Outline the potential advantages and disadvantages of a tracheostomy in the weaning of patients from mechanical ventilation.

[Click here to toggle visibility of the answers]

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:

Published literature:

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
  • 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

References

Durbin, Charles G. "Indications for and timing of tracheostomy." Respiratory care 50.4 (2005): 483-487.

Sue, Richard D., and Irawan Susanto. "Long-term complications of artificial airways." Clinics in chest medicine 24.3 (2003): 457-471.

Davis, Kenneth, et al. "Changes in respiratory mechanics after tracheostomy." Archives of surgery 134.1 (1999): 59-62.

Pierson, David J. "Tracheostomy and weaning." Respiratory care 50.4 (2005): 526-533.

De Leyn, Paul, et al. "Tracheotomy: clinical review and guidelines." European journal of cardio-thoracic surgery 32.3 (2007): 412-421.

Clec’h, Christophe, et al. "Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: A propensity analysis*." Critical care medicine 35.1 (2007): 132-138.

Frutos-Vivar, Fernando, et al. "Outcome of mechanically ventilated patients who require a tracheostomy*." Critical care medicine 33.2 (2005): 290-298.

Manthous, Constantine A., and Gregory A. Schmidt. "Resistive pressure of a condenser humidifier in mechanically ventilated patients." Critical care medicine 22.11 (1994): 1792-1795.