Indications

In the critical care setting, tracheostomy may be required to relieve upper airway obstruction, to expedite bronchopulmonary toilet, and to facilitate mechanical ventilation, particularly when prolonged (HeffnerJ988). A fourth indication often cited is to establish airway access in emergencies but, in the absence of upper airway obstruction, emergency airway access can usually be gained more efficiently by endotracheal intubation. Upper airway obstruction in critically ill patients may arise from malignancies, trauma, vocal cord paralysis, or laryngeal edema or spasm. Patients with excessive bronchopulmonary secretions or impaired clearance mechanisms, such as those with neurological conditions, may require tracheostomy in order to provide access for suctioning and therapeutic aerosol delivery. Probably the most common role for tracheostomy is to provide a stable interface between mechanically ventilated patients and their respirators.

Generally, acute airway management in intensive care patients initially involves the use of a translaryngeal endotracheal tube. The endotracheal tube is easily inserted, is less invasive for most patients, and provides an acceptable short-term airway. However, conversion to tracheostomy results in several benefits ( Tibie 1.)

(H§ffn§L,l?.88; H,QZQ[d.§La.L 1991). For the vast majority of conscious patients, tracheostomy is much more comfortable than translaryngeal intubation. Indeed, it can be argued that intubation is the greatest misery that is routinely visited on such patients, and few would contest the fact that tracheostomy is well tolerated. Few endotracheally intubated patients, alert and unrestrained, will fail to extubate themselves at the first opportunity; however, patients with tracheostomies rarely attempt to remove their airways. The ability to communicate is improved, oral feeding is often possible, and positioning out of bed into a chair, even ambulation in some patients, is facilitated. Apart from the elimination of the continuous discomfort and practical limitations of the translaryngeal tube, patients with tracheostomy are more easily managed from a nursing perspective. Clearance of bronchopulmonary secretions is facilitated. Patient cough efforts and suctioning by nursing staff are likely to be more effective with the shorter more direct airway access. Airway resistance and work of breathing are diminished, and this may facilitate weaning from the ventilator. Earlier tracheostomy may reduce the potential for injury to the larynx that endotracheal intubation provokes.

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Table 1 Benefits of tracheostomy

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