Tracheotomy for the long-term ventilator-dependent patient?

Abstract

Objective: Tracheotomy is commonly performed in long-term ventilated patients. The aim of this review is to discuss the advantages and disadvantages of tracheotomy. Methods: Review of the literature. Results: Disadvantages of tracheotomy include the risk of bleeding, infection, injury of the truncus brachiocephalicus, and of long-term tracheal injury. These risks must be compared with the risk of vocal cord trauma, laryngeal trauma, and subglottic stenosis following translaryngeal intubation. Despite a number of disadvantages and potentially even life-threatening complications, however, tracheotomy is a well-established technique for long-term airway management in critically ill patients. Potential advantages of tracheotomy include enhanced patient comfort, reduced airway resistance and dead space, a lower incidence of ventilator-associated pneumonia and a shorter duration of mechanical ventilation and hospital stay. Patient comfort before and after tracheotomy has not yet been seriously evaluated, using modern ventilators airway resistance does not longer play a major role. No data from randomized controlled trials actually support the thesis that tracheotomy reduces the incidence of ventilator-associated pneumonia. There is weak evidence for the concept that the duration of mechanical ventilation can be reduced in patients while using tracheotomy. Patients undergoing percutaneous dilational tracheotomy seem to have a reduced risk of bleeding and site infection and a shorter duration of the procedure when compared to those with conventional surgical tracheotomy. Conclusions: Many clinicians perform tracheotomies on the basis of expert opinion and clinical experience. So far, the benefits, however, have not been proven in large-scale randomized trials. Many of these studies suffer from design flaws, insufficient randomization and the absence of blinding. On the other hand, the lack of positive results do not rule out that tracheotomy may be beneficial for the ventilator-dependent patient. Percutaneous tracheotomy procedures may be superior to conventional surgical tracheotomies. Long-term results, however, will have to prove this preliminary observation.