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Tracheostomy Indications and Timing

return to: Tracheotomy, Tracheostomy & Modifications Redirecting to: https://medicine.uiowa.edu/iowaprotocols/tracheostomy-indications-and-timing I. Definitions

A.  Conventional (Cheung 2014)

    1.  'Tracheotomy' = any procedureinvolving opening the trachea (temporarly opening)

    2. Tracheostomy; = tracheal opeing with attachment to the skin

B. Consensus conference Clinical Consensus Statemetn: Tracheostomy Care Mitchell 2013)

    1. Tracheotomy is the operation of 'opening the trachea'

    2. Tracheostomy implies 'permanent opeing in the neck created by suturing skin flaps onto the tracheal walls"

    3. 'Near-unanimous agreement' was to employ term 'tracheostomy' through discussion with observance that 'tracheotomy' is the correct term for the surgical procedure

II. Indications for Tracheostomy

        A. Airway obstruction above the level of the trachea (present or anticipated)

        B. Airway obstruction in the upper/mid trachea requiring stenting (via tracheotomy tube)

        C. Need for prolonged intubation (advantages of tracheotomy over oro- or naso-tracheal intubation)

1. Improved comfort for the patient

2. Decreased risk of injurty (ie posterior glottic stenosis) to structures impacted by the endotracheal tube (ETT)

a. Early laryngeal injury after endotracheal intubation reported as high as 94% (Colice 1989)

b. Long-term sequelae (stenosis/granulomas) as high as 5% to 12% after endotracheal intubation with duration of intubation correlating with increased incidence(Whited 1984, McWhorter 2003)

3. Improves safety of airway control (shorter tubing, less likely to obstruct as with longer ETT, easier to replace if dislodged)

4. Improved management of airway secretions (suctioning, instillation of medications)

5. Improves resumption of oral intake

6. Improves capacity to for patient to speak

7. Decreased incidence of sinusitis (Holzapfel 1993 and Cheung 2014)

D.  Inability to intubate (with need for general anesthesia)

E.  Adjunct to major head and neck surgery/trauma management

F. Airway protection (neurologic diseases, traumatic brain injury) (Cheung 2014)

III. Timing for Tracheostomy

A.  Consensus conference (Plummer et al 1989) - mechanical ventilation for up to 10 days may be endotracheally intubated; tracheostomy is favored if mechanical ventilation predicted for greater than 21 days.

B. Tracheostomy following intubation was anslyzed through systemic literature review finding 11 studies (Liu 2015)

      1. Early tracheostomy performed within 7 days of intubation was associated with decrease in ICU length of stay

      2. Subgroup analysis did not suggest a difference in outcomes based on whether early trahceostomy was perofremd at 2-3 days, 4-5 days or 7-8 days of endotracheal intubation.

       2. No differences were noted in hospital mortality with insufficient data to conclude regarding effects of early tracheostomy on incidence of pneumonia, length of ventilation, or laryngotracheal injury 

This review article identified that the studies in their review were underpowered to detect true differences in laryngo-tracheal injury with prolonged intubation leading to conclusion there is insufficient evidence to identify a relationship between early v later tracheotomy and laryngotracheal long term injury

 

 

 

 

 

 

References:

Liu CC, LIvinstone D, Dixon E, and Dort JC: Early versus late trasheostomy: a systematic review and meta-analysis. Otolaryngol Head Neck Sur 2015 Feb;152(2):219-27

Plummer Al, Gracey Dr. Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest. 1989;96:178-180

Colice Gl, Stukel TA, Dain B. Laryngeal complications of prolonged intubastion. Chest. 1989;96:877-884

Whited RE A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope. 1984;94:367-377

McWhorter AJ. Tracheotomy: timing and techniques. Curr Opin Otolaryngol Head Neck Surg. 2003;11:473-479

Holzapfel L, Chevret S, Madinier G, Oben F, Demingeon G, Coupry A, Chadudet M: Influence of tong-term oro- or nasotracheal intubation on nosocomial maxillary sinusitis and pneumonia: results of a prospective randomized clinical trial. Crit Care Med 1993;21(8):1132-1138

Cheung NH and Napolitano LM: Tracheostomy: Epidemiology, Indications, Timing, Technique and Outcomes  Respiratory Care June 2014 Vol 59 No 6

Mitchell RB, Hussey HM, Setzen G, Jacobs IN, Nussenbaum B, Dawson C, Brown CA, and Brandt C: Clinical Consensus Statement: Tracheostomy Care. Otolaryngology–Head and Neck Surgery 148(1)6-20

 

 

 

 

 

 

 

 

 

 

 

 

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