Chapter 109: Controversies: Early Tracheotomy

INTRODUCTION

Tracheotomy is a common procedure with almost 1 in 4 ICU patients receiving a tracheotomy.¹ While a tracheotomy is a relatively straightforward surgical procedure, the medical complexity of patients requiring tracheotomy, and the debate about its timing and indications, make its utilization complex. Despite its common and widespread use there remains considerable debate in the literature regarding tracheotomies risks, benefits, and indications.

INDICATIONS AND BENEFITS

The indications for tracheotomy have evolved throughout the history of the procedure. With improved understanding of the disease processes affecting the airway, the indications have become more standardized and rigorous in recent years. Today there are numerous indications recognized in the adult population. These indications were defined by the American Academy of Otolaryngology and Head and Neck surgery in the 2010 Clinical Indicators Compendium,² and fall into 4 broad categories: to relieve a mechanical obstruction (or potential obstruction), to manage aspiration (and promote improved pulmonary toilet), to provide long-term ventilation (and avoid the complications of long-term translaryngeal intubation), and to promote weaning from the ventilator. The last 2 categories constitute the vast majority of patients included in studies on ET.

Tracheotomy offers a number of potential benefits over endotracheal intubation. Tracheotomy has been shown to decrease the mechanical workload of ventilator-dependent patients,^3,4 and patients with tracheotomies can be placed on and off the ventilator without any significant risk to the patient, potentially facilitating earlier extubation. Tracheotomy improves comfort level when compared with translaryngeal intubation. Patients with tracheotomies have improved tracheal suctioning, oral care, mobility, ability to take oral nutrition and articulate speech,^5,6 and decreased oropharyngeal and laryngeal trauma compared to intubated patients.⁷

RISKS

Different clinicians have different opinions on the risks and timings of tracheotomy. The risk of tracheotomy has decreased over time and varies depending on the skill and experience of the person performing the procedure. In 1833 Trousseau reported a 75% mortality rate for tracheotomy patients, compared with current mortality rates of approximately 1%.^8,9,10 Today, while tracheotomy is a relatively safe procedure, complications still occur. A recent study looking at 113,653 tracheotomies performed in the United States in 2006 showed a 3.2% complication rate and 0.6% mortality rate.¹¹ However, the experience and expertize of the physician performing the procedure can greatly impact the risk of tracheotomy. A recent study showed that surgeons performing the fewest tracheotomies demonstrated the highest complication rates, and that intraoperative complication rates varied greatly among practitioners with otolaryngologists having an intraoperative complication rate is 0.39% compared to 3.5% with tracheotomies done by nonotolaryngologists.¹²

TIMING

The optimal timing for a tracheotomy is dependent on the patient and the situation. There is significant controversy regarding the timing of surgery for those patients undergoing an elective tracheotomy after intubation, and ...