A 30-year-old man is admitted after an unhelmeted bicycling accident in which he suffered a skull fracture, traumatic subarachnoid and subdural hemorrhages, bifrontal contusions, and diffuse axonal injury. He was intubated without medications in the field, and on presentation, the Glasgow Coma Scale (GCS) score is 4. Computed tomography (CT) scan of the neck does not reveal bony injury to the cervical spine. A fiberoptic intracranial pressure (ICP) device is placed, and ICP, cerebral perfusion pressure (CPP), and brain tissue oxygen tension (Pbto2) are monitored. On hospital day 5, the GCS score is 5, ICP is 18 mm Hg, CPP is 70 mm Hg, and Pbto2 in the right frontal lobe near a contusion is 24 mm Hg. His cardiopulmonary status is stable. A rigid cervical collar is in place, and he is maintained on the controlled mechanical ventilation (CMV) mode at a set rate of 14 × 550 mL (actual respiratory rate [RR] is 21 beaths/min), fraction of inspired oxygen (Fio2) of 0.35, and positive end-expiratory pressure (PEEP) of 5.
Is tracheostomy indicated?
This patient is certain to have a prolonged course of mechanical ventilation as a result of neurologic failure, and he should undergo tracheostomy. Although prolonged endotracheal intubation with a modern high-volume low-pressure cuffed tube is safe, infrequently resulting in subglottic stenosis or vocal cord injury,1 tracheostomy offers several advantages in patients with severe brain injury. These include facilitation of weaning from mechanical ventilation,2, 3 prolonged access to the lower airways for secretions management, improved comfort,4, 5 and earlier mobilization for physical and occupational therapy. Tracheostomy often makes possible discontinuation of sedating medications,5 facilitating the neurologic examination, and may allow brain-injured patients with good cardiopulmonary function to be completely disconnected from mechanical ventilation, preventing the common complications of atelectasis and respiratory muscle atrophy. Disadvantages include perioperative and long-term complications of the procedure and introduction of a potential reservoir of bacterial colonization into the airway. General indications for tracheostomy in the neurocritically ill are presented in Table 39-1.
Table 39-1.Indications for Tracheostomy in the Neurocritically Ill |Favorite Table|Download (.pdf) Table 39-1. Indications for Tracheostomy in the Neurocritically Ill
|Prolonged mechanical ventilation (cardiopulmonary etiology) |
|Inadequate airway protective reflexes |
|Weak cough and failure to expectorate respiratory secretions |
|Bulbar dysfunction |
|Prolonged coma |
|Upper airway obstruction or injury |
What is the optimal timing of tracheostomy?
Optimal timing of tracheostomy in all patient groups is controversial. One randomized single-center trial in the medical intensive care unit (ICU) suggested lower mortality and other benefits when tracheostomy was performed by day 3 as opposed to day 14,6 but this finding was not replicated in two subsequent multicenter randomized trials.7, 8 A meta-analysis suggested benefits to early tracheostomy in patients expected to receive mechanical ...