A 28-year-old, previously healthy woman 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 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 pH 7.47, PCO2 37, PO2 60, and HCO3 26 torr. Her respiratory rate is 20 breaths per minute (bpm). All other vital signs are stable. You have been consulted to help perform a tracheotomy.
31.2.1 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 hope of minimizing long-term airway complications,3 but standard practice dictates a range of 7 to 10 days following the initial intubation. Griffiths et al did a meta-analysis of five studies on early (0-7 days) versus late (= 8 days) tracheotomy.4 No difference was shown in mortality and risk of pneumonia. Early tracheotomy decreased length of stay in the intensive care unit (ICU) and length of artificial ventilation. Dunham and Ransom showed no difference in mortality, pneumonia, or ventilator/ICU stay between early versus late tracheotomy except in patients with severe brain injury.5 Thus, if prolonged intubation is predicted based on patient circumstances, such as a high spinal cord injury, then earlier conversion to tracheotomy may be considered.
31.2.2 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,3,6 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.7
31.3.1 If a Tracheotomy Is Going to Be Performed Anyway, Why Is It Important to Know Whether This Patient Has a Difficult Airway or Anatomical Features Associated with Difficult Laryngoscopic Intubation?
In fact, it is extremely important to assess the airway prior to performing a tracheotomy. When performing either a surgical tracheotomy (ST) or a percutaneous dilational tracheotomy (PDT), during the ...