Tracheostomy

Percutaneous tracheostomy is commonly performed for patients in the ICU. Percutaneous dilatational tracheostomy (PDT) uses the insertion of a tracheal cannula by a modified Seldinger approach through the anterior tracheal wall, preferably between the 2nd and 3rd tracheal rings. This is followed by the insertion of a guidewire, and dilation is performed until the created stoma is large enough for the tracheostomy tube to be placed.

Summary

In general, tracheostomy should be delayed until at least 10 days after initiating mechanical ventilation
Selected patients eg neurotrauma, GBS, stroke may benefit from early tracheostomy
Timing of tracheostomy must be decided on a case-by-case basis

Benefits compared to endotracheal intubation

improves patient comfort
decreased need for sedation
physiologic: improved work of breathing (less dead space and airway resistance)

Surgical vs percutaneous approach

Both STs and PDTs can be performed safely in critically ill patients with a low incidence of complications. A meta-analysis of 22 studies (1,608 patients) demonstrated no significant difference in rates of mortality, intraoperative hemorrhage, and postoperative bleeding between the two procedures.

PDT, compated to ST, has a lower rate of wound infection, stomatitis, shorter procedural time, and cheaper.

Timing

No consensus on the optimal timing of trachostomy in ICU patients. With no clear superior benefit of early tracheostomy, the clinical decision should consider the patient’s prognosis, ability to wean, comorbidities, and risks associated with prolonged endotracheal intubation. - early (<10 days) vs late (10+ days) -- likely no difference in mortality - A meta-analysis of 13 trials (2,434 patients) demonstrated that all-cause mortality was not significantly lower in patients with an early (≤7 days of mechanical ventilation) versus late (>7 days) tracheostomy - unclear benefit on risk of VAP

TracMan (JAMA 2013)

tracheostomy at 1-4 days v >10 days invasive ventilation
Early tracheostomy associated with: — shorter duration of sedation (6.6 vs 9.3 days in the deferred group) — increased number of procedures and associated complications — no beneficial effect on overall mortality (139 vs 141 deaths at 30 days, no difference at 2 years either) or ICU/hospital LOS

Hosokawa et al. SRMA (Crit Care 2015)

Their analysis indicated that early (versus late) tracheotomy was associated with a larger number of ventilator-free days, shorter ICU stay, shorter duration of sedation and lower long-term mortality rates.

References

1) Effect of Early vs Late Tracheostomy Placement on Survival in Patients Receiving Mechanical Ventilation: The TracMan Randomized Trial | Critical Care Medicine | JAMA | JAMA Network 2) Hosokawa K, Nishimura M, Egi M, Vincent JL. Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials. Crit Care. 2015;19:424. doi:10.1186/s13054-015-1138-8