Indications for Tracheotomy
Tracheotomy is a common procedure in the ICU that is performed
in approximately 10% of critically ill patients who
require mechanical ventilation.104 Placement of a tracheotomy
is thought to allow a more secure and manageable
airway, earlier and safer enteral feeding, easier oral care,
and enhanced patient comfort while reducing sedation
needs and facilitating mobilization. Complications from
tracheotomy include stoma infection, pneumothorax, subcutaneous emphysema, tracheomalacia, and tracheostenosis.
105 Major questions concerning tracheotomy include
which patients with acute respiratory failure should have
the procedure and when it should be performed.
A review published in 1998 concluded that insufficient
evidence supports the view that timing of a tracheotomy
can alter the duration of mechanical ventilation
or prevent airway injury in critically ill patients.106 Since
then, individual studies have reported decreased days of
mechanical ventilation,107 decreased duration of ICU and
hospital LOS,108 and less damage to the upper airway107
with early tracheotomy. A meta-analysis attempted to
answer this question definitively. Unfortunately, only five
trials with 406 patients were found that met the inclusion
criteria.109 They reported that the timing of tracheotomy
did not alter mortality or increase the risk for hospitalacquired
pneumonia. Early tracheotomy did, however,
lower the duration of mechanical ventilation and the
overall LOS in the ICU (Table 101-3). The results were
far from conclusive. Heterogeneity was high in the metaanalysis
because of variability in inclusion and exclusion
criteria, definitions of early and late tracheotomy,