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