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.
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.
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
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
Likely coagulopathy secondary to CLD
Likely thrombocytopenia secondary to portal hypertension / hypersplenism.
May have systemic venous hypertension (portosystemic shunting, alcoholic cardiomyopathy etc.)
Increased in setting of chronic liver disease
Increased in obesity
Poor wound healing in heavy smoker
Loss of airway
Hypoxaemia (defer if FiO2 > 0.6 and PEEP > 10)
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.
Local resources for this topic:
Advantages of "PDT in general" are offered below:
Advantages of tracheostomy in general
Disadvantages of tracheostomy in general
Arguments against tracheostomy in this specific patient:
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.