Outline the potential advantages and disadvantages of a tracheostomy in the weaning of patients from mechanical ventilation.
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).
Local resources for this topic:
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
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