The Role of Tracheotomy in Weaning

doi:10.1378/chest.120.6_suppl.477S

Chest

Volume 120, Issue 6, Supplement, December 2001, Pages 477S-481S

https://doi.org/10.1378/chest.120.6_suppl.477S Get rights and content

Tracheotomy is commonly performed in ventilator-dependent patients. Disadvantages to the procedure are perioperative complications, long-term airway injury, and the cost of the procedure. Benefits ascribed to tracheotomy vs prolonged translaryngeal intubation include improved patient comfort, more effective airway suctioning, decreased airway resistance, enhanced patient mobility, increased potential for speech, ability to eat orally, a more secure airway, accelerated ventilator weaning, reduced ventilator-associated pneumonia, and the ability to transfer ventilator-dependent patients from the ICU. None of these benefits, however, have been demonstrated in large-scale, prospective, randomized studies. It is proposed that there should be an anticipatory approach wherein tracheotomy is considered after an initial period of stabilization with the patient receiving mechanical ventilation when it becomes apparent that the patient will require prolonged ventilator assistance. Tracheotomy then is performed when the patient appears likely to gain one or more of the benefits ascribed to the procedure.

Section snippets

Improved Patient Comfort

No prospective outcome studies in general populations of ventilator-dependent patients using validated measurement tools have established that tracheotomy results in greater patient comfort or mobility compared with prolonged translaryngeal intubation. Astrachan and coworkers³ interviewed ICU caregivers, however, and found that they believed that patients receiving mechanical ventilation were more comfortable after a tracheotomy. General consensus exists that patients supported with long-term

Effect of Tracheotomy on Decreasing Airway Resistance

The shorter length of a tracheostomy tube compared to an endotracheal tube is associated with less airway resistance when measured in vitro during constant flow and oscillatory conditions.¹⁶ Although the small radius of curvature of tracheostomy tubes increases turbulent airflow and airway resistance,¹⁷¹⁸ the short length of tracheostomy tubes more than compensates for airflow turbulence. The overall lower airway resistance may decrease the loads imposed on the respiratory system and thereby

Outcome Studies: The Impact of Tracheotomy on the Duration of Mechanical Ventilation

The impact of tracheotomy on the duration of mechanical ventilation has been examined by several different study designs. Most studies are retrospective, although a few prospective studies have been performed. Most studies have assigned patients to treatment groups on the basis of physician practice patterns rather than random assignment. Those studies that used random assignment frequently used quasi-randomization methods (eg, every other patient, every other day, hospital record number, or

Impact of Tracheotomy on Ventilator-Associated Pneumonia

Early tracheotomy and, alternatively, the avoidance of tracheotomy by maintaining a translaryngeal endotracheal tube in place have both been proposed as strategies to promote successful weaning from mechanical ventilation by avoiding ventilator-associated pneumonia. The occurrence of pneumonia is considered to be a cause of delayed weaning from ventilator support.

Few data support the conclusion, however, that the timing of tracheotomy alters the risk of pneumonia. Three prospective studies¹⁴²⁸³⁰

Effects on Weaning of the Technique for Tracheotomy

The advent of PDT has created the impression that tracheotomy may provide greater support of weaning from mechanical ventilation because it can be performed at lower costs, and also because it might be associated with fewer complications than a standard surgical tracheotomy.

Observational studies³¹³²³³³⁴ using hospital charge data have indicated that PDT performed in the ICU has lower associated charges (cost range, $l,742 to $1,370) than standard surgical tracheotomy performed in the operating

Future Investigations

It is probable that the timing of tracheotomy promotes weaning from mechanical ventilation in some, but not all, ventilator-dependent patients. The quality of existing studies, however, does not establish this clinical impression. Because of the difficulty in blinding caregivers to the presence or absence of tracheotomy, studies should use explicit weaning protocols to control for different levels of approaches toward weaning that the presence of a tracheotomy may invoke. Studies also could be

Conclusion

Insufficient data support the impression that tracheotomy provides universal benefit in promoting weaning from mechanical ventilation in all ventilator-dependent patients. Subsets of patients, however, may benefit from the procedure.

Patients requiring sedation to assist their toleration of translaryngeal endotracheal tubes may be more comfortable after tracheotomy (level III) and may be weaned more rapidly from mechanical ventilation with the discontinuation of treatment with sedative drugs

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Cited by (98)

Safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus
2024, Auris Nasus Larynx
In typical surgical tracheostomy, the thyroid isthmus is divided or retracted superiorly and preserved. However, at our institution, the thyroid isthmus is retracted inferiorly and preserved. Thereafter, a tracheal incision is made above the thyroid isthmus. This method, hereinafter defined as high tracheostomy, has the advantage of facilitating immediate access to the trachea in a superficial position; moreover, it can be quickly replaced with cricothyrotomy in emergency situations. However, tracheotomies placed too high can potentially damage the cricoid cartilage, thereby causing subglottic granulation and tracheal stenosis. We aimed to validate the safety and efficacy of high tracheostomy with inferior retraction of the thyroid isthmus.
This was a retrospective cohort analysis. We analyzed the operative method and other relevant characteristics of 90 patients who underwent surgical tracheostomy between April 2016 and June 2022. For those who underwent high tracheostomies, we analyzed the duration of surgery, amount of intraoperative bleeding, occurrence of complications, problems with stoma closure, and perioperative mortality.
High tracheostomy was performed in 73 patients. Subglottic granulation occurred in one patient, and the granulation tissue spontaneously shrank. Subcutaneous emphysema occurred in two patients. No patient developed wound infection or tracheoinnominate artery fistula. Moreover, no patient experienced false route tracheotomy tube insertion because the thyroid glands were located under the stoma.
The frequency of complications was comparable to that reported in other studies on tracheostomy. Additionally, no patient developed tracheal stenosis secondary to tracheostomy above the thyroid isthmus. Therefore, high tracheostomy with inferior retraction and preservation of the thyroid isthmus is safe and advantageous.
Early vs. late tracheostomy in ventilated COVID-19 patients – A retrospective study
2021, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
Tracheostomy is one of the most common surgical procedures performed on ventilated COVID-19 patients, yet the appropriate timing for operating is controversial.
Assessing the effect of early tracheostomy on mortality and decannulation; elucidating changes in ventilation parameters, vasopressors and sedatives dosages immediately following the procedure.
A retrospective cohort of 38 ventilated COVID-19 patients, 19 of them (50%) underwent tracheostomy within 7 days of intubation (early tracheostomy group) and the rest underwent tracheostomy after 8 days or more (late tracheostomy group).
Decannulation rates were significantly higher while mortality rates were non-significantly lower in the early tracheostomy group compared with the late tracheostomy group (58% vs 21% p < 0.05; 42% vs 74% p = 0.1, respectively). Tidal volume increased (446 ml vs 483 ml; p = 0.02) while PEEP (13 cmH₂0 vs 11.6 cmH₂O, p = 0.04) decreased at the immediate time following the procedure. No staff member participating in the procedures was infected with SARS-CoV-2 virus.
Early tracheostomy might offer improved outcomes with higher decannulation rates and lower mortality rates in ventilated COVID-19 patients, yet larger scale studies are needed. Most likely, early exposure to COVID-19 patients with appropriate personal protective equipment during open tracheostomy does not put the surgical team at risk.
Surgical strategy and optimal timing of tracheostomy in patients with COVID-19: Early experiences in Japan
2021, Auris Nasus Larynx
Citation Excerpt :
Despite the efficiency of tracheostomy in COVID-19 patients, the optimal timing of tracheostomy remains controversial. Traditionally, a tracheostomy is performed to accelerate ventilator weaning, to enhance clearance of secretions, to improve patient mobility, to reduce VAP, and to increase potential for speech, ability to eat orally [16]. In randomized controlled trials that compared early and late tracheostomies, the timing of tracheostomy was divided as follows: very early (< 4 days), moderately early (< 10 days) and late (> 10 days) tracheotomies [17–20].
Tracheostomy is an important surgical procedure for coronavirus disease-2019 (COVID-19) patients who underwent prolonged tracheal intubation. Surgical indication of tracheostomy is greatly affected by the general condition of the patient, comorbidity, prognosis, hospital resources, and staff experience. Thus, the optimal timing of tracheostomy remains controversial.
We reviewed our early experience with COVID-19 patients who underwent tracheostomy at one tertiary hospital in Japan from February to September 2020 and analyzed the timing of tracheostomy, operative results, and occupational infection in healthcare workers (HCWs).
Of 16 patients received tracheal intubation with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, five patients (31%) received surgical tracheostomy in our hospital. The average consultation time for surgical tracheostomy was 7.4 days (range, 6 - 9 days) from the COVID-19 team to the otolaryngologist. The duration from tracheal intubation to tracheostomy ranged from 14 to 27 days (average, 20 days). The average time of tracheostomy was 27 min (range, 17 - 39 min), and post-wound bleeding occurred in only one patient. No significant differences in hemoglobin (Hb) levels were found between the pre- and postoperative periods (mean: 10.2 vs. 10.2 g/dl, p = 0.93). Similarly, no difference was found in white blood cell (WBC) count (mean: 12,200 vs. 9,900 cells /µl, p = 0.25). After the tracheostomy, there was no occupational infection among the HCWs who assisted the tracheostomy patients during the perioperative period.
We proposed a modified weaning protocol and surgical indications of tracheostomy for COVID-19 patients and recommend that an optimal timing for tracheostomy in COVID-19 patients of 2 - 3 weeks after tracheal intubation, from our early experiences in Japan. An experienced multi-disciplinary tracheostomy team is essential to perform a safe tracheostomy in patients with COVID-19 and to minimize the risk of occupational infection in HCWs.
When To Do a Tracheostomy?
2021, Encyclopedia of Respiratory Medicine, Second Edition
The precise indication and optimal timing of tracheostomy in acute respiratory failure is still a matter of debate. An early tracheostomy may allow to shorten the weaning process by reducing the work of breathing (WOB) and decreasing the risks associated with prolonged intubation. However, it may unnecessarily expose some patients to potential complications related to the procedure. The question of the best timing for tracheostomy is closely related to the question of the early detection of patients who will experience difficult weaning.
Giants in Chest Medicine: John E. Heffner, MD, FCCP
2019, Chest
Timing of percutaneous tracheotomies in intensive care unit
2017, Brazilian Journal of Anesthesiology

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Chest

The Role of Tracheotomy in Weaning

Section snippets

Improved Patient Comfort

Effect of Tracheotomy on Decreasing Airway Resistance

Outcome Studies: The Impact of Tracheotomy on the Duration of Mechanical Ventilation

Impact of Tracheotomy on Ventilator-Associated Pneumonia

Effects on Weaning of the Technique for Tracheotomy

Future Investigations

Conclusion

Am J Med

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Ann Thorac Surg

Chest

Chest

Timing of tracheotomy in mechanically ventilated patients

Am Rev Respir Dis

Prolonged intubation vs tracheotomy: complications, practical and psychological considerations

Laryngoscope

Perioperative complications of elective tracheostomy in critically ill patients

Crit Care Med

The role of early tracheotomy in the management of the neurosurgical patient

Laryngoscope

Tracheotomy: indications and timing

Respir Care

Consensus conference on artificial airways in patients receiving mechanical ventilation

Chest

A prospective study of laryngotracheal sequelae in long-term intubation

Laryngoscope

Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit

Crit Care Med

Early tracheostomy for primary airway management in the surgical critical care setting

Surgery

Additional work of breathing imposed by endotracheal tubes, breathing circuits, and intensive care ventilators

Crit Care Med