Timing of Tracheostomy in Mechanically Ventilated Patients

 

Hilton Ventilator

The number of individuals living with acute and chronic conditions is gradually increasing with the improvement of medicine and technology in healthcare. Early diagnostic tests prevent mortality by detecting diseases in early stages when treatment is most successful with least complications. Immunizations protect millions of individuals against chicken pox, polio, measles, pneumonia etc.

 

Many individuals, especially children, are capable of living a life with neurological and neuromuscular conditions, congenital conditions affecting diaphragm, tumors obstructing upper airways, and many more diseases due to respiratory therapy interventions. Patients presenting with post-surgery complications, trauma, burns, diabetes mellitus, congestive heart failure and many more critically ill patients use PMV to stay alive. It is estimated that over 600,000 patients will require prolonged mechanical ventilation (PMV) by the year 2020 due to cardiopulmonary impairments. PMV consumes a very high portion of health care resources and is associated with burden and high costs for the family.  Mechanical ventilation may not be used for an extended period of time, therefore tracheostomy (TT) is the PMV for critically ill patients.¹ TT has improved patient comfort by increased potential ability to speak and orally feed. The most important benefit of TT is the ability to resume normal daily activities once the patient is stable or after six weeks of procedure. ²  This paper will go into detail on the timing of tracheostomy, as it has been a very controversial topic among the medical team.

TT provides an access to the trachea by surgically making an opening to the neck. It has been used in acute and chronic conditions. The most frequent indication of TT is failure to extubate (48%) and prolonged MV (95%, after a median of 20 days). ² Tracheostomy is known to avoid complications of translaryngeal intubation that often occurs with endotracheal intubation in the intensive care unit. It has also been very successful in weaning from PMV as compared with an endotracheal tube. Endotracheal intubation can only be tolerated for a short period of time and requires heavy sedation that impairs secretion clearance and increases airway resistance. The TT procedure should be performed before patient’s condition deteriorates and the risk of complications increases. A retroperspective distributive study concluded that due to the limited clinical data on TT timing, it is recommended to wait at least two weeks before implementing TT.  Quality of life and resource utilization are very important to consider when implementing the TT beyond the intensive care unit. ³

The timing of TT procedure has been a very challenging debate among medical providers. The few studies that we have do not show mortality change in initiating TT early vs late nor great clinical values. Some physicians include TT as a routine practice while others only in rare instances. TT timing is crucial; early before irreversible airway damage is done, yet late enough to endanger confidence that TT is a necessary procedure. It is hard to predict which particular patients might need TT. Early TTs will increase the number of procedures undertaken, thus increasing the amount of complications that might be avoidable otherwise. The procedure can be done at the bedside using percutaneous techniques or in the operating room performed by surgeons. It is not as complex as the complications that can occur in the immediate, early, and late stage of the procedure. Hemorrhage, air embolism, hypoxemia, hyperoxia, and even death are considered immediate complications that the surgeons should be very familiar with. Accidental decannulation, infection, dysphasia, tracheomalacia, and aspirations can occur any time after the surgery. Infection poses a risk to the patient’s health; therefore, special TT care is done at least every 8 hours when the TT is in place to improve outcomes. ⁴

Early TT has been defined as within 3-10 days of MV, whereas late anytime after.³ A single institution study compared early vs late TT placement. Early TT within 5 days, 118 patients, showed shorter MV duration and shorter ICU stay compared with the late TT, 401 patients. Hospital costs were consistency higher in MV patients ($31,574) especially on day 1 verses in patients without the need for MV ($12,932). Overall hospital stay was much higher in MV patients ($47,158 ± $57,703 vs $23,707 ± $34,574). ⁵

As mentioned earlier, TT can reduce the duration of MV, which is associated with development of ventilator-associated pneumonia (VAP). VAP is defined as pneumonia that occurs after 48 hours or more after endotracheal intubation. A study strongly suggests that early TT decreased the risk for VAP because it reduced the duration of MV. ³ VAP is associated with high intensive care unit mortality rate and hospital costs. Sedated patients do not have the ability to clear tracheobronchial secretions therefore contaminated mucous is more likely to get into the lower airways causing pneumonia. Decreased VAP has also been noted in a meta-analysis study in patients with MV who received early TT (305 patients) versus late or no TT (386 patients). ⁶

Current research does not show any difference in mortality rates in early vs late TT. ^1-8 Timing also does not affect the use of long-term care because many patients need medical attention after the procedure as before. The most important finding noted in the American Medical Association editorial was specifying that many patients in the Italian heath care group were successfully managed without a TT. Based on their research, it is indicated to wait at least two weeks before initiating TT. The editorial clearly states that ICU stay decreased for patients with TT, but the overall hospital stay was the same as with endotracheal patients. Serious complications were also noted to show that TT procedure caused to posterior tracheal perforation, tracheoinominate artery fistula, and death. ⁷ Another study of 444 patients favored late TT; waiting 10 days before initiating TT. Only 45% of patients needed TT after 10 days, and more than two thirds of the rest, TT was not required after 10 days because they have recovered. ⁸

In conclusion, the timing of TT will be a challenging question for physicians until we find data on variance of mortality. Early TT has not been shown to decrease mortality or mobility rate, however it is proved that early TT decreased the risk of pneumonia in the intensive unit. Interventions to prevent VAP should never be abandoned as VAP causes a high mortality rate in the intensive care units. ⁶ Early TT may help wean patients off ventilators and decrease the length of intensive care unit stay. It can also expedite recovery and mobility in critically ill patients. However, timing of TT will be different for every patient depending on the disease prognosis, family, and patient’s needs.  It is unethical to perform an unnecessary surgical procedure without strong indications for its need. Benefits should always outweigh the complications.

References:

1. Bice T, Nelson JE, Carson SS. To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill. Semin Respir Crit Care Med 2015;36(6):851-858.
2. Blot F, Melot C, Commission d’Epidemiologie et de Recherche Clinique. Indications, timing, and techniques of tracheostomy in 152 French ICUs. Chest 2005;127(4):1347-1352.
3. Sole ML, Talbert S, Penoyer DA, Bennett M, Sokol S, Wilson J. Characteristics, resource utilization, and nursing care of patients who undergo percutaneous tracheostomy. Clin Nurse Spec 2014;28(5):288-295
4. Cheung NH, Napolitano LM. Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes. Respir Care 2014;59(6):895-919 25p.
5. Donahoe MP. Current venues of care and related costs for the chronically critically ill. Respir Care 2012;57(6):867-86; discussion 886-8.
6. Siempos II, Ntaidou TK, Filippidis FT, Choi AM. Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med 2015;3(2):150-158.
7. Scales DC, Ferguson ND. Early vs late tracheotomy in ICU patients. JAMA 2010;303(15):1537-1538.
8. Young D, Harrison DA, Cuthbertson BH, Rowan K. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA 2013;309(20):2121-2129 9p.