Clinicians

Many clinicians consider a tracheostomy a better choice for the long term if a patient continues to need invasive ventilator support, when compared to an endotracheal tube. It frees the structures of the mouth from the pressures caused by having the tube in place. Although the benefits of advancing the prolonged-intubation-dependent patient to a tracheostomy are well accepted, many times the dangers and complications of the tracheotomy are overlooked, considered too lightly and/or not properly explained to the patient, nor his or her family. Informed consent, in one study, was found to be occur in only 60% of cases. (1).

Informed consent from the patient and family should include an entire explanation of the common occurrences which arise from tracheotomy procedures:

  • Infections and complications from the procedure may be severe and life-threatening, especially in elderly or immunologically compromised patients.
  • Loss of voice
  • Psychological distress
  • Speech and language complications, especially in youth development
  • Higher risk of aspiration, along with impaired swallowing capabilities
  • Loss of smell and taste
  • Compromised nutritional health
  • Secretion issues
  • Loss of physiological PEEP and poor oxygenation
  • Tracheomalacia
  • Tracheal Stenosis
  • Tracheitis
  • Necrotizing Tracheostomal Infection
  • Increased Volume of Pulmonary Secretions
  • Tracheal Scarring and Malformation
  • Need for direct airway suctioning

Early Complications of Trach include:

Early complications can occur in up to 32% of patients (1) and can include:

  • Bleeding and infection occurring at the surgery location
  • Pneumothorax in up to 4% of patients (15)
  • Pneumomediastinum
  • Subcutaneous emphysema in up to 11% of patients with the potential for tracheal or esophageal damage and possible pulmonary restriction
  • Injury to the  (recurrent laryngeal nerve)
  • Esophageal damage
  • Misplacement or displacement of the tracheostomy tube in up to 15% of patients. (15)

Later Complications of Trach that may Occur While the Tracheostomy Tube is in Location Include:

Later complications can occur in up to 65% of patients (15) and can include:

  • Unintentional removal of the tracheostomy tube (inadvertent decannulation).This can be a potentially disastrous problem. It can be caused by a variety of reasons including inadequately secured tubes, frequent coughing, patient movement, or even short/thick neck or obesity. Some studies have recorded a displacement rate of up to 15% of patients. (15)
  • Infection in the trachea and/or stoma around the tracheostomy tube
  • The trachea itself may become damaged from a number of conditions, including pressure from the tube; bacteria that cause infections and form scar tissue; or erosion from tube movement
  • Abnormal tissue masses, or granulations, in the airways
  • Narrowing or collapse of the airway above the trach tube’s location can occur in up to 8% of patients. (15)
  • Blockage of the tracheostomy from dried secretions and mucus masses (also called plugs)
  • Obstruction of the tracheostomy tube
  • Development of increasing risk of aspiration
  • Development of (tracheoinnominate fistula), which can generate life-threatening bleeding
  • Bacterial conditions, which may cause illness, such as pneumonia

Patients should be informed that tracheostomy tubes can be obstructed by blood clots, mucus or pressure of the airway walls; and that obstructions will need to be continually treated by using suctioning, humidification of the air, and using the proper fitting tracheostomy tube.

Clinician’s duty

With the many potential immediate and late procedural and chronic use complications associated with tracheostomy tube placement it becomes imperative that clinicians caring for patients for whom their illness may result in them needing to have a tracheotomy considered be highly skilled in the techniques and therapeutic interventions with the potential of preventing the trach procedure. With the potential of multiple side effects and even perhaps permanence of the commitment to trach for a patient, a failed spontaneous breathing trial or two is not adequate justification. There is good data demonstrating the use of the NIV techniques of NIPPV, BCV and HHNC used individually or in combination can offer increased opportunity for success in the process of avoiding intubation or supporting the patient to, through and following extubation. Some patients will respond best to one or the other of these and others will respond best to the combination approach, but until all efforts using these tools have been exhausted the patient should not be considered for trach tube placement.