Tracheostomy in Stroke Patients

Abstract

Patients with severe ischemic and hemorrhagic stroke may require tracheostomy in the course of their disease. This may apply to stroke unit patients whose deficits include a severe dysphagia posing such risk of aspiration as it cannot be sufficiently counteracted by tube feeding and swallowing therapy alone. More often, however, tracheostomy is performed in stroke patients so severely afflicted that they require intensive care unit treatment and mechanical ventilation. In these, long-term ventilation and prolonged insufficient airway protection are the main indications for tracheostomy. Accepted advantages are less pharyngeal and laryngeal lesions than with prolonged orotracheal intubation, better oral hygiene and nursing care, and higher patient comfort. Optimal timing of tracheostomy is unclear, in general, as in stroke intensive care unit patients. Potential benefits of early tracheostomy concerning ventilation duration and length of stay, respirator weaning, airway safety, rate of pneumonia, and other complications, outcome and mortality have been suggested in studies on non-neurologic subgroups of critical care patients. Stroke patients have hardly been investigated with regard to these aspects, and mainly retrospectively. A single randomized pilot trial on early tracheostomy in 60 ventilated patients with severe hemorrhagic and ischemic stroke demonstrated feasibility, safety, and less need of sedation. Regarding the technique, bedside percutaneous dilational tracheostomy should be preferred over surgical tracheostomy because of several reported advantages. As the procedural risk is low and early tracheostomy does not seem to worsen the clinical course of the ventilated stroke patient, it is reasonable to assess the need of further ventilation at the end of the first week of intensive care and proceed to tracheostomy if extubation is not feasible. Reliable prediction of prolonged ventilation need and outcome benefits of early tracheostomy, however, await further clarification. Decannulation of stroke patients after discontinued ventilation has to follow reliable confirmation of swallowing ability, as by endoscopy.

Electrical pharyngeal stimulation for dysphagia treatment in tracheotomized stroke patients: a randomized controlled trial

“…A tracheotomy is one of the most common surgical procedures on the intensive care unit (ICU) and is reported to be performed in 10-15 % of cases in mixed patient collectives [15]. In stroke patients treated on the ICU a tracheotomy seems to be performed even more frequently with numbers ranging from 15 to 35 % [16,17].…”

“…In stroke patients treated on the ICU a tracheotomy seems to be performed even more frequently with numbers ranging from 15 to 35 % [16,17]. Typical indications for a tracheotomy in general critical care are long-term ventilation due to prolonged respiratory failure, need for airway protection because of dysphagia with an increased aspiration risk, functional/ mechanical obstruction, or prolonged need for endotracheal suctioning of secretions [15]. Although there is still some debate surrounding this topic, today a tracheotomy in ventilated ICU patients is supposed to prevent laryngeal and tracheal damage, to shorten the duration of mechanical ventilation, to reduce the length of stay on the ICU, and to cut down the related hospital costs [18,19].…”

“…Severe dysphagia with related insufficient airway protection is given as the main reason why in successfully weaned patients the treatment goal of decannulation is not promptly achieved and patients need to remain tracheotomized [15]. Thus, depending on the case mix and the assessment method, disordered swallowing is found in 30-70 % of tracheotomized patients with the neurologically ill probably being the most vulnerable [26][27][28][29].…”

Increase of Substance P Concentration in Saliva after Pharyngeal Electrical Stimulation in Severely Dysphagic Stroke Patients – an Indicator of Decannulation Success?

“…Patients with post-stroke dysphagia have a three-times higher risk to develop pneumonia; if aspiration can be detected, the risk rises up to 11.5-times higher [4]. 1.3 – 7.1% of all stroke patients are tracheotomized [8, 9] due to severe dysphagia with prolonged insufficient airway protection or the need for long-term ventilation [10]. The tracheostomy rate of stroke patients on the intensive care unit (ICU) is even higher and ranges between 14 – 35%, exceeding the tracheostomy rates of mixed ICU patient collectives which lie at 10 – 15% [10-12].…”

Predictors of extubation success in acute ischemic stroke patients

“…Another small study that included only middle cerebral artery infarcts suggested that laterality might be associated with extubation success, with left hemisphere AIS having considerably better outcome 5 . However, there are no well-defined clinical tools to guide extubation practices in AIS patients 6 .…”