A 67-year-old male has been intubated and ventilated in your ICU for the last 15 days following an upper GI bleed and banding of oesophageal varices. He is obese (BMI 31), has alcoholic liver disease and smokes heavily. He has been assessed as unsuitable for transplantation. His ICU stay has been complicated by aspiration pneumonia, acute kidney injury and ongoing encephalopathy.
 
Discuss the potential benefits and risks of percutaneous dilatational tracheostomy (PDT) in this patient.

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College Answer

PDT is a common procedure in Australasian ICUs to facilitate airway management and/or weaning from MV. PDT in this man may be helpful in this regard, but presents significant problems related to body habitus and acute and chronic comorbidities.
Benefits:
 May help facilitate ventilatory weaning
 Increased patient comfort
 Improved management of secretions
 May facilitate mobilisation during weaning
 Potentially reduced sedation requirements

 Provide a secure airway in the setting of a fluctuating conscious state

Risks:

Difficult placement / maintenance:
o Should mention potentially difficult airway
o May have difficult neck anatomy as obese/increased risk of malposition or tracheal injury
o High risk of dislodgement later on if standard trache tube used

Bleeding risk
 Likely coagulopathy secondary to CLD
 Likely thrombocytopenia secondary to portal hypertension / hypersplenism.
 May have systemic venous hypertension (portosystemic shunting, alcoholic cardiomyopathy etc.)

Infection risk
 Increased in setting of chronic liver disease
 Increased in obesity
 Poor wound healing in heavy smoker

General risks
 Loss of airway
 Pneumothorax
 Hypoxaemia (defer if FiO2 > 0.6 and PEEP > 10)
 Cardiac arrest
 Death

Wisdom issues
 Prognosis guarded at best even with tracheostomy; long-term outlook is poor and it will not treat any of this man's underlying issues: therefore requires due consideration / deliberation.
 Number of prior presentations for the same problem are also a factor
 Patient's previously expressed wishes a consideration but ultimately a medical decision
 Risk/benefit ratio may not be favourable: ongoing aggressive treatment of encephalopathy with view to primary extubation may be better.
 If deemed appropriate to proceed, surgical tracheostomy may be a safer alternative

Examiners' comments: Some candidates discussed PDT in general rather than issues as they related to this patient.

Discussion

Local resources for this topic:

Published literature:

Advantages of "PDT in general" are offered below:

Advantages and Disadvantages of Tracheostomy

Advantages of tracheostomy in general

  • 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 in general

  • 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

Arguments against tracheostomy in this specific patient:

  • Difficulty:
    • Morbid obesity makes the procedure more risky
    • Morbid obesity also makes future dislodgement more likely
    • Agitation from encephalopathy makes dislodgement more likely
    • Coagulopathy from liver disease makes the procedure more risky
  • Futility:
    • Ineligibility for transplant makes long-term prognosis poor
    • Multi-organ system failure in this (presumably, Child-Pugh class C) patient is associated with a near-100% in-hospital mortality (see the chapter on Staging and prognosis of chronic liver disease in ICU)

References

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.