Timing of tracheotomy for intubated patients

Case presentation E.W. is a 67-year-old woman with a medical history of hypertension, obesity, obstructive sleep apnea, diabetes mellitus, and atrial fibrillation. Her social history included a 45 pack-year history of tobacco use and social alcohol consumption. She was admitted to the medical intensive care unit (ICU) for post-hemorrhagic stroke in the right middle cerebral artery territory. The patient was intubated due to poor airway protection, and has failed several attempts to wean completely from ventilator support during the past 2 weeks. The medical intensive care team requested a consult for a tracheotomy 4 days after admission; however, the surgeon consultant was uncomfortable performing the procedure so early after intubation, and asked that further attempts at weaning be tried. After 2 weeks, the patient remains intubated on a low level of ventilator support. Her neurologic function has improved but remains poor. Should this patient undergo a tracheotomy? If so, where should the procedure be performed, in the operating room or in the ICU? Elective tracheotomy in the intensive care unit Tracheotomy is one of the oldest known surgical procedures [1], and one of the most common procedures for patients in the ICU [2]. This procedure may be beneficial to the patient for a variety of reasons: decrease in dead space ventilation improves ventilation mechanics [3] suctioning and bronchial clearance are facilitated need for long-term sedation is decreased, reducing associated complications access for intermittent mechanical ventilation is available without reintubation process of weaning from mechanical ventilation is hastened phonation and swallowing are supported [4] overall patient comfort is improved.