Tracheostomy in critically ill adult patients: useful or futile?

Abstract

While tracheostomy is commonly performed in critically ill adult patients requiring prolonged mechanical ventilation, no consensual recommendations exist regarding its use. The aim of this article is to provide a synthesis of the contemporary literature on tracheostomy. The currently most debated questions are addressed: What are the expected benefits of tracheostomy? In which patients should tracheostomy be performed? Should tracheostomy be performed early in the course of mechanical ventilation? Is percutaneous dilatational tracheostomy (PDT) preferable to surgical tracheostomy? How should patients be managed following tracheostomy placement? Due to the relatively low level of evidence of available studies, no definitive recommendations for tracheostomy can be made. However, these studies highlight several important issues. Firstly, early tracheostomy has failed to demonstrate any beneficial impact over prolonged translaryngeal intubation on mortality, infectious complications and duration of mechanical ventilation; however, it may reduce the need for sedative drugs, improve patients’ comfort and lead to earlier mobilisation and autonomy. Secondly, no specific subgroup of patients likely to draw the maximum benefit from tracheostomy has been identified so far. Thirdly, PDT seems to be preferable to surgical tracheostomy with respect to complications and costs. Finally, the optimal management of tracheostomized patients is far from being standardized. Further investigations are thus warranted to identify the best candidates for tracheostomy and delineate optimal care following tracheostomy placement. Until then, tracheostomy practices will remain largely influenced by physicians and patients’ preferences and preconceived opinions on tracheostomy.