Why would a trach be prescribed?
A tracheostomy is an artificial airway that is used for patients requiring prolonged support with a positive pressure ventilator. Tracheostomy is also utilized for conditions resulting in upper airway obstruction.
Due to the possible life-threatening dangers of tracheotomy procedures, as well as the probable early and later complications, a tracheotomy is typically used as a last resort or in emergency situations.
Because of the known dangers and dependency inherent with a tracheostomy, attempts to avoid the procedure can be more beneficial than receiving the surgery for some patients. Complications have been reported to occur in up to 40% of tracheotomies. (7)
Since only roughly 3% of mechanically ventilated patients in an intensive care setting need a surgical tracheostomy (3), other means of support are typically highly-preferred, such as mask ventilation, high flow nasal cannula or Biphasic Cuirass Ventilation.
A tracheostomy is usually performed for one of three situations:
- to provide a direct interface between a ventilator circuit and the trachea for longer term support of ventilation and oxygenation
- to bypass an obstructed upper airway
- as a direct entry port to suction and remove secretions from the airway
The majority of trachs are performed non-emergently or electively as a considered next step; however in rare circumstances there are certain conditions which would restrict or prohibit air from reaching the airways, forcing an emergency trach procedure to be performed.
Non-emergently, prior to tracheostomy placement, when non-invasive support techniques have failed or the patient’s respiratory status is deteriorating quickly or when the patient is unable to maintain and protect their own airway, an endotracheal or ET tube will be inserted to support breathing. The ET tube is usually attached to a mechanical breathing device (ventilator) and will be inserted into the mouth and down the throat into the trachea or wind pipe. The procedure in which the ET tube is inserted is called intubation. While the ET tube is in place the patient’s airway status is “intubated”. The ET tube is inserted in order to help a patient breathe, and is a short term airway management intervention. Intubation has its own set of potential dangers and is also best avoided whenever possible or reversed (extubation) as soon as possible. Since a prolonged period of intubation can cause other medical issues and can be very uncomfortable, beyond a certain point a tracheostomy may be considered if the patient cannot safely be supported without an airway tube. This will typically be done if breathing support is needed for more than 7-10 days, depending upon a facility’s internal guidelines. In cases where alternatives may allow avoiding a trach procedure tracheostomy may be delayed as long a 30 days and in rare cases even longer.
A tracheostomy can also be used emergently to bypass an airway that has become blocked as a result of:
- accidentally swallowing something which gets lodged in the windpipe (trachea), such as a piece of bone
- an injury, infection, burn, or a severe allergic reaction (anaphylaxis) that causes the throat to become swollen, blocking air from reaching the lungs
- swelling after head or neck surgery
- a cancerous tumor – sometimes associated with mouth cancer, laryngeal cancer, or thyroid gland cancer
Also, some children are born with defects that can cause their airways to be abnormally narrow. They may need a tracheostomy to help them breathe.
The Ideal Solution is to Avoid a Trach
Patients can typically stay on mechanical ventilation for an average of 11 days before surgical tracheotomy procedure is suggested. In a significant number of cases other means of support known as non-invasive ventilation (NIV) exist which can help avoid a trach. These are Biphasic Cuirass Ventilation (BCV), Heated & Humidified Highflow Nasal Cannula (HHNC) or mask ventilation (PAP or NIPPV). All types of non-invasive ventilation are is known to be able to provide support to patients on extubation (removal of the ET tube) increasing their chances of the patient successfully separating from the ventilator, and allowing a trach to be avoided. Since BCV uses a chest shell known as a cuirass which leaves the face and neck open, it can be used in conjunction with mechanical ventilation, prior to extubation to improve the potential for successful discontinuation of the invasive ventilator and extubation avoiding the use of a tracheostomy. Mask non-invasive ventilator support can be implemented immediately at the time of extubation to offer a way to allow better chance of successful weaning without a trach, as can HHNC. These interventions can also be used in a combined fashion in certain cases improving chances for successfully avoiding a trach. A trach should only be required after all alternative non-invasive means of support have been trialed unsuccessfully. Only then should a surgical intervention as serious as a tracheostomy be considered unless emergent.