Introduction

The need for invasive mechanical ventilation is a major cause of admission to intensive care units [1,2,3,4,5,6]. The maintenance of an artificial airway for advanced support in several acute and chronic pathologies is the reality of services that deal with critical patients. Such a profile is found at various levels of care, from low-complexity units to intermediate support units to intensive care units with patients that demands 100% of human resources and specialized materials for critical care.

For these reasons, 10% of patients requiring at least 3 days of mechanical ventilation may need a definitive airway. In this case, the alternative is the tracheostomy [1,2,3,4,5,6].

Tracheostomy is usually an elective procedure in the intensive care context. Although several techniques have been developed in recent years (conventional or percutaneous techniques), the lack of appropriately designed studies to evaluate short- and long-term complications—such as major bleeding, infections, and tracheal stenosis—makes it difficult to choose the most appropriate method in the intensive care unit. Concerning the complications, the risk seems to be the same, with slight superiority of percutaneous techniques related to infections and cosmetic changes, and, depending on the technique, a lower risk of major bleeding [1,2,3,4,5,6].

Furthermore, although there is extensive experience with the procedure, with known indications and presumed benefits, many of the suggested benefits are based on uncontrolled studies, observational studies, expert opinion, and controversial data [1,2,3, 7]. Regarding the timing of the tracheostomy, there is no consensus on the best time to perform it, whether early (at 4–10 days), at 10–14 days, or at up to 21 days of translaryngeal cannula use. The need for individualization of each patient’s situation by the intensivist for effective prediction of the ideal time to execute the procedure, using clinical judgment, is well known though [1,2,3, 7,8,9].

This chapter has the main objective of delineating the main indications for tracheostomy in intensive care, with a description of techniques, complications, and the most appropriate time for performing tracheostomy in general and specific situations.

Indications, Advantages, and Disadvantages of Tracheostomy

Indications

In the intensive care environment , there are five main indications for tracheostomy [1, 4, 5, 10, 11]:

  1. (a)

    Obstructed airway, either by a foreign body, tumor, laryngeal stenosis, burns, trauma, or infection

  2. (b)

    To provide continued invasive mechanical ventilation to patients who have difficulty in weaning off artificial ventilation or patients who have chronic neuromuscular diseases or degenerative diseases

  3. (c)

    To prevent damage to the airway with prolonged translaryngeal cannulation

  4. (d)

    To prevent aspiration in high-risk patients

  5. (e)

    To optimize clearance of pulmonary secretions, improving airway patency

It should be emphasized that tracheostomy is not performed due to a disease itself, but due to complications generated by the pathology. In addition, tracheostomy has been used in airway management, but today it is used only in specific cases, except for the aforementioned indications leading to supraglottic direct trauma, preventing oral intubation [2, 3, 6, 8, 9].

Benefits and Disadvantages

As already mentioned , there are several presumed benefits provided by tracheostomy for eligible patients: to protect the larynx from lesions such as tracheal stenosis; reduction in the incidence of ventilator-associated pneumonia; greater comfort for the patient; less need for sedation and mechanical ventilation; shorter intensive care length of stay and shorter hospital stay; possibility of returning to oral nutrition; return of phonation; more secure ventilatory support; and easier nursing care [1,2,3,4,5,6].

On the other hand, while many of these benefits are supported by scientific data, some of these gains that the procedure can supposedly provide are theoretical and based on observational studies and clinical experience [1, 8, 10] , except for lower use of sedatives, (reported in several randomized controlled trials and one multicenter study), fewer days of mechanical ventilation, and shorter intensive care and hospital stays [2, 3, 6, 8, 9].

The presumed tracheal protection against stenosis or long-term complications, despite being observed in patients in daily practice, should not be taken as irrefutable truth. There is also a shortage of large studies following tracheostomized patients for more than 6 months. Moreover, according to a systematic review published in 2015 in Critical Care Medicine , comparing long-term outcomes in critically ill patients, most analyzed studies have been unable to demonstrate a relationship between the procedure and reduced rates of these complications, especially regarding tracheal stenosis. Such complications are underdiagnosed and lack structured criteria [12].

Likewise, there is controversial evidence concerning the reduction in ventilator-associated pneumonia; from the point of view of evidence-based medicine, it cannot be proven that such a strategy—although it can reduce the use of sedatives and may lead to more days free of mechanical ventilation—can effectively minimize the risk of developing this complication [6, 9].

In relation to the patient’s quality of life and safety, even if there is a practical hypothesis that the tracheostomized patient would be less subject to events related to airway cannulation, manifold observational and controlled studies have shown increases in the number of endotracheal cannula replacements and severe events such as hypoxia, subcutaneous emphysema, false pathway, and even cardiorespiratory arrest being related to endotracheal cannula obstruction. However, these events are more related to patient discharge to units with a patient-to-nurse ratio of >2:1 and lack of continuous monitoring. In addition, there is flexibility in monitoring and surveillance, even in closed units. In fact, it is believed that there is a relationship between decannulation and increased mortality [1, 6, 8, 9, 12, 13, 14] when that occurs in lower-complexity care units.

There is also the fact that patients report self-image changes, especially in relation to aesthetic factors; they present with fewer painful events and complaints of discomfort [1, 8, 12, 13].

The disadvantages of the procedure are related to the procedure itself, which will be discussed later, and to the permanence of the tracheal cannula, such as:

  1. (a)

    Tracheal complications such as tracheal stenosis, tracheomalacia, tracheoesophageal fistula, tracheal granuloma, soft tissue infection, and tracheobronchitis

  2. (b)

    Risk of a false pathway in the replacement of the cannula, lumen obstruction, hypoxemia due to obstruction, subcutaneous emphysema, and cardiorespiratory arrest

  3. (c)

    Increased mortality after discharge from the intensive care unit, as discussed above

  4. (d)

    Failure in the cicatrization process, with the need for tracheoplasty

Patients also report a high incidence of anxiety attacks and panic syndrome after decannulation, in addition to the aforementioned changes in the way the patients see themselves [1, 3, 4, 11, 12].

When to Perform Tracheostomy

Initially, it is important to make clear that we have not yet been able to define the ideal time for performing tracheostomy. Some authors in the 1990s and early 2000s suggested that early tracheostomy would be beneficial, both from the point of view of weaning off mechanical ventilation and in preventing ventilator-associated pneumonia, with a shorter intensive care unit length of stay. However, these advantages have not been replicated in major studies and systematic reviews [1, 11, 13].

The last major randomized controlled trial that was published—the TRACMAN study , performed in different centers of intensive care in the UK—failed to demonstrate superiority of early tracheostomy (after 4 days of intubation) in comparison with tracheostomy at between 10 and 14 days. There were no significant differences in mortality at 90 days, hospitalization times, or infection rates, i.e., there was no difference in outcome. However, it was demonstrated that in the early tracheostomy group the use of sedatives was lower, leading to shorter mechanical ventilation time. An important finding was that the physicians involved in direct patient care failed to predict the optimal timing of tracheostomy. Despite this, the authors recognized flaws in the design of the study. First, it was impossible for a blinded study to be conducted. A second point was that the study was discontinued by suspension of research funding, making it impossible to achieve the sample size originally calculated to prove the hypothesis. Another problem was the absence of patient subtypes that presumably would benefit from the early strategy, such as neurocritical and postoperative cardiovascular surgery patients [10].

In 2015, after a meta-analysis, Cochrane concluded that the early strategy would be the most beneficial for shorter mechanical ventilation and early discharge from the intensive care unit. However, in this review, only four studies were considered adequate for evaluation [7].

Therefore, in general, we do not have enough data to recommend an early strategy for all patients, thus further research is required. Individualization is always important, and there seems to be a consensus based on expert opinion and clinical experience that an indication for tracheostomy at between 12 and 14 days of orotracheal intubation is more adequate [1, 4, 7, 10].

Analyzing the data from clinical experience and the available literature, we recommend that tracheostomy in critical care patients be generally performed between the 10th and the 14th days of intubation.

Important Exceptions

There are some exceptions that warrant discussion: patients with moderate and severe traumatic brain injury predicted to require more than 4 days of mechanical ventilation; postoperative cardiovascular surgery patients who have failed weaning off mechanical ventilation; and patients with amyotrophic lateral sclerosis of the bulbar type.

Moderate and Severe Traumatic Brain Injury

In patients with moderate to severe traumatic brain injury who are expected to need more than 4 days of mechanical ventilation, early choice of tracheostomy, according to literature data, appears to reduce infectious complications, especially ventilator-related pneumonia, and the durations of mechanical ventilation and hospitalization. The Brazilian guideline for mechanical ventilation , in its latest (2013) edition, recommends that in these patients the procedure should be performed after the first 4 days if there is no possibility of mechanical ventilation withdrawal [14,14,18].

It should be noted that in unstable patients with uncontrolled intracranial hypertension, the approach should be delayed until stabilization, as manipulation of the trachea increases intracranial pressure, leaving the patient at risk [15, 16, 18, 19].

In neurocritical patients, for different reasons, there is no such strong recommendation, and we must use an individual approach. A study published in Stroke showed that tracheostomy at 4 days had a relative benefit, although it was a small study and had some measurement bias, thus this study was not sufficient to change paradigms [14,15,16,17,19].

After Cardiac Surgery

Some authors suggest that performing early tracheostomy in cardiovascular surgery patients who have failed mechanical ventilation weaning at the fourth postoperative day may reduce the rate of ventilator-associated pneumonia, use of sedatives, the duration of mechanical ventilation, and the incidence of delirium. A randomized trial from a French group, published in 2011 in the Annals of Internal Medicine , also suggested such advantages, although it was a single-center study [20].

Amyotrophic Lateral Sclerosis

In patients with amyotrophic lateral sclerosis who present with respiratory insufficiency and quite compromised muscular force—mainly patients with bulbar involvement—the best option is tracheostomy. In this case, the recommendation is that tracheostomy is the first choice when an artificial airway is needed, avoiding tracheal intubation [17, 21, 22].

Tracheostomy Techniques, Complications Related to the Procedure, and Contraindications

Conventional (Open) Tracheostomy

There is a consensus opinion among the authors of this chapter that the best place in which to perform the tracheostomy, whether conventional or percutaneous, is the intensive care unit itself because this avoids unnecessary transportation of the patient. Moreover, experience shows that a well-trained intensive care physician can replace the surgeon, even for performing the conventional technique [1, 4].

Preparation of the Patient

In order to perform the open technique, it is necessary to position the patient with neck extension (if there are no contraindications) and to identify anatomical marks. The points of anatomical reference, which are easily identifiable, are the lower border of the cricoid cartilage, cricothyroid membrane, cricoid cartilage, and sternal notch. Adequate preparation of the aseptic technique with placement of sterile fields and anesthetic induction should be performed [1, 4, 5, 11, 23].

Incision and Access to the Trachea

A vertical or horizontal incision can be performed; however, the latter gives the best aesthetic results.

From the incision, which must have adequate depth to surpass the platysma, hemostasis with an electric scalpel is performed. The anatomical sequence begins with the sternohyoid muscle, the anterior jugular veins, the sternothyroid muscle, and the thyrohyoid muscle. After stretching the muscles with retractors, we can easily reach the area that contains the isthmus of the thyroid, at which time special care must be taken. In most situations, with cranial displacement of the isthmus, we can easily reach the third tracheal ring; in some cases it may be necessary to dissect the isthmus or even perform isthmectomy [1, 4, 10, 11, 28,29,26].

Tracheal Incision and Cannula Insertion

The incision is made from the second to the fourth tracheal ring. Most authors recommend performing suturing at the lateral edges of the tracheal incision to better identify the structures, although this may vary among surgeons, then the appropriate tracheal cannula is inserted through the incision [1, 4, 11, 28,29,26].

Percutaneous Techniques

Percutaneous tracheal dilatation is currently the most commonly used percutaneous method for performing tracheostomies in intensive care units. Here, again, a trained intensivist can replace the surgeon. There are several forms of training. There are courses recognized by the international societies of intensive care medicine, thoracic surgery, otorhinolaryngology, and head and neck surgery; and there is the possibility of the training intensive care physician to accompany an experienced surgeon or intensivist to become familiar with the technique. It is recommended that in both cases the professional is able to perform the procedure without supervision only after at least 20 supervised procedures [23,23,24,25,26,27,, 24, 22,28,29,30,31].

Some studies postulate that if the professional does not have the necessary experience to perform the percutaneous technique, it is safer to perform the conventional surgical technique. Even though the percutaneous technique is apparently simpler to perform, it requires adequate identification of anatomical landmarks and some other aspects, which will be discussed below [27, 25,26,31].

Percutaneous techniques are similar; only the commercially available kits for carrying them out differ. They are based on the Seldinger technique with the use of a guide wire, which can be blinded or assisted by bronchoscopy (more recommended) and, more currently, with the use of ultrasonography. The use of ultrasonography involves a shorter learning time and involves materials less fragile than the optical fiber of the bronchoscope [4, 27, 25,26,31].

Technique, Preparation, and Access to the Trachea

The patient should be in a supine position, with neck extension , and needs to be ventilated continuously with a 100% inspiratory oxygen fraction. The orotracheal tube is then withdrawn with direct visualization after deflation of the cuff, identifying the third and fourth tracheal rings. Adequate skin disinfection is performed with placement of surgical fields. The visualization of the natural anatomical landmarks in this case is more important than in the surgical technique [4, 23, 25,26,31].

We use a 14-gauge needle attached to a syringe filled with distilled water or saline solution, puncturing from the second to the fourth tracheal ring until there is a decrease in resistance, air aspiration, and evidence of bubble formation in the solution. We confirm the placement of the cannula under direct visualization with a bronchoscope, insert the guide wire through the needle, fit the dilator through the guide wire, and, with a little pressure, dilate the tracheal ring and remove and mount the dilator. The cannula is then positioned in the trachea. The patient is then ventilated, observing the resistance in the airway and confirming the position of the cannula with the bronchoscope [4, 27, 25,26,31].

Performing a simple chest X-ray to rule out immediate complications of the procedure is necessary. A major advantage of using ultrasonography is the ability to waive this test [4, 23, 25,26,31].

There are several commercial kits available on the market, and dilatation can be performed with curved, straight, or tapered dilators, or even using a balloon.

Conventional Versus Percutaneous Techniques

Although researchers have failed to demonstrate clear superiority (from the point of view of long-term structural complications) of either percutaneous or conventional tracheostomy, and although the studies have been mostly observational and nonrandomized, a meta-analysis performed by Dempsey et al., published in Critical Care Medicine in 2015 , suggested that the majority of events such as major bleeding, infection, and tracheal stenosis are less frequent with the percutaneous technique [12].

Complications Related to the Procedure

The following complications can occur, related to the procedure [1, 3,4,5, 11, 12, 29,30,31,, 26, 32, 33]:

  1. (a)

    Pneumothorax (1–5%)

  2. (b)

    Vascular lesions with major bleeding (up to 5%)

  3. (c)

    Injury of the thyroid isthmus (<1%)

  4. (d)

    Recurrent laryngeal nerve injury (<1%)

  5. (e)

    False pathway (<1%)

  6. (f)

    Subcutaneous emphysema (<1%)

  7. (g)

    Esophageal lesion with tracheoesophageal fistula (<1%)

  8. (h)

    Tracheal laceration (<1%)

  9. (i)

    Tracheal stenosis (<1%)

  10. (j)

    Hypoxia and cardiorespiratory arrest (<1%)

The following complications can occur, related to the presence of the cannula [1, 3,4,5, 11, 12, 29,30,31,, 26, 32, 33]:

  1. (a)

    Cannula obstruction

  2. (b)

    Surgical wound infection

  3. (c)

    Tracheobronchitis

  4. (d)

    Tracheomalacia

  5. (e)

    Formation of granuloma

  6. (f)

    Stoma necrosis

  7. (g)

    Esophagotracheal fistula and tracheal stenosis

Contraindications

The following are contraindications to the procedure [1, 3,4,5, 11, 12, 29,30,31,, 26, 32, 33]:

  1. (a)

    Platelet count <50,000 or coagulopathy (with both techniques). In this case it is recommended to perform a platelet transfusion before the procedure: 1 unit for each 10 kg of patient weight until a target above 50,000 platelets is reached [33].

  2. (b)

    Active bleeding in the cervical region, cervical trauma, thyroid goiter (with both techniques).

  3. (c)

    Cervical instability (with both techniques).

  4. (d)

    Abnormal anatomy/tumors (with the percutaneous technique).

Conclusions

Tracheostomy is one of the most common procedures performed in the intensive care unit. The indications for the procedure in patients who require intensive care are due not to their diagnosis per se but to the inherent complications of caring for patients with severe acute or chronic disease [1,2,3,4,5,6].

Continuous use of mechanical ventilation is one of the main indications. Advances in education and training of professionals, and the development and evolution of critical care medicine as an internationally recognized medical specialty, make the intensive care physician the most appropriate professional, with suitable training, to perform the procedure in the context of critical patient care [1,2,3,4,5,6].

However, with the aging population and the increases in chronic degenerative diseases, urban violence, and accidental injuries, more patients will require this strategy. We still require appropriate studies to assess the long-term complications of the procedure, the best time to perform it, and the issues of whether it provides real benefits or comfort to patients, whether the benefits exceed the aesthetic disadvantages, and the quality of life of patients undergoing tracheostomy [1,2,3,4,5,6,7,8,9,10,11,12, 32, 33,34,35,37].

Finally, perhaps the greatest challenge for professionals dealing with this population is to individualize the management of patients more and more, to make families aware of the importance and safety of tracheostomy, and to demystify the idea that the procedure is an eternal sentence for patients, since this airway path is nothing more than a bridge to facilitate withdrawal of the ventilatory strategy and resumption of the functional potential of each patient. With improvements in rehabilitation strategies, physical therapy, speech therapy, and occupational therapy, cannula withdrawal can then be performed safely in a controlled environment [1,2,3,4,5, 7,8,9,10,11].