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Tracheostomy protocol: Experience with development and potential utility*

Freeman, Bradley D. MD; Kennedy, Carie RN; Robertson, T Elizabeth MD; Coopersmith, Craig M. MD; Schallom, Marilyn RN; Sona, Carrie RN; Cracchiolo, Lisa RT; Schuerer, Douglas J. E. MD; Boyle, Walter A. MD; Buchman, Timothy G. PhD, MD

doi: 10.1097/CCM.0b013e318174d9f6
Clinical Investigations

Objectives: To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning.

Design: Prospective, observational data collection.

Setting: Academic medical center.

Patients: Surgical intensive care unit patients requiring mechanical ventilatory support.

Interventions: None.

Measurements and Main Results: Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75–8.0) and 7.0 (5.0–10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0–19.0] vs. 6.0 [4.0–8.0], p < .001). For patients requiring ventilatory support for ≥20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy.

Conclusions: A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

From the Departments of Surgery (BDF, CK, TER, CMC, DJES, TGB) and Anesthesiology (CMC, WAB), Washington University School of Medicine, St. Louis, MO; and Department of Nursing (MS, CS, LC), Barnes Jewish Hospital, St. Louis, MO.

Supported, in part, by an unrestricted educational grant from the Cook Corporation (BDF), by the National Institutes of Health (BDF, TER), and by the James S. McDonnell Foundation (TER, TGB).

The authors have not disclosed any potential conflicts of interest.

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© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins