
- •
The cuff pressure is monitored with a calibrated device and maintained at less than 20 mm Hg.1
Summary
Tracheostomy tubes are increasingly used to manage patients with prolonged respiratory failure and management of upper airway impairment. PT using the Ciaglia technique is commonly utilized. It is important to recognize the complications of tracheostomy, and measures should be taken to prevent these complications before, during, and after insertion of tracheostomy tubes. Multidisciplinary and protocolized approach with optimal training of the caregivers is essential for long-term management of
References (52)
- et al.
Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials
Br J Anaesth
(2015) - et al.
Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients
Am J Med
(1981) - et al.
Some important details in the technique of percutaneous dilatational tracheostomy via the modified Seldinger technique
Chest
(1996) - et al.
Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report
Chest
(1985) - et al.
Comparison between single-step and balloon dilatational tracheostomy in intensive care unit: a single-centre, randomized controlled study
Br J Anaesth
(2010) - et al.
Comparison of open versus bedside percutaneous dilatational tracheostomy in the cardiothoracic surgical patient: outcomes and financial analysis
Ann Thorac Surg
(2005) - et al.
Fiberoptic bronchoscopy-assisted percutaneous tracheostomy is safe in obese critically ill patients: a prospective and comparative study
J Crit Care
(2009) - et al.
Posterior tracheal wall perforation during percutaneous dilational tracheostomy: an investigation into its mechanism and prevention
Chest
(1999) - et al.
Is tracheal stenosis caused by percutaneous tracheostomy different from that by surgical tracheostomy?
Chest
(2005) - et al.
Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review
Br J Anaesth
(2006)
Tracheotomy: clinical review and guidelines
Eur J Cardiothorac Surg
Tracing the tracheostomy
Ann Otol Rhinol Laryngol
Tracheostomy from A to Z: historical context and current challenges
Respir Care
Anatomy and physiology of tracheostomy
Respir Care
Changes in respiratory mechanics after tracheostomy
Arch Surg
Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial
JAMA
Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial
Ann Intern Med
Stroke-related early tracheostomy versus prolonged orotracheal intubation in neurocritical care trial (SETPOINT): a randomized pilot trial
Stroke
The role of tracheostomy in weaning from mechanical ventilation
Respir Care
Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial
JAMA
Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation
BMJ
Percutaneous tracheotomy
J Am Med Assoc
Percutaneous dilational tracheostomy: a comparison of single- versus multiple-dilator techniques
Crit Care Med
Tracheostomy in the intensive care unit: a nationwide survey
Anesth Analg
Safety and efficiency of interventional pulmonologists performing percutaneous tracheostomy
Respiration
Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program
Crit Care Med
Cited by (13)
Practice of tracheostomy in patients with acute respiratory failure related to COVID–19 – Insights from the PRoVENT–COVID study
2022, PulmonologyCitation Excerpt :Tracheostomy is a frequently performed intervention in critically ill patients who require prolonged invasive ventilation, facilitating liberation from the ventilator and possibly reducing sedation needs due to increased patient comfort.1
Risk factors and outcomes of tracheostomy after prolonged mechanical ventilation in pediatric patients with heart disease
2018, Progress in Pediatric CardiologyCitation Excerpt :Therefore, the indications for tracheostomy should be carefully evaluated in each case. Tracheostomy is considered when prolonged mechanical ventilation is required [4]. However, determining the need for and timing of tracheostomy is often difficult because multiple factors must be assessed, especially in pediatric patients with heart disease [10–12].
Trends for Percutaneous Tracheostomy in Italian Acute Care Setting over a 5-Year Period
2023, Medicina (Lithuania)Intensivist-led ultrasound-guided percutaneous tracheostomy: a phase IV cohort study
2023, Critical Care ScienceAnesthetic Management for Surgery of the Respiratory Tract
2022, Equine Anesthesia and Co-Existing Disease, First EditionThe role of tracheotomy in patients with moderate to severe impairment of the lower airways
2022, Acta Otorhinolaryngologica Italica
Conflict of Interest: None.
Funding: None.