Timing of Tracheostomy in the Critically III Patient: Late Tracheal Stenosis

Late Tracheal Stenosis
Late tracheal stenosis after tracheostomy has received sporadic attention in case reports since at least 1964. In follow-up of 237 patients (120 responding) who had more than 3 days of intubation in a large multidisciplinary ICU at Victoria Hospital, 52 were intubated 7 days or less, and only 1 of these had necessary surgical removal of a granuloma; 63% had no complication. Of 17 intubated more than 7 days, 48% had no complication, and the remainder had minor complications—most frequently hoarseness, which did not persist. Of patients who had tracheostomy after prolonged intubation, only 23% were free from complications. These authors concluded that tracheostomy should be avoided as long as possible, but that frequent evaluation of the larynx should be undertaken after 7 days.

The immediate and severe complications from tracheostomy are not unique to this means of airway management, but they are more prominent than with endolaryngeal intubation and are therefore also involved in this decision. Although some otolaryngologists do recommend early tracheostomy because of the lower incidence of laryngeal injury, this decision is not to be undertaken lightly in the face of increased incidence of severe and late complications, although it usually becomes necessary to perform a tracheostomy after 10-12 days of intubation. One group attempted to provide a decision-making tool based on an injury-seventy score (ISS) to permit assessment of longterm needs for ventilation. ISS scores >30 were always associated with intubation for more than 7 days; therefore, one could opt for early tracheostomy if the ISS was >30.
Summary
The decision for timing of tracheostomy remains controversial. The relative complication rates in two retrospective series, in which 79 and 150 critically ill patients were examined, respectively, showed increased incidence of late complications with tracheostomy and led Pettys group to conclude “The value of tracheotomy when an artificial airway is required for periods as long as 3 weeks is not supported by data obtained in this study.”

Category: Tracheostomy

Tags: acute lung injury, mechanical ventilation, pulmonary, respiratory failure