CHAPTER 33: Performing an Elective Percutaneous Dilational Tracheotomy in a Patient on Mechanical Ventilation

CASE PRESENTATION

A 28-year-old, previously healthy female was thrown off an all terrain vehicle (ATV) and sustained blunt trauma to her chest. Her injuries included a flail chest with fractures of the right first and second ribs, a pulmonary contusion, as well as a right femur fracture and ruptured spleen. Following a splenectomy on the first night, she stabilized hemodynamically and subsequently underwent an open reduction internal fixation of the fractured femur. On the 10th day, she failed an extubation attempt due to hypoxemia. Currently she is being ventilated with a pressure support of 12 cm H₂O, positive end-expiratory pressure (PEEP) of 5 cm H₂O and FiO₂ 0.50. Her ABG shows a pH 7.47, PCO₂ 37 mm Hg, PO₂ 60 mm Hg, and HCO₃ 26 mEq·L⁻¹. Her respiratory rate is 20 breaths per minute. All other vital signs are stable. You have been consulted to help perform a tracheotomy.

INTRODUCTION

Why Would You Perform a Tracheotomy on This Patient?

Local changes occur in airway mucosal surfaces following as little as 2 hours of endotracheal intubation. These pathophysiologic changes include a well-documented progression of mucosal ulceration, pressure necrosis, granulation tissue with subsequent healing, fibrosis, and occasionally stenosis.^1,2 There exists no consensus on the ideal timing of performing a tracheotomy in the hopes of minimizing long-term airway complications,³ but standard practice dictates a range of 7 to 10 days following the initial intubation. While a Cochrane review⁴ showed lower mortality in an early tracheotomy group (<10 days) and a higher propensity for discharge from the ICU at day 28, a meta-analysis found no difference in mortality, length of ICU stay, or risk of ventilator-acquired pneumonia when compared to the late tracheotomy group (>10 days) but did find that the duration of sedation was decreased.⁵ Notwithstanding, in a retrospective study of early versus late tracheotomy in trauma patients, Hyde et al.⁶ showed a significantly lower length of ICU stay, ventilator-acquired pneumonia, and ventilator days in the early group. However, in this study early tracheotomy was shorter than the previous analyses, <5 days. Thus, if prolonged intubation is predicted based on patient circumstances such as trauma, for example, a high spinal cord injury, then earlier conversion to tracheotomy may be considered.

What Are the Advantages of a Tracheotomy Over a Prolonged Translaryngeal Intubation?

The potential advantages of a tracheotomy over a prolonged translaryngeal intubation include less direct endolaryngeal injury, a potentially decreased risk of nosocomial pneumonia in certain patient subgroups,^3,7 more effective pulmonary toilet, and possibly decreased airway resistance for promoting weaning from mechanical ventilation. Additional benefits include improved patient comfort, communication and mobility, increased airway security, decreased requirements for sedation, better nutrition, and earlier discharge from ICU.^8,9