Tracheostomy Advantages and Disadvantages

Tracheostomy – advantages and disadvantages

13/9/10

Tracheostomy = an airway that is inserted subglottically through neck tissues directly into the trachea

INDICATIONS

- bypass glottic or supraglottic stenosis/obstruction - access for tracheal toilet - provision of a more comfortable airway for prolonged ventilation - protection from aspiration

ADVANTAGES

- reduced sedation requirement (greater comfort than oro-tracheal intubation) - airway protection while unconscious - allows gradual weaning of ventilatory support (reduced work of breathing) - enhanced communication (written or phonation) - decreased ICU mortality - enhanced nursing care (mouth care and mobility) - ease of replacement of tracheal tube - can facilitate transfer to the ward

DISADVANTAGES/COMPLICATIONS

- requirement for a surgical procedure

Immediate

- haemorrhage - surgical emphysema - pneumothorax - air embolism - ciricoid cartilage damage - pretracheal dilation and placement - endobronchial placement - cuff herniation - occlusion of tip by carina or tracheal wall - …death

Delayed

- infection (tracheostomy site, larynx, tracheobronchial tree, mediastinum) - obstruction with secretions - ulceration/perforation (mucosal, inominate artery, tracho-oesophageal fistula) - dysphagia c/o mechanical compression of oesophagus (requires N/G or PEG for enteral nutrition) - problems with de-cannulation -> emergency airway management

Jeremy Fernando (2011) - tracheal granulomata - tracheal or laryngeal stenosis - persistent sinus @ tracheostomy site - tracheomalacia - aphonia/dysphonia (recovery of voice, laryngeal or cord dysfunction) - tracheal dilatation

EVIDENCE

- decreased ICU mortality - no difference in nosocomial pneumonia - no difference in outcome if early (< 7 days) or late (>7 days) - no change in hospital mortality (Clec’h et al, Critical Care Med, 2007 Jan; 35(1):132)

Jeremy Fernando (2011)