In broad, critically ill populations, early tracheostomy has not improved survival, but may decrease ventilator associated pneumonia or hospital length of stay in trauma patients. Early tracheostomy in traumatic brain injury is particularly helpful. In severe TBI (GCS <8), early tracheostomy (within 3-7 days) has demonstrated decreased ventilator days and ICU LOS. A recent TQIP study reported shorter MV, ICU LOS and hospital LOS for early trachesotomy (within 8 days) vs late in TBI patients (head AIS 3 or greater). The EAST Practice Management Guidelines are below:
Level I
There is no
mortality difference between patients receiving early tracheostomy (3-7 days)
and late tracheostomy or extended endotracheal intubation.
Level II
Early
tracheostomy decreases the total days of mechanical ventilation and ICU LOS in
patients with head injuries. Therefore, it is recommended that patients with a
severe head injury receive an early tracheostomy.
Level III
Early
tracheostomy may decrease the total days of mechanical ventilation and ICU LOS
in trauma patients without head injuries. Early tracheostomy may decrease the
rate of pneumonia in trauma patients. Therefore, it is recommended that early
tracheostomy should be considered in all trauma patients who are anticipated to
require mechanical ventilation for >7 days, such as those with neurologic
impairment or prolonged respiratory failure.
For obese
patients (BMI>30), consider extra-long tapered tracheostomy.
Sutures may
potentiate pressure ulceration, especially on the lower edge of the flange.
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