College Answer

Limited actual clinical trial data is available to support the performance of a tracheostomy over maintaining prolonged endotracheal intubation. Purported advantages include: less laryngeal pathology (not supported by the literature); improved patient comfort including reduced respiratory work of breathing and less sedation requirements for tube tolerance; improved communication (speech not possible with ETT), enhanced nursing care (including mouth care & mobility), ease of replacement of tracheal tube, ease of removal/reinstitution of ventilatory support, facilitate transfer to ward (with airway protection and ready airway access for suctioning).

Potential disadvantages include: requirement for surgical procedure and therefore associated peri-operative and post- operative procedural risks including haemorrhage, pneumothorax, tracheal perforation, and even death; increased aspiration risk, increased incidence of nosocomial pneumonia; increased risk of subglottic stenosis and granuloma formation; infection of stoma; occlusion of tracheostomy tube (posterior tracheal wall, granulomata, secretions [if not regular change of tube or inner cannula and/or problems with humidification]); problems associated with decannulation (either elective or emergent: including complicate emergency airway management).

Discussion

Local resources for this topic:

• Advantages and disadvantages of tracheostomy

Published literature:

• Durbin (2005)
• De Leyn(2007)

Advantages of tracheostomy

• Improved patient comfort
  • Decreased sedation requirement
  • Enhanced ability to communicate
  • Improved positioning and mobility
• Avoidance of orotracheal tube-related complications
  • Less vocal cord damage
  • Less risk of laryngeal stenosis
  • Better recovery of voice quality
  • Less damage to the tongue and lips
• Improved mechanics of ventilation
  • Lower resistance to air flow
  • Decreased work of breathing
  • Decreased apparatus dead space
  • Improved respiratory function parameters:
  • More rapid weaning from mechanical ventilation 
• Advantages in airway care and secretion control
  • Lower incidence of tube obstruction
  • Better oral hygiene
  • Better clearance of secretions by suctioning
  • Lower incidence of VAP
• Advantages for upper airway function
  • Better preservation of swallowing
  • Earlier oral feeding
  • Preservation of "glottic competence"
  • Decreased aspiration risk 
• Pragmatic advantages
  • Less skilled insertion
  • Less skilled care
  • Deferral of end-of-life decisions to a better time

Disadvantages of tracheostomy

• Disadvantages related to safety and complications
  • The complications of the percutaneous and surgical tracheostomy
  • Potential for dislodgement
  • Humidification is inadequate
  • Passive humidifiers increase the work of breathing
  • Blockage with secretions
• Disadvantages related to care for the artifical airway
  • Complication of emergency airway management
  • Skilled care is still required
• Ethical implications
  • Failure to wean despite tracheostomy is still possible
  • There is no mortality benefit from tracheostomy