A 30-year-old man is admitted after an unhelmeted bicycling accident in which he suffers skull fracture, traumatic subarachnoid and subdural hemorrhages, bifrontal contusions, and diffuse axonal injury. He is intubated without medications in the field, and on presentation, the Glasgow Coma Scale (GCS) score is 4. 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 is 5, ICP, 18 mm Hg; CPP, 70 mmHg; and Pbto2 in the right frontal lobe near a contusion, 24 mm Hg. His cardiopulmonary status is stable. A rigid cervical collar is in place, and he is maintained on CMV mode ventilation at a set rate of 14 × 550 cc (actual RR is 21), Fio2, 0.35; and PEEP, 5.
Is tracheostomy indicated?
This patient is likely to have a prolonged course of mechanical ventilation due to neurologic failure and should undergo tracheostomy. Although prolonged endotracheal intubation with a modern high-volume, low-pressure cuffed tube is safe, rarely resulting in subglottic stenosis or vocal cord injury,1,2 tracheostomy offers several advantages in patients with severe brain injury.3,4 These include facilitation of weaning from mechanical ventilation,5,6 prolonged access to the lower airways for secretions management, improved comfort,7-9 and earlier mobilization for physical and occupational therapy.10 Tracheostomy often makes possible discontinuation of sedating medications,9,11 facilitating 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 peri-operative 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 45-1.
Table 45-1.Indications for Tracheostomy in the Neurocritically Ill |Favorite Table|Download (.pdf) Table 45-1. 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 with high aspiration risk |
|Prolonged coma |
|Upper airway obstruction or injury |
What is the optimal timing of tracheostomy?
Optimal timing of tracheostomy in all patient groups is controversial. The benefit of early tracheostomy in neurocritical care is debatable, with conflicting results from multiple studies,12-15 but has a trend toward benefit in all populations.16 A meta-analysis suggested benefits to early tracheostomy in patients expected to receive mechanical ventilation for prolonged periods,17 or those with infratentorial lesions.18 Multiple retrospective studies suggest clinical and economic benefit when tracheostomy is performed before day 7, compared with delayed tracheostomy.19-23 A recent multicenter randomized controlled trial showed a nonsignificant trend toward less ...