Controversies in Mechanical Ventilation: When Should a Tracheotomy Be Placed?

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With the large and increasing population of mechanically ventilated patients, critical care physicians frequently face the dilemma of whether to perform tracheotomy. The decision is a complex one, requiring a detailed understanding of the risks and benefits of both tracheotomy and prolonged translaryngeal intubation (TLI). It also must be individualized, taking into consideration the patient's preferences and expected clinical course. This article reviews the medical literature regarding the benefits and risks of tracheotomy as compared with TLI. The authors then discuss current data regarding the optimal timing for the procedure and propose an algorithm that may aid intensivists in clinical decision making.

Section snippets

Indications for tracheotomy

Tracheotomy has been used for airway management since ancient times [3] and remains one of the most commonly performed intensive care unit procedures [4]. The clinical indications for tracheotomy include relief of upper airway obstruction, assistance with removal of secretions, and provision of airway access for prolonged mechanical ventilation. Examples of airway obstruction requiring tracheotomy are severe maxillofacial trauma, foreign bodies in the upper airway, bilateral vocal cord

Patient comfort

Though patient comfort is often cited as an advantage of tracheotomy, there are limited data to support this. Astrachan and colleagues [5] surveyed 60 critical care nurses on their attitudes regarding tracheotomy and prolonged TLI. Of those polled, 90% felt that patient comfort was enhanced with tracheotomy and 75% thought patients with tracheotomies fared better psychologically. To the authors' knowledge, no studies have directly surveyed patients undergoing tracheotomy.

A decrease in sedation

Risks of tracheotomy

Despite being a commonly performed procedure, tracheotomy is not risk free. Clinicians must consider the risk of immediate and long-term complications, as well as the time and expense of the procedure. This section briefly discusses commonly performed techniques and the contraindications to tracheotomy. The authors will then review the reported rates of early and late complications associated with the procedure.

Impact on outcome in critically ill patients

The effect of tracheotomy on intensive care unit (ICU), hospital, and overall outcomes is also controversial. To date, there is only one prospective, RCT comparing early versus late tracheotomy [43], and none comparing tracheotomy versus persistent TLI in the general ICU population. A more recent RCT restricted to severe head injured patients found no difference in outcome between tracheotomy and TLI patients [33].

The remainder of the data on outcomes are retrospective and involve heterogeneous

Putting it all together

Because of gaps in the literature, tracheotomy practice varies considerably. Nathens and colleagues [80] examined procedure rates in over 17,000 trauma patients from approximately 100 centers across the United States entered into the National Trauma Databank from 2001 to 2003. They found the rate of tracheotomy varied from 0 to 59 per 100 hospital admissions. Although several patient characteristics were predictive of the procedure, they explained only 14% of the variance across centers. Eighty

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    The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as the views of the Department of the Army or the Department of Defense.

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