Tracheostomy Weaning from Longer Term Ventilation

Tracheostomy Weaning from Longer Term Ventilation 

Hospitai da Senhora da Oiiveira-Guimaraes, Guimaraes, Portugai 

Many lives are saved in critically ill patients by the introduction of an endotracheal tube (ETT) and mechanical ventilation. Most patients are capable of weaning from such invasive support once the acute process has resolved. Approximately 10% to 24% (1,2) are unable to wean from endotracheal intubation and require the surgical placement of a tracheostomy. Although timing of tracheostomy placement is controversial, a tracheostomy may offer advantages over more prolonged intubation (3). 

General indications for tracheostomy placement include (i) upper airway obstruction, (ii) invasive mechanical ventilation (IV), (Hi) airway clearance, (iv) airway protection, and rarely (v) obstructive sleep apnea. Engoren et al. (1) demonstrated that those able to wean from tracheostomy support, whether during or after hospital admission, had an improved survival rate. Whether this is a reflection of a less severe underlying condition or whether the tracheostomy itself portends a worse outcome is uncertain. Tracheostomy weaning is often conducted outside of acute care hospitals and therefore this skill is not limited to those who work in intensive care settings. 

Tracheostomy tubes are associated with long-term complications, particularly related to cuff inflation (4). As this population has already failed endotracheal weaning, they must be approached in a systematic way to optimize the likelihood of success. Ceriana et al. have suggested a decision tree to help with this process (5). 

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Tracheostomy Weaning from Longer Term Ventilation... 

Nosawa et al. (8) analyzed 45 patients who between 1997 and 1999 required LTV > 10 days and had to undergo tracheostomy at the Hospital das Clinicas at the University of Sao Paulo. Of the 45 patients studied, 22 were weaned from mechanical ventilation within eight weeks and discharged from the ICU. Of the other 23 patients, 8 required longer-term ventilation and 15 died. The authors pointed out that patients receiving LTV consumed substantial resources. 

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