Etiology - Due primarily to airway obstruction or respiratory arrest, caused by depressed respiratory drive as a result of:

• Pharmacologic sedation/alcohol intoxication
• Aspiration
• Pulmonary and chest wall injury
• Neurogenic pulmonary edema
• Infection, such as pneumonia or TB prior to injury due to immune suppression
• Fat embolus

Treatment

• Intubation: Requires intubation prior to admission and prolonged endotracheal intubation, artificial respiration, or tracheostomy during acute care for long-term mechanical ventilation and relief of upper airway obstruction. Although tracheostomy is more costly than intubation and may cause bleeding, pneumothorax, and damage to adjacent structures during surgical placement, tracheostomy is indicated to:
  • Assist with pulmonary toilet
  • Spare further injury to the larynx
  • Facilitate nursing care, such as airway suctioning
  • Facilitate oral feeding
  • Facilitate speech, particularly with a fenestrated or "talking" tracheostomy, or a Passey-Muir valve
  • Facilitate mobility
  • Facilitate transfer to a lower level of care

  Tracheostomy is more likely to be necessary in patients with a GCS < or =8, an ISS > or =25, and ventilator days > 7. Performing tracheostomy late does not reduce pneumonia rates or ventilator, ICU, or hospital days (Gurkin, et al 2002). Ventilator-associated pneumonia occurs frequently in severe TBI (Zygun, et al 2006).

• Proper Care: Requires proper care to prevent complications, such as infection, atelectasis, injury to the vocal cords, arytenoid, and mucosa, tracheal stenosis, subglottic stenosis, glottic stenosis, tracheomalacia, and tracheal granuloma, particularly at Rancho Level I. Proper care includes:
  • Proper choice of tube -- 8-9 mm for men, and 7-9 mm for women - or a tracheostomy "button" if the patient is not at risk of aspiration, to facilitate speech and decrease irritation
  • Proper posturing
  • Chest physiotherapy to mobilize secretions in patient with atelectasis and bronchorrhea
  • Meticulous airway management, including daily cleaning of tracheostomy tubes and stoma, and weekly (but no more than monthly) replacement of the entire apparatus
  • Avoidance of agitation and tugging of ventilation tubes
  • Use of low-pressure cuffs to prevent tracheal stenosis; cuff pressure should not exceed 20-30 mmH2O
  • Adequate sedation and humidification to prevent them

Decannulation

• Predictors of successful decannulation include younger age, alert cognitive status, medical stability, minimal secretions, intact swallow, and tracheostomy capping of 24-48 consecutive hours

• Methods include:
  • Use of progressively smaller, uncuffed tubes at 2-3 day intervals, with plugging of the tube beginning when an adult size of 4-5 mm is reached, and removal of the tube when 24-48 hours of plugging can be tolerated
  • Progressive plugging of the same-sized tube and removal of the tube when 24-48 hours of plugging can be tolerated