Acute respiratory failure tracheostomy

Qregoretti C, Squadrone V, Fogliati C, et al. Trans-tracheal open ventilation in acute respiratory failure secondary to severe COPD exacerbation. Am J Respir Crit Care Med 2006 173 877-881. Bach JR, Alba AS. Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest 1990 97 679-683. 

Acute paralytic poliomyelitis is still endemic in some countries and vaccine-associated poliomyelitis continues to occur (125). After many years of stability, some patients do deteriorate (126). This post-polio syndrome may be characterized by the development of progressive weakness associated with respiratory symptoms among those ventilated during their acute illness (127). Respiratory failure results from thoracic restriction as well as muscle weakness and bulbar involvement (128). Tracheostomy can be avoided with continuous NIV and aggressive mechanical in-exsufflation (128). Retrospective studies of NIV have reported survival rates >90% at five years, making this group the one with the highest benefit (76,129). 

Figure 1 The management of respiratory failure in the United States. Many patients are admitted initially to an acute care hospital. If they wean ptomptiy, they may spend time in an LTAC hospital for rehabilitation, and eventually return home. If they fail to wean, they undergo tracheostomy and are transferred to an LTAC when stable. Weaning attempts continue, and a mincnity of patients return home the rest remain at the LTAC or are transferred to a SNF. Patients who deteriorate while at LTACs or at home return to the acute care hospital fOT stabilization. Some patients with chronic respiratory failure do not require acute care but are ventilated noninvasively and remain home. Abbreviations COPD, chronic obstructive pulmonary disease NIV, noninvasive ventilation LTAC, long-term acute care SNF, skilled nursing facility.

If the onset of respiratory failure is foreseeable, such as in progressive NMD, end-of-life issues should be discussed early on. One survey found that if patients had previously decided to have a tracheostomy, 88% would do so again compared with only 38% of patients who had not decided before an acute deterioration (38). This emphasizes the importance of discussing the issue of tracheostomy early with patients who have degenerative neurological conditions, so that they can be prepared for the respiratory crises and not undergo an unwanted tracheostomy or hospitalization if they would prefer to be cared for at a hospice or at home. Families should be involved in these decisions, if possible, as they bear much of the burden of care, often at the cost of their own personal lives (16). 

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