Timing of tracheostomy

The optimal timing for tracheostomy, a subject surrounded by much controversy, depends on a number of considerations. These include consideration of the relative risk-benefit ratio of prolonged translaryngeal intubation versus tracheostomy, the presence of absolute or relative contraindications to tracheostomy, the degree of discomfort experienced by the endotracheally intubated patient, the extent of problems relating to pulmonary toilet, and the anticipated duration of endotracheal intubation. On the whole, conscious patients who are obviously experiencing severe and constant discomfort from translaryngeal intubation should be considered for tracheostomy relatively early in their courses, whereas those in deep coma might be expected to endure the endotracheal tube longer. Between these extremes, much clinical judgment is called for. Patients with thick secretions, poor airway guarding, or weak cough might be considered candidates for early tracheostomy, while those in whom secretions are minimal or strong cough reflexes are evident might be assigned to later tracheostomy if extubation cannot be accomplished expeditiously. In many patients, obvious oral or labial breakdown arising from the endotracheal tube might dispose toward tracheostomy. Generally speaking, patients for whom prolonged dependence upon an artificial airway can be anticipated, such as those with traumatic cervical spine injuries, should be considered as candidates for early tracheostomy.

Such concerns have led to widely varying recommendations regarding timing of tracheostomy, with some authorities recommending tracheostomy within the first few days of intubation, and others advising delays of 3 to 4 weeks in anticipation of extubation. The emergence of percutaneous tracheostomy, with its simplicity and markedly reduced morbidity, may affect these recommendations. Our own approach is to perform tracheostomy, usually by the percutaneous dilatation method, within 7 days in patients who have not been and show no signs of being able to be weaned from the ventilator. In patients in whom conditions exist that would obviously preclude extubation within this time frame, such as those with high spinal cord injury or many with acute respiratory distress syndrome, we elect to perform tracheostomy within 3 to 5 days of intubation.

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