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Tracheostomy in Stroke Patients

  • Julian BöselEmail author
CRITICAL CARE NEUROLOGY (KN SHETH, SECTION EDITOR)
Part of the following topical collections:
  1. Topical Collection on Critical Care Neurology

Opinion statement

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.

Keywords

Stroke Acute ischemic stroke Intracerebral hemorrhage Subarachnoid hemorrhage Tracheostomy Tracheotomy Percutaneous dilational tracheostomy Intensive care Critical care Dysphagia Long-term ventilation Weaning Sedation Treatment 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Julian Bösel has received speaker honoraria and had travel/accommodations expenses covered/reimbursed by Covidien, Sedana, and Orion Pharma.

Human and Animal Rights and Informed Consent

This article does not contain any studies with animal subjects performed by the author. With regard to the author’s research cited in this paper, all procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: •Of importance •• Of major importance

  1. 1.
    Bath PM, Bath FJ, Smithard DG. Interventions for dysphagia in acute stroke. Cochrane Database Syst Rev. 2000;CD000323.Google Scholar
  2. 2.
    Martino R, Foley N, Bhogal S, et al. Dysphagia. after stroke: incidence, diagnosis, and pulmonary complications. Stroke. 2005;36:2756–63.PubMedCrossRefGoogle Scholar
  3. 3.
    Falsetti P, Acciai C, Palilla R, et al. Oropharyngeal dysphagia after stroke: incidence, diagnosis, and clinical predictors in patients admitted to a neurorehabilitation unit. J Stroke Cerebrovasc Dis. 2009;18:329–35.PubMedCrossRefGoogle Scholar
  4. 4.
    Daniels SK, Anderson JA, Willson PC. Valid items for screening dysphagia risk in patients with stroke: a systematic review. Stroke. 2012;43:892–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Meng NH, Wang TG, Lien IN. Dysphagia. in patients with brainstem stroke: incidence and outcome. Am J Phys Med Rehabil. 2000;79:170–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Flowers HL, Skoretz SA, Streiner DL, Silver FL, Martino R. MRI-based neuroanatomical predictors of dysphagia after acute ischemic stroke: a systematic review and meta-analysis. Cerebrovasc Dis. 2011;32:1–10.PubMedCrossRefGoogle Scholar
  7. 7.
    Doggett DL, Tappe KA, Mitchell MD, et al. Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature. Dysphagia. 2001;16:279–95.PubMedCrossRefGoogle Scholar
  8. 8.
    Smithard DG, Smeeton NC, Wolfe CD. Long-term outcome after stroke: does dysphagia matter? Age Ageing. 2007;36:90–4.PubMedCrossRefGoogle Scholar
  9. 9.
    McMicken BL, Muzzy CL. Prognostic indicators of functional outcomes in first time documented acute stroke patients following standard dysphagia treatment. Disabil Rehabil. 2009;31:2196–203.PubMedCrossRefGoogle Scholar
  10. 10.
    Sellars C, Bowie L, Bagg J, et al. Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke. 2007;38:2284–91.PubMedCrossRefGoogle Scholar
  11. 11.
    Ickenstein GW, Stein J, Ambrosi D, et al. Predictors of survival after severe dysphagic stroke. J Neurol. 2005;252:1510–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Trapl M, Enderle P, Nowotny M, et al. Dysphagia bedside screening for acute-stroke patients: the Gugging Swallowing Screen. Stroke. 2007;38:2948–52.PubMedCrossRefGoogle Scholar
  13. 13.
    Dziewas R, Warnecke T, Olenberg S, et al. Towards a basic endoscopic assessment of swallowing in acute stroke - development and evaluation of a simple dysphagia score. Cerebrovasc Dis. 2008;26:41–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Warnecke T, Teismann I, Oelenberg S, et al. Towards a basic endoscopic evaluation of swallowing in acute stroke - identification of salient findings by the inexperienced examiner. BMC Med Educ. 2009;9:13.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Lin YN, Chen SY, Wang TG, et al. Findings of videofluoroscopic swallowing studies are associated with tube feeding dependency at discharge in stroke patients with dysphagia. Dysphagia. 2005;20:23–31.PubMedCrossRefGoogle Scholar
  16. 16.
    Daniels SK, Ballo LA, Mahoney MC, Foundas AL. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. Arch Phys Med Rehabil. 2000;81:1030–3.PubMedCrossRefGoogle Scholar
  17. 17.
    Daniels SK, Schroeder MF, McClain M, et al. Dysphagia in stroke: Development of a standard method to examine swallowing recovery. J Rehabil Res Dev. 2006;43:347–56.PubMedCrossRefGoogle Scholar
  18. 18.
    Bours GJ, Speyer R, Lemmens J, Limburg M, de Wit R, et al. Bedside screening tests vs videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. J Adv Nurs. 2009;65:477–93.PubMedCrossRefGoogle Scholar
  19. 19.
    Hinchey JA, Shephard T, Furie K, et al. Formal dysphagia screening protocols prevent pneumonia. Stroke. 2005;36:1972–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Geeganage C, Beavan J, Ellender S, Bath PM. Interventions for dysphagia and nutritional support in acute and subacute stroke. Cochrane Database Syst Rev. 2012;10, CD000323.PubMedGoogle Scholar
  21. 21.
    Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomized controlled trial. Lancet Neurol. 2006;5:31–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Perry L. Screening swallowing function of patients with acute stroke. Part one: identification, implementation and initial evaluation of a screening tool for use by nurses. J Clin Nurs. 2001;10:463–73.PubMedCrossRefGoogle Scholar
  23. 23.
    Perry L. Screening swallowing function of patients with acute stroke. Part two: detailed evaluation of the tool used by nurses. J Clin Nurs. 2001;10:474–81.PubMedCrossRefGoogle Scholar
  24. 24.
    Colodny N. Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (fees) using the penetration-aspiration scale: a replication study. Dysphagia. 2002;17:308–15.PubMedCrossRefGoogle Scholar
  25. 25.
    Warnecke T, Teismann I, Oelenberg S, et al. The safety of fiberoptic endoscopic evaluation of swallowing in acute stroke patients. Stroke. 2009;40:482–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Dziewas R, Warnecke T, Hamacher C, et al. Do nasogastric tubes worsen dysphagia in patients with acute stroke? BMC Neurol. 2008;8:28.PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Dennis MS, Lewis SC, Warlow C. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multi-center randomized controlled trial. Lancet. 2005;365:764–72.PubMedCrossRefGoogle Scholar
  28. 28.
    Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetration-aspiration scale. Dysphagia. 1996;11:93–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Steiner T, Mendoza G, De Georgia M, et al. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 1997;28:711–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Wijdicks EF, Scott JP. Causes and outcome of mechanical ventilation in patients with hemispheric ischemic stroke. Mayo Clin Proc. 1997;72:210–3.PubMedCrossRefGoogle Scholar
  31. 31.
    Berrouschot J, Rossler A, Koster J, Schneider D. Mechanical ventilation in patients with hemispheric ischemic stroke. Crit Care Med. 2000;28:2956–61.PubMedCrossRefGoogle Scholar
  32. 32.
    Santoli F, De Jonghe B, Hayon J. Mechanical ventilation in patients with acute ischemic stroke: survival and outcome at one year. Intens Care Med. 2001;27:1141–6.CrossRefGoogle Scholar
  33. 33.
    Holland MC, Mackersie RC, Morabito D, et al. The development of acute lung injury is associated with worse neurologic outcome in patients with severe traumatic brain injury. J Trauma. 2003;55:106–11.PubMedCrossRefGoogle Scholar
  34. 34.
    Pelosi P, Ferguson ND, Frutos-Vivar F, et al. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med. 2011;39:1482–92.PubMedCrossRefGoogle Scholar
  35. 35.
    Rabinstein AA, Wijdicks EF. Outcome of survivors of acute stroke who require prolonged ventilatory assistance and tracheostomy. Cerebrovasc Dis. 2004;18:325–31.PubMedCrossRefGoogle Scholar
  36. 36.
    Kurtz P, Fitts V, Sumer Z, et al. How does care differ for neurological patients admitted to a neurocritical care unit vs a general ICU? Neurocrit Care. 2011;15:477–80.PubMedCrossRefGoogle Scholar
  37. 37.
    Durbin Jr CG. Tracheostomy: why, when, and how? Respir Care. 2010;55:1056–68.PubMedGoogle Scholar
  38. 38.
    MacIntyre N. Discontinuing mechanical ventilatory support. Chest. 2007;132:1049–56.PubMedCrossRefGoogle Scholar
  39. 39.
    Davis Jr K, Campbell RS, Johannigman JA, Valente JF, Branson RD. Changes in respiratory mechanics after tracheostomy. Arch Surg. 1999;134:59–62.PubMedCrossRefGoogle Scholar
  40. 40.
    Shapiro M, Wilson RK, Casar G, Bloom K, Teague RB. Work of breathing through different sized endotracheal tubes. Crit Care Med. 1986;14:1028–31.PubMedCrossRefGoogle Scholar
  41. 41.
    Wilson AM, Gray DM, Thomas JG. Increases in endotracheal tube resistance are unpredictable relative to duration of intubation. Chest. 2009;136:1006–13.PubMedCrossRefGoogle Scholar
  42. 42.
    Blot F, Similowski T, Trouillet JL, et al. Early tracheotomy vs prolonged endotracheal intubation in unselected severely ill ICU patients. Intens Care Med. 2008;34:1779–87.CrossRefGoogle Scholar
  43. 43.
    Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med. 1999;27:1714–20.PubMedCrossRefGoogle Scholar
  44. 44.
    Seneff MG, Zimmerman JE, Knaus WA, Wagner DP, Draper EA. Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest. 1996;110:469–79.PubMedCrossRefGoogle Scholar
  45. 45.
    Huttner HB, Kohrmann M, Berger C, Georgiadis D, Schwab S. Predictive factors for tracheostomy in neurocritical care patients with spontaneous supratentorial hemorrhage. Cerebrovasc Dis. 2006;21:159–65.PubMedCrossRefGoogle Scholar
  46. 46.
    Szeder V, Ortega-Gutierrez S, Ziai W, Torbey MT. The TRACH score: clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage. Neurocrit Care. 2010;13:40–6.PubMedCrossRefGoogle Scholar
  47. 47.
    Qureshi AI, Suarez JI, Parekh PD, Bhardwaj A. Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support. Crit Care Med. 2000;28:1383–7.PubMedCrossRefGoogle Scholar
  48. 48.
    Bösel J, Schiller P, Hacke W, Steiner T. Benefits of early tracheostomy in ventilated stroke patients. Current evidence and study protocol of the randomized pilot trial SETPOINT (Stroke-related Early Tracheostomy vs Prolonged Orotracheal Intubation in Neurocritical care Trial). Int J. Stroke. 2012;7:173–82.Google Scholar
  49. 49.
    Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161:1530–6.PubMedCrossRefGoogle Scholar
  50. 50.
    King CS, Moores LK, Epstein SK. Should patients be able to follow commands prior to extubation? Respir Care. 2010;55:56–65.PubMedGoogle Scholar
  51. 51.
    Esteban A, Alia I, Gordo F, Fernandez R, et al. Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation. The Spanish Lung Failure Collaborative Group. Am J Respir Crit Care Med. 1997;156:459–65.PubMedCrossRefGoogle Scholar
  52. 52.
    Epstein SK. Decision to extubate. Intens Care Med. 2002;28:535–46.CrossRefGoogle Scholar
  53. 53.
    Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med. 1995;332:345–50.PubMedCrossRefGoogle Scholar
  54. 54.
    Skoglund K, Enblad P, Hillered L, Marklund N. The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury. Crit Care Med. 2012;40:216–22.PubMedCrossRefGoogle Scholar
  55. 55.
    Skoglund K, Enblad P, Marklund N. Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care. 2009;11:135–42.PubMedCrossRefGoogle Scholar
  56. 56.
    Helbok R, Kurtz P, Schmidt MJ, et al. Effects of the neurological wake-up test on clinical examination, intracranial pressure, brain metabolism and brain tissue oxygenation in severely brain-injured patients. Crit Care. 2012;16:R226.PubMedCrossRefGoogle Scholar
  57. 57.
    Brochard L, Rauss A, Benito S, et al. Comparison of three methods of gradual withdrawal from ventilatory support during weaning from mechanical ventilation. Am J Respir Crit Care Med. 1994;150:896–903.PubMedCrossRefGoogle Scholar
  58. 58.
    Govindan SV, Goldenberg DM, Elsamra SE, et al. Radionuclides linked to a CD74 antibody as therapeutic agents for B-cell lymphoma: comparison of Auger electron emitters with beta-particle emitters. J Nucl Med. 2000;41:2089–97.PubMedGoogle Scholar
  59. 59.
    Boynton JH, Hawkins K, Eastridge BJ, O'Keefe GE. Tracheostomy timing and the duration of weaning in patients with acute respiratory failure. Crit Care. 2004;8:R261–7.PubMedCrossRefGoogle Scholar
  60. 60.
    van der Lely AJ, Veelo DP, Dongelmans DA, et al. Time to wean after tracheotomy differs among subgroups of critically ill patients: retrospective analysis in a mixed medical/surgical intensive care unit. Respir Care. 2006;51:1408–15.PubMedGoogle Scholar
  61. 61.
    Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005;330:1243.PubMedCrossRefGoogle Scholar
  62. 62.
    Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA. 2010;303:1483–9.PubMedCrossRefGoogle Scholar
  63. 63.•
    Young D, Harrison DA, Cuthbertson BH, Rowan K. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309:2121–9. Largest (n > 900) randomized controlled trial on early vs late tracheostomy in mixed ICU patients.PubMedCrossRefGoogle Scholar
  64. 64.
    Scales DC, Thiruchelvam D, Kiss A, Redelmeier DA. The effect of tracheostomy timing during critical illness on long-term survival. Crit Care Med. 2008;36:2547–57.PubMedCrossRefGoogle Scholar
  65. 65.
    Pinheiro Bdo V, Tostes Rde O, Brum CI, et al. Early vs late tracheostomy in patients with acute severe brain injury. J Bras Pneumol. 2010;36:84–91.PubMedCrossRefGoogle Scholar
  66. 66.••
    Bösel J, Schiller P, Hook Y, et al. Stroke-related Early Tracheostomy vs Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke. 2012;44:21–8. Only prospective randomized trial on early vs late tracheostomy ventilated ICU stroke patients.PubMedCrossRefGoogle Scholar
  67. 67.
    Price DG. Techniques of tracheostomy for intensive care unit patients. Anaesthesia. 1983;38:902–4.PubMedCrossRefGoogle Scholar
  68. 68.
    McGregor IA, Neill RS. Tracheostomy and the Bjork flap. Lancet. 1983;2:1259.PubMedCrossRefGoogle Scholar
  69. 69.
    Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest. 1985;87:715–9.PubMedCrossRefGoogle Scholar
  70. 70.
    Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg JA. A simple percutaneous tracheostomy technique. Surg Gynecol Obstet. 1990;170:543–5.PubMedGoogle Scholar
  71. 71.
    Fantoni A, Ripamonti D. A non-derivative, non-surgical tracheostomy: the translaryngeal method. Intens Care Med. 1997;23:386–92.CrossRefGoogle Scholar
  72. 72.
    Byhahn C, Lischke V, Halbig S, Scheifler G. Westphal K [Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy. Technique and early clinical results]. Anaesthesist. 2000;49:202–6.PubMedCrossRefGoogle Scholar
  73. 73.
    Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilation. A preliminary report. Intens Care Med. 2002;28:299–303.CrossRefGoogle Scholar
  74. 74.
    Zgoda MA, Berger R. Balloon-facilitated percutaneous dilational tracheostomy tube placement: preliminary report of a novel technique. Chest. 2005;128:3688–90.PubMedCrossRefGoogle Scholar
  75. 75.
    Cabrini L, Monti G, Landoni G, et al. Percutaneous tracheostomy, a systematic review. Acta Anaesthesiol Scand. 2012;56:270–81.PubMedCrossRefGoogle Scholar
  76. 76.
    Durbin Jr CG. Techniques for performing tracheostomy. Respir Care. 2005;50:488–96.PubMedGoogle Scholar
  77. 77.
    Polderman KH, Spijkstra JJ, de Bree R, et al. Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication. Chest. 2003;123:1595–602.PubMedCrossRefGoogle Scholar
  78. 78.
    Diaz-Reganon G, Minambres E, Ruiz A, et al. Safety and complications of percutaneous tracheostomy in a cohort of 800 mixed ICU patients. Anaesthesia. 2008;63:1198–203.PubMedCrossRefGoogle Scholar
  79. 79.
    Dempsey GA, Grant CA, Jones TM. Percutaneous tracheostomy: a 6 yr prospective evaluation of the single tapered dilator technique. Br J Anaesth. 2010;105:782–8.PubMedCrossRefGoogle Scholar
  80. 80.
    Durbin Jr CG. Early complications of tracheostomy. Respir Care. 2005;50:511–5.PubMedGoogle Scholar
  81. 81.
    Higgins KM, Punthakee X. Meta-analysis comparison of open vs percutaneous tracheostomy. Laryngoscope. 2007;117:447–54.PubMedCrossRefGoogle Scholar
  82. 82.
    Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000;118:1412–8.PubMedCrossRefGoogle Scholar
  83. 83.
    Seder DB, Lee K, Rahman C, et al. Safety and feasibility of percutaneous tracheostomy performed by neurointensivists. Neurocrit Care. 2009;10:264–8.PubMedCrossRefGoogle Scholar
  84. 84.
    Kocaeli H, Korfali E, Taskapilioglu O, Ozcan T. Analysis of intracranial pressure changes during early vs late percutaneous tracheostomy in a neuro-intensive care unit. Acta Neurochir (Wien). 2008;150:1263–7. discussion 1267PubMedCrossRefGoogle Scholar
  85. 85.
    Kleffmann J, Pahl R, Deinsberger W, Ferbert A, Roth C. Effect of percutaneous tracheostomy on intracerebral pressure and perfusion pressure in patients with acute cerebral dysfunction (TIP Trial): an observational study. Neurocrit Care. 2012;17:85–9.PubMedCrossRefGoogle Scholar
  86. 86.•
    Warnecke T, Suntrup S, Teismann IK, et al. Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med. 2013;41:1728–32. Very interesting prospective study on endoscopic swallowing assessment prior to decannulation in 68 tracheotomized (post-)ICU stroke patients.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of HeidelbergHeidelbergGermany

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