Page 577 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 46: Tracheostomy 397

TABLE 46-1 Selected Examples of Indications for Tracheostomy TABLE 46-2 Complications of Tracheostomy
Prolonged Respiratory Estimated Incidence, %
Failure and Mechanical Excessive Secretions/
Airway Obstruction Ventilation Impaired Cough Percutaneous Dilational
Surgical Tracheostomy Tracheostomy
Trau ma ARDS Chronic pulmonary Intraprocedural
• Head and neck trauma COPD infections
• Facial/inhalational burns • Cystic fibrosis Paratracheal insertion 0-10 0-4
• Traumatic brain injury Pulmonary fibrosis • Other bronchiectasis Loss of airway 0-4 0-8
Persistent decreased level of Neuromuscular disease • Chronic bronchitis Posterior tracheal wall injury <0.01 0-13
consciousness Chest wall restrictive Neurological injury
Airway infections disease • Traumatic brain injury Hypoxia 0-8 0-25
• Epiglottitis • Anoxic brain injury Intratracheal fire <1 Not applicable
• Head and neck abscess • Spinal cord injury Death <0.01 <0.01
Airway neoplasms Early Postprocedural
Anaphylaxis Hemorrhage
Vocal cord paralysis Minor 11-80 10-20
Congenital airway abnormalities Major 0-7 0-4
These examples are provided for illustrative purposes only, and are not intended to represent a complete list.
Pneumothorax 0-4 0-4
Subcutaneous emphysema 0-11 0-5
Although the decision to perform a tracheostomy is most straight- Accidental decannulation 0-15 0-5
forward as an emergency treatment of upper airway obstruction, this Stoma infection 0-63 0-10
indication is uncommon. By far the most common reason patients in the
ICU will receive a tracheostomy is to assist with the delivery of mechani- Late Postprocedural
cal ventilation, especially among those expected to require mechanical Tracheal stenosis 11-63 7-27
ventilation for a prolonged time or in anticipation of difficult weaning. Tracheomalacia 0-8 0-7
However, predicting which patients will require mechanical ventilation
of sufficient duration to justify the risks of the procedure is often dif- Tracheoesophageal fistula <1 <1
ficult (see later), and many of the anticipated benefits of performing Tracheo-innominate fistula <1 <1
tracheostomy for these patients have not been confirmed. Delayed stoma closure 10-54 0-39
Cosmetic deformity 5-40 0-20
BENEFITS AND RISKS OF TRACHEOSTOMY
Estimates vary widely based on those reported in the literature, and are adapted from references. 8,9,73
For patients who receive tracheostomy because they are expected to
require prolonged mechanical ventilation, the risks and benefits of the
procedure must be compared to those of prolonged endotracheal intu- mobilization and a greater degree of patient participation in care, such
bation. As with most surgical procedures, there are risks of both short- as physiotherapy. However, the potential of tracheostomy for decreasing
and long-term complications from tracheostomy. In the short term, the sedation requirements has not been consistently observed. 11,13 This may
most serious risks include loss of the airway, bleeding, and damage to be in part due to the evolving evidence base emphasizing the benefits of
nearby structures such as the esophagus, pleura, and recurrent laryn- daily awakening to minimizing sedative infusions in all patients receiv-
geal nerves. Longer-term complications may include infection, skin ing mechanical ventilation, causing differences in sedation require-
8
or cartilage necrosis, tracheo-innominate fistula, tracheomalacia, and ments previously noted with tracheostomy to be minimized. Other
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tracheal stenosis. Other complications that are important yet more less quantifiable variables such as improved lip reading and better oral
9
difficult to quantify include problems with cosmesis and body image as care may further improve the comfort of tracheostomy. Furthermore, in
well as potentially a greater need for long-term care and higher caregiver the longer term, patients with tracheostomy do have the potential for
requirements. The exact incidence of complications does depend to swallowing and for speech; though in general this is not possible until
2
some extent on the technique selected: surgical tracheostomy or percu- positive pressure ventilation is no longer required.
taneous dilational tracheostomy (Table 46-2). Compared to endotracheal intubation, tracheostomy does provide
Many potential benefits have been claimed for performing tracheos- an airway that is less easily dislodged. This is particularly true once a
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tomy in patients expected to require prolonged endotracheal intubation. mature tract has formed which enables relatively easy and safe replace-
Most notable of these is a belief that the procedure will decrease the ment of a dislodged tracheostomy tube. Once a mature tract has formed,
duration of mechanical ventilation and, consequently, shorten the dura- this allows for greater confidence with mobilization and physiotherapy
tion of ICU stay. Tracheostomy does allow for greater flexibility in wean- as well as the potential transfer to a level of care without immediate
ing patients from the mechanical ventilator. The decreased dead space access to personnel with advanced airway skills.
and, more importantly, the decreased resistance of the shorter trache- In the past, endotracheal intubation has been implicated as a con-
ostomy tube allow for the patient to be entirely disconnected from the tributor to airway complications such as tracheal and laryngeal stenosis.
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ventilator and breathing unsupported, without the need for extubation The prevention of subglottic stenosis has been cited as a major reason
and reintubation. Whether these physiological and practical advantages to avoid prolonged endotracheal intubation in ICU patients and to per-
actually translate to a shortened duration of mechanical ventilation or form tracheostomy after a certain duration of mechanical ventilation.
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ICU stay remains controversial (see later). The actual incidence of airway trauma from endotracheal intubation is
Most critical care practitioners agree that tracheostomy provides a likely low now that high volume, low pressure cuffs are standard on
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more comfortable conduit for mechanical ventilation than endotracheal endotracheal tubes. Tracheostomy tubes have also been associated with
intubation. 11-13 This may allow for a reduction in sedation requirements, tracheal stenosis attributed to cuff insufflation, tracheal trauma and
and thus facilitate weaning from the ventilator and allow for earlier granulomas from the tube tip, and long-term stenosis at the tracheotomy

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