Elsevier

Mayo Clinic Proceedings

Volume 80, Issue 12, December 2005, Pages 1632-1638
Mayo Clinic Proceedings

REVIEW
Tracheostomy in Critically Ill Patients

https://doi.org/10.4065/80.12.1632Get rights and content

Tracheostomy is a common critical care procedure in patients with acute respiratory failure who require prolonged mechanical ventilatory support. Tracheostomy usually is considered if weaning from mechanical ventilation has been unsuccessful for 14 to 21 days. A recent clinical trial suggested that early tracheostomy may benefit patients who are not improving and who are expected to require prolonged respiratory support. In this study, early tracheostomy improved survival and shortened duration of mechanical ventilation. Minimally invasive bedside percutaneous tracheostomy was introduced recently as an alternative to the traditional surgical technique. In expert hands, the 2 techniques are equivalent in complications and safety; however, the bedside percutaneous approach may be more cost-effective. Tracheostomy should be considered early (within the first week of mechanical ventilation) in patients with a high likelihood of prolonged mechanical ventilation. Depending on local medical expertise and costs, either the percutaneous or the surgical technique may be used.

Section snippets

INDICATIONS AND TIMING OF TRACHEOSTOMY IN PATIENTS WITH ACUTE RESPIRATORY FAILURE

Tracheostomy is performed primarily in critically ill patients with acute respiratory failure who require prolonged mechanical ventilation and/or in whom multiple attempts to wean from mechanical ventilation have been unsuccessful for 14 to 21 days.10 Tracheostomy facilitates weaning by decreasing the work of breathing in patients with limited reserve.11, 12 However, the effect on dead space ventilation is marginal.13 Tracheostomy decreases the requirement for sedation and may allow for earlier

TRACHEOSTOMY TECHNIQUES

Tracheostomy can be performed with the open technique in the operating room, with the open technique at the bedside, or with the percutaneous approach at the bedside. In the open technique, a small transverse incision is made between the lower border of the cricoid cartilage and the suprasternal notch. The strap muscles are retracted laterally to expose the underlying thyroid gland and the trachea. The thyroid isthmus is retracted in a cephalad direction or divided, exposing the tracheal rings.

WHICH TECHNIQUE IS SUPERIOR?

Numerous studies40, 41, 42, 43, 44, 45 and 2 meta-analyses in 199946 and 200047 have tried to determine which technique is superior. Dulguerov et al,46 in their meta-analysis, included all study designs (retrospective, observational, and prospective) and all studies of percutaneous tracheostomy irrespective of techniques analyzed. The surgical technique studies were grouped according to the historical period: 1960–1984 (17 studies including 4185 patients) and 1985–1996 (21 studies including

CONCLUSIONS

Many critically ill patients require prolonged mechanical ventilation and tracheostomy. In patients with high risk of mortality and morbidity based on the presence of shock at onset of mechanical ventilation and high severity of illness scores and in whom no evidence of improvement can be shown during the first few days of mechanical ventilation, the option of early tracheostomy (within the first week from initiation of mechanical ventilation) should be discussed with the patient and/or family

REFERENCES (62)

  • B Afessa et al.

    Predicting 3-day and 7-day outcomes of weaning from mechanical ventilation

    Chest

    (1999)
  • Y Friedman et al.

    Comparison of percutaneous and surgical tracheostomies

    Chest

    (1996)
  • BD Freeman et al.

    A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients

    Chest

    (2000)
  • JE Heffner

    Percutaneous dilatational vs standard tracheotomy: a meta-analysis but not the final analysis [editorial]

    Chest

    (2000)
  • NG Mansharamani et al.

    Safety of bedside percutaneous dilatational tracheostomy in obese patients in the ICU

    Chest

    (2000)
  • S Kluge et al.

    Percutaneous tracheostomy is safe in patients with severe thrombocytopenia

    Chest

    (2004)
  • JD Cooper

    Trachea-innominate artery fistula: successful management of 3 consecutive patients

    Ann Thorac Surg

    (1977)
  • EA Frost

    Tracing the tracheostomy

    Ann Otol Rhinol Laryngol

    (1976)
  • C Jackson

    Tracheotomy

    Laryngoscope

    (1909)
  • RD Hubmayr et al.

    Statement of the 4th International Consensus Conference in Critical Care on ICU-Acquired Pneumonia—Chicago, Illinois, May 2002

    Intensive Care Med

    (2002)
  • G van den Berghe et al.

    Intensive insulin therapy in the critically ill patients

    N Engl J Med

    (2001)
  • JP Kress et al.

    Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

    N Engl J Med

    (2000)
  • Acute Respiratory Distress Syndrome Network

    Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome

    N Engl J Med

    (2000)
  • A Esteban et al.

    How is mechanical ventilation employed in the intensive care unit? an international utilization review

    Am J Respir Crit Care Med

    (2000)
  • K Davis et al.

    Changes in respiratory mechanics after tracheostomy

    Arch Surg

    (1999)
  • JL Diehl et al.

    Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients

    Am J Respir Crit Care Med

    (1999)
  • AM Mohr et al.

    The role of dead space ventilation in predicting outcome of successful weaning from mechanical ventilation

    J Trauma

    (2001)
  • MJ Rumbak et al.

    A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients [published correction appears in Crit Care Med. 2004;32:2566]

    Crit Care Med

    (2004)
  • J Griffiths et al.

    Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation

    BMJ

    (2005)
  • AD Brook et al.

    Early versus late tracheostomy in patients who require prolonged mechanical ventilation

    Am J Crit Care

    (2000)
  • WH Teoh et al.

    The role of early tracheostomy in critically ill neurosurgical patients

    Ann Acad Med Singapore

    (2001)
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    1

    Dr Rana is now with Mercy Medical Center, Des Moines, Iowa.

    2

    Dr Pendem is now with St. Alexius Medical Center, Bismarck, ND.

    3

    Dr Pogodzinski is now with the US Air Force, Yokota, Japan.

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