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Semin Respir Crit Care Med 2015; 36(06): 851-858
DOI: 10.1055/s-0035-1564872
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill

Thomas Bice
1   University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
,
Judith E. Nelson
2   Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
,
Shannon S. Carson
1   University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
› Author Affiliations
Further Information

Publication History

Publication Date:
23 November 2015 (online)

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Abstract

The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging.

Keywords

prolonged mechanical ventilation - tracheostomy - health outcomes - patient-centered outcomes - comparative effectiveness - chronic critical illness
 

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