Version May 2024
INTRODUCTION — Tracheostomy is a surgical procedure that creates an opening in the anterior wall of the trachea to facilitate airway access and ventilation. This topic reviews the rationale, indications, and contraindications for tracheostomy. Procedural details, complications, and general maintenance of a tracheostomy tube are provided separately. (See "Tracheostomy in adults: Techniques and intraoperative complications" and "Tracheostomy: Postoperative care, maintenance, and complications in adults".)
TERMINOLOGY — We use the term "tracheostomy" and "tracheostomy tube" when referring to the placement of a tube through an opening in the anterior wall of the trachea; a tract is created between the trachea and the skin of the neck along the length of the tube.
Although interchangeably used, we prefer to reserve the term "tracheotomy" for procedures that directly connect the trachea with the skin of the neck (eg, following laryngectomy the transected trachea is directly anastomosed with the skin of the neck). A tracheostomy tube can also be placed through a tracheotomy.
INDICATIONS — Indications for tracheostomy are emergent or elective. In our experience, the most common indication is ventilator weaning for patients with acute respiratory failure who are unable to be liberated from mechanical ventilation in the intensive care unit.
Emergency — Patients in whom an emergent tracheostomy is indicated include the following:
●Patients with acute upper airway obstruction who failed intubation with an endotracheal tube or in whom an endotracheal tube cannot be placed.
Examples include those with severe upper airway obstruction due to angioedema, anaphylaxis, hematoma, infection (eg, submandibular space infections, retropharyngeal abscess), or a mass (eg, malignant or benign tumors, foreign body that cannot be removed). (See "Approach to the difficult airway in adults for emergency medicine and critical care" and "Management of the difficult airway for general anesthesia in adults" and "Airway foreign bodies in adults".)
Although it can be argued that emergency cricothyrotomy should be performed in this population, emergency tracheostomy is an alternative in the hands of an experienced operator.
●Patients who have undergone an emergency cricothyrotomy. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults" and "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)
●Patients with select fractures of the oropharynx, face, and neck (eg, LeFort III fracture of the mid face (figure 1)). (See "Initial evaluation and management of facial trauma in adults", section on 'Fractures'.)
●Patients with penetrating laryngeal trauma.
Elective — Patients in whom an elective tracheostomy is indicated include the following:
●Patients who have undergone, or are anticipated to require, prolonged mechanical ventilation and have difficulty weaning off the ventilator. (See "Management of the difficult-to-wean adult patient in the intensive care unit", section on 'Tracheostomy' and 'Optimal timing in mechanically ventilated patients' below.)
●Patients with poor airway protection who need ventilation and/or secretion control (eg, neuromuscular disorders associated with bulbar weakness or recurrent aspiration). (See "Respiratory muscle weakness due to neuromuscular disease: Management", section on 'Tracheostomy'.)
●Patients with severe obstructive sleep apnea who are refractory to other therapies. (See "Obstructive sleep apnea: Overview of management in adults", section on 'Hypoglossal nerve surgery'.)
●Patients with severe subglottic stenosis unresponsive to conventional therapies. (See "Congenital anomalies of the larynx", section on 'Congenital subglottic stenosis'.)
●Patients with severe vocal cord paralysis who are refractory to other therapies.
CONTRAINDICATIONS — Contraindications are both absolute and relative (table 1).
Noteworthy, is that some of these conditions may influence the decision of whether a surgical (open) or percutaneous approach is chosen. Selecting surgical versus percutaneous tracheostomy is discussed separately. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Selecting percutaneous versus operative'.)
Absolute — There are few absolute contraindications to tracheostomy (percutaneous or surgical). However, we generally consider the following as absolute contraindications for this procedure: cellulitis of the anterior neck, absence of a cervical trachea (eg, due to prior resection), and uncorrectable bleeding diathesis.
Relative — Relative contraindications to both open and percutaneous tracheostomy include hemodynamic instability and severe hypoxemia (eg, positive end expiratory pressure >12 cm H2O, fraction of inspired oxygen >0.6), although the latter is more problematic with percutaneous than with open tracheostomy.
Additional relative contraindications pertinent to percutaneous tracheostomy include gross distortion of the neck due to, for example, hematoma, tumor, thyromegaly, and scarring from previous neck surgery. Others include documented or clinically suspected tracheomalacia or disease associated with cartilage abnormalities (which results in poor airway control due to collapse), obese and/or short neck (which obscures landmarks), and inability to extend the neck because of cervical fusion, rheumatoid arthritis, or other causes of cervical spine instability [1,2].
A high-riding innominate or thyroid internal mammary artery is also generally considered a relative or absolute (by some clinicians) contraindication to percutaneous tracheostomy due to the increased risk of bleeding and should warrant consideration of an open approach, if present.
Percutaneous tracheostomy is also relatively contraindicated in children under the age of 15 years due to an immature trachea.
While cricothyrotomy is considered the preferred approach during emergencies, percutaneous tracheostomy is an alternative when performed by an experienced operator. (See "Emergency cricothyrotomy (cricothyroidotomy) in adults" and "Needle cricothyroidotomy with percutaneous transtracheal ventilation".)
RATIONALE FOR TRACHEOSTOMY VERSUS ENDOTRACHEAL TUBE — In the context of prolonged ventilatory support, there are several advantages of tracheostomy compared with endotracheal intubation, which are outlined in the table (table 2). In this population, we consider that the advantages outweigh the disadvantages or potential complications associated with tracheostomy. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Complications'.)
Reduced work of breathing — Data from small studies suggest that in both ventilated and spontaneously breathing patients, tracheotomy reduces work of breathing, airway resistance, peak inspiratory pressures, and intrinsic positive end expiratory pressure (ie, auto-PEEP) [3-6].
As a result, standard weaning parameters such as the rapid shallow breathing index improve in difficult-to-wean patients following the conversion from an endotracheal tube to a tracheostomy tube [7]. (See "Weaning from mechanical ventilation: Readiness testing", section on 'Rapid shallow breathing index'.)
In addition, ventilator synchrony and triggering may be improved, although tidal volume, respiratory rate, and dead space ventilation remain unchanged [3,8].
Improved comfort and reduced need for sedation — Tracheostomy tubes are more comfortable and, as a result, may reduce the need for sedation, when compared with an endotracheal tube.
In an observational study of 722 patients who underwent tracheostomy following mechanical ventilation for ≥48 hours, fentanyl and midazolam administration decreased from 866 to 71 mcg/patient-day and from 44 to 7 mg/patient-day, respectively [9]. In addition, time spent heavily sedated decreased from 7 to 1 hour/day with no increase in agitation time. (See "Sedative-analgesia in ventilated adults: Management strategies, agent selection, monitoring, and withdrawal".)
Facilitation of weaning — A tracheostomy tube may facilitate weaning from mechanical ventilation compared with an endotracheal tube, some of which may be related to the reduced work of breathing associated with a tracheostomy tube. The process of weaning and decannulation are described separately. (See "Management and prognosis of patients requiring prolonged mechanical ventilation", section on 'Weaning' and "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Decannulation'.)
Improved patient communication and swallowing — Compared with an endotracheal tube, patient communication can be greatly enhanced following tracheostomy [10,11]. The value of communication devices is discussed separately. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Speech devices'.)
Similarly, swallowing may be improved in some patients with tracheostomy compared with an endotracheal tube. Further details regarding swallowing and nutrition in patients with a tracheostomy tube are provided separately. (See "Management and prognosis of patients requiring prolonged mechanical ventilation", section on 'Nutrition' and "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Dysphagia'.)
Other advantages — Other advantages of tracheostomy compared with endotracheal intubation include improved mobility and, therefore, ability to participate in physical therapy [12], improved secretion clearance and oral hygiene, ability to manage patients outside the intensive care unit (ICU) and a lower likelihood of laryngeal injury, and easier replacement if accidental decannulation occurs (provided the tract is matured; typically ≥7 days).
Unclear benefits
Risk of aspiration and pneumonia — Aspiration and pneumonia are common complications in patients who have a tracheostomy or an endotracheal tube. However, it is unclear whether tracheostomy lowers the risk of either outcome compared with endotracheal intubation because data are conflicting:
●Suggesting that tracheostomy is associated with a higher rate of nosocomial pneumonia, a prospective cohort study of over 800 mechanically ventilated patients found that tracheostomy was independently associated with a six-fold increase in the risk of nosocomial pneumonia compared with endotracheal intubation [13].
●Suggesting that tracheostomy is associated with a lower rate of nosocomial pneumonia, a case-control study of 354 patients who were mechanically ventilated for more than seven days found a lower rate of nosocomial pneumonia in patients who underwent tracheostomy compared with those who did not undergo tracheostomy (4.8 versus 9.2 episodes per 1000 ventilator days) [14]. These findings were supported by another retrospective cohort study [15].
Further details regarding factors that predict aspiration and pneumonia in tracheostomized patients are provided separately. (See "Tracheostomy: Postoperative care, maintenance, and complications in adults", section on 'Aspiration and nosocomial pneumonia'.)
Mortality — The impact of tracheostomy on mortality is uncertain due to conflicting data. However, these studies are susceptible to selection bias [16,17].
●Suggesting that tracheostomy may improve survival, an international prospective cohort study of 5081 mechanically ventilated patients found that tracheostomy was associated with decreased ICU but not hospital mortality compared with ICU patients who did not undergo tracheostomy [18]. A case-control study of over 500 patients found a decrease in both ICU and hospital mortality among patients who required long-term mechanical ventilation and underwent tracheostomy (within 12 days of initial intubation) [19].
●Suggesting that tracheostomy does not improve survival, a multicenter prospective cohort study of 2186 mechanically ventilated patients found no significant difference in ICU mortality in patients who underwent tracheostomy compared with those who did not undergo tracheostomy [20]. Post-ICU mortality was higher among those who underwent tracheostomy, particularly those in whom the tracheostomy tube was left in position.
Tracheostomy-related deaths are more frequent during the weekend and more common among patients with cancer (especially oropharyngeal cancer), chronic lower respiratory tract disease, and patients with complications of medical or surgical care [21,22]. Deaths also appear to be more common in patients who identified themselves as African American or Hispanic American [21].
OPTIMAL TIMING IN MECHANICALLY VENTILATED PATIENTS — For patients who are unable to wean from invasive mechanical ventilation, tracheostomy and transfer to a long-term assisted care facility for weaning is often considered.
In our practice, we typically perform a daily assessment of the patient's progress and their readiness to wean and be successfully extubated before making the decision that tracheostomy is warranted. The decision of when to perform tracheostomy is a collaborative one and should be part of the overall approach to patient-centered care in the intensive care unit (ICU). We discuss with caregivers the value of tracheostomy in the context of the likelihood of weaning, patient preferences, and expected outcomes, together with the alternatives of continued intubation or palliation [23,24].
General guidance on the timing of tracheostomy in mechanically ventilated patients is provided in this section. Information on discussions with families and caregivers is provided separately. (See "Communication in the ICU: Holding a meeting with families and caregivers" and "Withholding and withdrawing ventilatory support in adults in the intensive care unit" and "Ethical issues in palliative care".)
General population — There is no optimal time for transition to tracheostomy, and practice varies among clinicians, with most transitioning between one and three weeks following intubation [25].
●We typically do not perform a tracheostomy before 10 days of mechanical ventilation. Our preference is based on the rationale that early tracheostomy (ie, before 10 days) is of no proven benefit and may lead to unnecessary surgery and prolonged mechanical ventilation in patients who may otherwise be extubated. Supporting this timeline is an international multicenter study of 1638 patients, which found that tracheostomy was performed after a median of 11 days [26].
●We also believe that patients should not be ventilated via an endotracheal tube for longer than three weeks unless they are either unstable or unlikely to benefit from tracheostomy [27-29]. This opinion is based upon the advantages of tracheostomy compared with endotracheal intubation (table 2). (See 'Rationale for tracheostomy versus endotracheal tube' above.)
Factors that weigh into the decision include clinical circumstances and the patient's or caregiver's preference. For example, early tracheostomy may be reasonable in those in whom prolonged mechanical ventilation is likely. By contrast, later tracheostomy may be preferred when successful extubation is likely and when more time is needed either to treat the underlying reversible disorder or for caregivers to make the decision. Examples are provided below. (See 'Special populations' below.)
Data from observational series, randomized trials, and meta-analyses have not demonstrated a clear benefit from routinely performing early tracheostomy in terms of mortality, length of stay, and duration of mechanical ventilation [30-44]. Data are conflicting but support the observation that early tracheostomy promotes the performance of unnecessary surgery in patients who might otherwise have been successfully extubated. As examples:
●One meta-analysis of 14 trials failed to demonstrate reduced mortality, duration of mechanical ventilation, ICU stay, or ventilator-associated pneumonia, finding only that early tracheostomy (≤10 days of initial intubation) led to more procedures (risk ratio [RR] 2.53, 95% CI 1.18-5.40) and a shorter duration of sedation (RR -2.78 days, 95% CI -3.68 to -1.88) compared with later tracheostomy (>10 days) [45]. A subsequent meta-analysis of nine trials in non-neurologically injured adults showed similar results [43].
●By contrast, in another meta-analysis of 12 studies (2689 patients) that compared early tracheostomy (<10 days) with late tracheostomy (≥10 days), patients who underwent an early tracheostomy had more ventilator-free days (weight mean difference [WMD] 2.12, 95% CI 0.94-3.30), a shorter ICU stay (WMD -5.14, 95% CI -9.99 to -0.28), a shorter duration of sedation (WMD -5.07, 95% CI -10.03 to -0.10, p <0.05), and reduced long-term mortality (odds ratio 0.83, 95% CI 0.69-0.99) [46]. However, early tracheostomy was associated with a higher overall rate of tracheostomy, suggesting that improved outcomes were influenced by patients who might otherwise have avoided a tracheostomy altogether.
●In a sentinel multicenter trial, 1032 adult patients on mechanical ventilation for less than four days and expected to receive more than seven days of mechanical ventilation were randomly assigned to either early tracheostomy (within four days of intubation) or late tracheostomy (≥10 or more days after intubation) [41]. The timing of tracheostomy did not impact 30-day or two-year mortality or ICU length of stay. In addition, over one-half of the patients randomized to the late tracheostomy arm never received the intervention. This suggests that postponing tracheostomy allowed a subset of patients to avoid the intervention and that investigators were unable to identify those likely to require long-term ventilation.
●By contrast, another multicenter trial of 419 mechanically ventilated patients reported that early tracheostomy (mean seven days) may improve some short-term clinical outcomes compared with late tracheostomy (mean 14 days) [38]. These included a higher likelihood of weaning from the ventilator (77 versus 68 percent), shorter ICU stay (48 versus 39 percent), a trend towards a lower rate of pneumonia (14 versus 21 percent), similar survival at one month, and earlier return to walking, talking, and eating. However, early tracheostomy did not change any outcomes at one year. Adverse events occurred in 39 percent of patients who underwent tracheostomy, most frequently hypoxemia, stoma inflammation, stoma infection, and bleeding. The major limitation of this trial was that many patients did not undergo tracheostomy (31 and 43 percent in the early and late tracheostomy groups, respectively), again suggesting that some patients may have avoided a tracheostomy.
Special populations
COVID-19 — Tracheostomy is considered to be an aerosol-generating procedure. Although the optimal timing of tracheostomy in patients with Coronavirus disease 2019 (COVID-19) is unknown, in our opinion, the later timing of tracheostomy may be a justifiable consideration in this population, especially if the risk of infectious transmission is less of a concern later in the course [47-49]. Although practice varies [50], in our experience, many patients with COVID-19 can be safely extubated later in the course of their critical illness (eg, 14 to 21 days or longer), avoiding the need for tracheostomy. The performance of tracheostomy in COVID-19 patients and optimal infection precautions in this setting are discussed separately. (See "COVID-19: Management of the intubated adult", section on 'Tracheostomy' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)
Data in patients with COVID-19 informing timing and outcome are limited [51-54].
●In one retrospective review of 148 patients with COVID-19, median length of stay was 40 days in those who underwent early tracheostomy (within 10 days of endotracheal intubation) and 49 days in those who underwent late tracheostomy (≥10 days following endotracheal intubation) [51]. Patients who had a late tracheostomy were less likely to discontinue mechanical ventilation (hazard ratio 0.84, 95% CI 0.55-1.28). However, given the retrospective nature and small number of patients, these data are subject to misinterpretation and bias.
●An earlier meta-analysis of 12 studies totaling over 2,000 COVID-19 patients, reported that early tracheostomy (<14 days) reduced the ICU length of stay and duration of mechanical ventilation compared with late tracheostomy (≥14 days), but the mortality rate was similar in both groups [53]. However, subsequent meta-analyses reported that tracheostomy timing did not affect the length of stay or mortality (mean performance was 16.5 days) [54,55].
Stroke — Patients with stroke who need mechanical ventilation should have a similar approach to those in the general population (see 'General population' above). This approach is based upon a single randomized trial of 382 patients with stroke who required mechanical ventilation [56]. At six months, patients who underwent early tracheostomy (≤5 days of intubation) did not experience improved functional outcome compared with those who received usual care with ventilator weaning and a tracheostomy, if required, after 10 days (44 versus 47 percent). While 95 percent of patients in the early tracheostomy group received the intervention, only two-thirds in the usual care group needed a tracheostomy, confirming the observation that early tracheostomy is associated with an increased rate of unnecessary surgery. Adverse events were similar, and among the serious adverse events, 5 percent were tracheostomy-related in those who had an early tracheostomy compared with 3.4 percent in those who received usual care.
Predicted need for prolonged mechanical ventilation — There are certain patients for whom prolonged mechanical ventilation can be easily determined early in the course of their illness, thereby justifying the need for early tracheostomy. These include patients with the following:
●Cervical spine trauma (especially trauma resulting in transection of the spinal cord at C3-5)
●Traumatic or hypoxic brain injury [42,57]
●General and multiple traumas
●Severe, progressive, or slowly resolving neuromuscular conditions (eg, bulbar amyotrophic lateral sclerosis, severe Guillain Barré syndrome)
Additional factors that may increase the likelihood that a tracheostomy will be required include poor prehospitalization functional status, poor nutritional status, poor pulmonary function, advanced age, significant cognitive impairment, nosocomial pneumonia, administration of aerosol treatments, a witnessed aspiration event, multiple failed extubations, reintubation, the presence of a ventricular support device, or underlying malignancy [16].
Extensive head and neck tumors or trauma — Prophylactic tracheostomy is frequently indicated in patients with extensive head and neck or upper aerodigestive tumors or patients with extensive upper airway trauma or surgery (eg, laryngectomy). In addition, in patients with cancer, a tracheostomy is often required in preparation for radiation-or surgical-related airway edema.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Weaning from mechanical ventilation" and "Society guideline links: Airway management in adults".)
SUMMARY AND RECOMMENDATIONS
●Introduction – Tracheostomy is a surgical procedure that creates an opening in the anterior wall of the trachea to facilitate airway access and ventilation. Although often interchangeable, we reserve the term "tracheotomy" for procedures that directly connect the trachea with the skin of the neck. (See 'Introduction' above and 'Terminology' above.)
●Indications and contraindications
•Emergent tracheostomy is indicated in patients with acute upper airway obstruction who failed intubation with an endotracheal tube or in whom an endotracheal tube cannot be placed (eg, obstructing edema or mass), patients who have undergone an emergency cricothyrotomy, patients with select fractures of the face and neck (eg, LeFort III fracture of the mid face (figure 1)), and patients with penetrating laryngeal trauma. (See 'Emergency' above.)
•Elective tracheostomy is indicated in patients who have difficulty weaning off mechanical ventilation, patients who cannot protect their airway and who need ventilation and/or secretion control, patients with severe obstructive sleep apnea who are refractory to other therapies, and patients with severe subglottic stenosis or vocal cord paralysis who are not responsive to conventional therapies. (See 'Elective' above.)
Cellulitis of the anterior neck, absence of a cervical trachea, or uncontrolled bleeding diathesis are absolute contraindications to tracheostomy. These and relative contraindications are listed in the table (table 1). In the case of relative contraindications, surgical tracheostomy may be selected rather than the percutaneous approach. (See 'Contraindications' above.)
●Timing in mechanically ventilated patients – We individualize the timing of tracheostomy according to the clinical circumstances and the patient's preference. Our approach is as follows (see 'Optimal timing in mechanically ventilated patients' above and 'General population' above):
•For most patents on mechanical ventilation, we suggest tracheostomy be performed between 7 and 21 days (Grade 2C).
-We typically do not perform a tracheostomy before 10 days. This preference is based on the rationale that early tracheostomy is of no proven benefit and may lead to unnecessary surgery and prolonged mechanical ventilation in patients who may otherwise be extubated.
-We also believe that patients should not be ventilated via an endotracheal tube for longer than three weeks unless they are either unstable or unlikely to benefit from tracheostomy. This view is based upon the advantages of tracheostomy compared with endotracheal intubation (table 2).
•Certain populations may warrant special consideration. Later tracheostomy placement may be reasonable in patients with COVID-19, while early tracheostomy may be justified in patients with a predicted need for long-term mechanical ventilation (eg, patients with cervical spine trauma, traumatic or hypoxic brain injury, general and multiple traumas, and those with severe, progressive, or slowly resolving neuromuscular conditions), and patients with extensive head and neck tumors or trauma. (See 'Special populations' above.)
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