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Why do tracheostomy rates fluctuate so drastically between ICUs? What is the true reason for so many tracheostomies? What are the long-term effects of tracheostomies?

 

Episode Transcription

Kali Dayton 0:00
I have been needing to talk about tracheostomies for a while. A discussion on tracheostomy is incredibly relevant to this podcast that is about avoiding sedation and immobility. Yet, it’s difficult for me for a few reasons. One, it is not my expertise.

The “Awake and Walking ICU” is in a tertiary hospital that receives transfers from many states for severe respiratory failure and ARDS. It has a bone marrow transplant unit in the hospital and takes patients with horrific multi organ failure, fluid overload sepsis graft versus host and so on. Patients often stay on the ventilator for weeks. And yet, they rarely stop walking and hardly ever receive tracheostomies.

One of my colleagues told me once that he loved doing tracheostomies. It was his favorite procedures and all during fellowship, he did them all the time. Then he came to the awakened walking ICU, and it suddenly stopped. There was no one to do tracheostomies on. So again, it’s not a practice that I’m especially fluent in.

I understand that in settings such as neuro and some traumas, it is unavoidable. Yet with most medical surgical cases, such as COVID, the instances in which I’ve seen tricky ostomies or with unique exceptions, such as advanced interstitial lung disease, muscular dystrophy, and so on. It is also difficult for me to approach this because, in my mind, it is such a sad and ugly side of critical care. It pains me to hear that spoken of so lightly by ICU providers.

And then to hear survivors talk about their sufferings even after decannulation. Then I have to study the research and learn about these higher rates. And it just is depressing. But we cannot correct what we can’t confront. So let’s talk about the secret parts of tracheostomies.

There’s a study published in the journal Critical Care Medicine in 2019. That looked at 8,343 patients that had received tracheostomies for respiratory failure. Pneumonia was the most common diagnosis for the respiratory failure, and made up 79% of the sample group. 56% of those had additional diagnoses such as severe sepsis. The study looked at the outcomes over the first year following discharge. It found that the in hospital mortality rates for patients that receive tricky ostomies for respiratory failure was 18.9%.

After 30 days, it was 22.1%. After one year, mortality rate was 46.5%. Of those 8,343 patients with tracheostomies, it was seen that 86% of those survivors were sent to long term care facilities with their tracheostomy and only 11% were sent home. 60% of patients were readmitted to the hospital within one year of tracheostomy, 1/3 or 36% of those patients spent more than 50% of their days alive in the hospital and short term acute care. On average, the total hospital costs for patients who survived the first year of tracheostomy was $215,369.

So we should be asking, why is the mortality rate so high for patients with tracheostomy? I think this is a complicated question. I surmise that part of the answer lies in the initial phase and treatment of critical illness. How we manage patients on ventilators determines their trajectory over the next few days, weeks, but even the six will have to follow after discharge.

To understand why they are at such high risk of dying after receiving tracheostomies, we really have to understand what set them up to receive them, and why it became necessary to have a tracheostomy.

One study looked at 124 ICU patients and found that the indicator for 80.5% of tracheostomies was prolonged intubation. And the second main reason was diaphragmatic paralysis being almost 20% of all trachs So let’s talk about these two risk factors: prolonged intubation and diaphragmatic paralysis.

Throughout this podcast, we have discussed research and case studies demonstrating beyond a doubt that avoiding sedation and then mobilizing patients that decrease their time on the ventilator. So if prolonged intubation is so often preventable by evidence-based practice, such as avoiding sedation and early mobility, than how many tracheostomies could be avoided by implementing the interventions that will get patients off the ventilator quicker?

As for diaphragmatic paralysis and or dysfunction. This is again a complicated issue. I am including on the blog some wonderful articles explaining all the finer detail of it. Yet, Jereon Molinger spent three episodes trying to help us understand the importance of muscles and preventing multiorgan failure, as well as the role of the diaphragm and maintaining the ability to independently breathe and wean off the ventilator.

He taught us the storm of complex factors that rage against diaphragm during critical illness, such as inflammation, hypermetabolism, catabolism, and the disuse of the diaphragm to breathe while on the ventilator all exacerbated by sedation and mobility.

I had long wondered why the sickest patients in the “Awake and Walking ICU” were still able to wean off the ventilator and didn’t have tracheostomies like the rest of the ICU world. So the ventilator was doing the work with the diaphragm for breathing despite the patient’s walking, which would be just like patients that were sedated.

So why is there such a difference in outcome? When Jeroen explained the role the diaphragm plays in walking- a light went off. The difference in these patients is likely a mix of improved inflammation due to preservation of muscle mass, but also the engagement of the diaphragm while walking. When patients move- even on the ventilator, they are less likely to develop this ventilator-induced diaphragmatic dysfunction.

Moving and especially walking on the ventilator decreases time on the ventilator as well as mortality because it combats and prevents ICU acquired weakness and diaphragm dysfunction. When it comes down between those two in terms of risk for mortality, ICU acquired weakness is more common in patients on ventilators and more deadly. What studies show that survivors that only had ICU acquired weakness were 30% more likely to die within two years after discharge compared to those that did not have ICU acquired weakness.

So when we sedate and leave our patients and bed to atrophy, we put them at a far higher risk of ICU acquired weakness and therefore needing a tracheostomy. The high mortality rates of survivors that receive tracheostomy likely has to do more with their atrophy and weakness that consequently make the tracheostomy necessary. When we weaken them enough to be too weak to breathe on their own. We weaken them to be too weak to survive.

It seems to me that recipe that tricky ostomies and these respiratory failures are hardly from a lung failure, or simply from a sick lung. But from a failure to keep the rest of the body and respiratory muscles strong. Maybe it should be seen as our failure to treat that rather than the lungs failure to breathe. We have to understand this and be talking about this the moment a patient comes through our doors. Right after intubation, we have to look at our patient each other and ourselves and decide right then if sedating them is worth increasing their chances of deconditioning in the next few days, and having to trach them in a few weeks, just to have them die, and a few months or a year.

If they are in severe respiratory failure, then this is all the more reason to start combating atrophy and preserving the whole body. We have to stop being so afraid of now versus on the ventilator, or at least change our response to them. Instead of knocking patients down the second their PEEP is above 8, I dare to suggest we should be more eager to mobilize them.

If a patient is headed towards or in ARDS, then they are especially going to need their diaphragm and all their respiratory muscles to move stiff lungs. A study just came out in the Journal of respiratory care with a study from Brazil that demonstrated that sitting and exercising significantly improve lung aeration and PF ratios in patients with moderate severe hypoxemia.

This is so consistent with my experiences with patients and bed that write on the board that they can’t breathe and need to get to the chair and patients in the chair writing “Thank you I can breathe better.”

Try it. lay on the ground and pay attention to how much your diaphragm has to work to drop and the resistance your lungs face to expand compared to when you are sitting up and your diaphragm can drop with gravity. When you’re in a coughing fit or feel short of breath. What position do you innately go to supine, are sitting nursing 101 tells us that walking helps prevent pneumonia and patients with pneumonia should walk.

So where is our logic coming from? When we habitually sedate all patients on ventilators especially refuse to move them when their ventilator settings requirements are getting higher? If they can, if they can oxygenate with movement. Why do we hesitate to have them do the things that will improve their aeration and help maintain their ability to breathe. There is also a cultural myth that tracheostomy is our Safer from ability listener. I am open to being proven wrong. But I cannot find a comparative study demonstrating that.

Rather, there is plenty of evidence showing that it is safe and feasible to walk patients that are intubated with an endotracheal tube and acute respiratory failure. The incident rates for things like unplanned intubation, hypoxia, falls, etc are nearly 0% percent pilot, Polly Bailey and Louise best in the pioneer in peace for this process that have been on the podcast published a study back in 2007. It was the first study to ever show that it is safe and feasible to walk patients on ventilators.

Out of the 1,449 activity events in this study, less than 1% had any adverse events. And there were no self excavations. Again, studies are on the blog. And I would also add comparatively, the adverse outcomes for immobilizing patients are far beyond 1%. So where is the real risk? Where do our safety priorities lie?

Again, when we choose deep prolonged sedation and immobility the moment they’re intubated, then we are essentially choosing a tracheostomy for them in a week or two. You do not need a tracheostomy to mobilize patients. Yet. If I’m your patient, and that is the only way you’re willing to let me wake up and move. Then fine. Cut me. I will trade tracheal stenosis for post ICU dementia, post ICU, PTSD and long term weakness.

If I get trached for sepsis, ARDS, or even pneumonia, I am still going to be irked after seeing how preventable it was. One article from the Journal of respiratory and critical care medicine provided a literature review of almost a dozen studies on tracheostomies. The consensus among the studies was that early tracheostomy had no benefit on mortality, no benefit to duration of mechanical ventilation or ICU length of stay, and minimal to no benefit on sedation use.

The Journal of Otolaryngology published a study that showed that the overall inpatient tracheostomy complication rate was 47%. The outpatient tracheostomy complication rate was 15%. The all cause 30 day hospital readmission rate for patients that had left the hospital with tricky ostomies was 33% and tracheostomy specific readmission rate was 13%. The overall mortality rate during the study was 11%.

A travel nurse from the South was astounded by their experience in the “Awake and walking ICU”. He reported that in his previous facility, anyone on a ventilator automatically got for said and after a few days got tricked and paid. How inhumane to make no effort to maintain function during critical illness and put every patient through delirium, muscular atrophy, extensive rehabilitation and then likely lifelong disability.

He came to me at the end of his contract and said he felt so haunted by years of working on his past facility the way he did. Then the same kind of patients in the “Awake and Walking ICU”, they’re not being trached, and they’re walking out of the ICU. He then felt so conflicted and wasn’t sure how we could go elsewhere after knowing and seeing how to truly help patients.

One of the problems is, we don’t see the reality of tracheostomy in the ICU. We do it and then usually ship them out shortly after. The same study implying that tracheostomies are usually from preventable causes also showed that cutting a hole into patients throat is not without short and long term consequences. It showed that one year after discharge 13.9% had tracheal stenosis, and 25% had sub subglottic stenosis.

This is a way bigger deal than an unfortunate scar damage from tricky ostomies can be big blows to quality of life. On this ICU survivor page, I see far too many posts from survivors trying to get help, or at least validation, whether post tracheostomy sufferings, the research and data is important, but I find that their testimonials to be the most compelling. So let’s have them tell us what it is really like to have narrowed airways requiring frequent dilations loss of vocal cords, tracheal resections, and all the other complications that can come after a tracheostomy,

Survivor 1 16:26
Hey, this is Margaret love, I just want to leave my message about my trikes I had to actually in January of 2020. And when I came home, actually from the rehab, I felt like I couldn’t breathe. When I tried to sleep I felt like I was just going to choke on to there. I wasn’t able to lift my arms up above my head, especially like in the shower to wash my hair, because it would cut my wound off. I’ve had a chronic cough since 2020. Since January actually and I’ve had to bronchoscopy is because of this one showed polyps one directly active surgery shows polyps from the use of the trach.

And the next one showed scar tissue in the in rock, trachea. I’ve actually just had a surgery. Today was a one month ago to use a to do like about elation of my trachea to try to open it back up because it was closing. And actually when the doctor was in there, and he said that one of the rings in my trachea had been collapsed from using from the trach itself. I’m still on the journey with this trying to figure it out. Like I’m sure you can hear in my voice. I have another appointment with probably my fifth pulmonologist.

They say my lungs are fine, my the trachea, the trach is the problem. And I don’t know where we’ll go from there. But that’s my journey. Thank you. I had one in 2000 they’re not comfortable, a nice option, it feels like you’re drowning, they actually had a replacement for the big one. And and that was really paint that might take it’s super sensitive. I don’t do turtleneck. I try not to wear necklaces or anything like that.

Survivor 2 18:20
So I had the tracheostomy in for about three months in the end. And I tried several times to check it out. But it was it was quite a process. It also affected my vocal style. At one point, I came down with sepsis after one of the dilations we’re still not quite sure how we think I’m I’ve inhaled food into my lungs. And that turned into pneumonia, which we didn’t pick up on. And then unfortunately that that infection kind of spread elsewhere and got into my bloodstream. So that was quite scary in itself. And that was quite an extensive intensive care stay with the sepsis.

Anyway, the dilations eventually settled down. It took a very long time I went on the I think it’s called the mayo protocol. So they put me on my extensive steroids and antibiotics for quite a long period of time. And that seemed to settle down and we got them every six weeks and then every 12 weeks and then every six months and now it’s sitting at about every six months but the airway is only ever going to be 10 millimeters wide.

So the option will always be if I want to have a reconstruction I can but that will involve another trach and they’re very worried if they put it another trach that they’re not going to be able to get it out. The vocal cords are also dysfunctional as well. It’s called vocal cord dysfunction. So between the two it takes both my physio and my speech, a lot of a hands on work and practical work. It really affected me long term. I knew if I had a trachy again, I’d never get back to my job in the classroom.

As a teacher physically with preschool children, it’s quite demanding job. Or sometimes even younger children depending on where I am that day. Which room so there’s a lot of stuff that I worked really hard had to get back to. But I’m very grateful that I can go back. But I certainly do pay the price for that in other ways. Trachy on its own is very stressful with the voice and you are talking all day every day and my voice hasn’t really been up to it or the infections that I’m catching up work have affected the airway really badly can cause some problems there.

Muscle wise, it’s been very interesting, I did lose quite a bit of weight last year, about 35 kilos, I don’t know what that is in pounds over there. But that significantly helped my lung capacity in my confidence and state of mind as well. Emotionally, it was quite quite hard to bounce back from that and realize that I’ll never work full time as a teacher again. Currently, I work about 25 hours a week, sometimes up to 30. And I’m happy with that.

But it has impacted me emotionally. I’ve got some scars on my neck and things. But overall, I’m very grateful. Yeah, just so grateful to be doing what I’m doing to be able to walk and exercise and talk and eat. That was a really big obstacle for me to get back off the tube feeds or reconstruction, I think would would fix the dilations long term. But it would also put me out of out of action for probably a year or more again, and financial. It’s had a big impact on me and being quite hard in that way as well. But I’m very grateful for the care I’ve received over here. And yeah, that’s about it.

Kali Dayton 21:25
We also have to be aware that after patients receives a tracheotomy and as shipped off to LTACH, they do not bounce right back to their feet. Rehabilitation from ICU acquired a weakness is horrific. Please go back to the beginning of the podcast and listen to the survivors talk about what it’s like to quote unquote wake up with a functional capacity of a newborn.

Susan East told us an episode three about being carried home as she was boycot in her LTACH and then been able to rehabilitate better at home than in the LTACH where she felt like she was very mistreated. I had an LTACH nurse tell me stories of patients having sedation shut off right as they roll into their doors. Then they are left to deal with a terrible delirium on top of trying to rehabilitate once once functional adults turn into flats at wet noodles, all with the ratio of 20 patients on a ventilator to one nurse.

Of course, as I said, there are situations in which a tracheostomy is unavoidable, especially a neuro patient. Yet a source in billing for ICU charges did some digging for me. This is off the record, but kind of on the record, I was informed that hospitals receive at least $40,000 for a tracheostomy from acute respiratory failure. It’s not something we published so take it for what it is and don’t quote me on it. This likely varies from location and patient. But the principle remains instead of being held responsible for the preventable damage we’ve done.

Hospitals are fiscally awarded for failing to get patients weaned off the ventilator. So where is the incentive to provide proper staffing ratios? Avoid station hire more physical therapist and utilize them? Where is the incentive to keep patients awake, communicative, autonomous and strong? If we made “walk TID” as ingrained as “turne q2”, everything would change.

How much money would it save if we didn’t have a process of care that unnecessarily allowed or caused millions of barely surviving patients to atrophy and spend weeks longer on the ventilator with a tracheostomy and a care facility and require extensive follow up rehabilitation and re hospitalizations?

How much lighter with a burden on the system be? Yet most importantly, how much quality of life could be restored? Don’t get me wrong, I know I’m sounding angry. I know that people care. I am increasingly contacted by inspired and motivated providers that are wanting more information, webinars, support and so on. I am talking about a system problem.

When Medicare says they won’t reimburse for hospital acquired infections, boom, we make a process of care that gets so centralized, cleaned and Foley’s out ASAP. Yet, if we’re going to make money off of keeping staffing ratios at bare bones, cranking up sedation and letting patients atrophy and cutting holes in their throats, then why would we change?

The NP in Episode 11. Susie got in trouble with the LTACH she worked at because she was getting patients off the benzodiazepines and narcotics and out of bed and they were being discharged before their 30 days of state that Medicare would pay for. She was losing the LTACH money and they didn’t appreciate her vision and approach. So she started her own respiratory units and nursing homes and apply to the “Awake and Walking ICU” way to patients that were supposed to be trached on vents forever. She flipped the average decannulation rate from around 13% to above 60%.

These problems are not just in the ICU. This is a plague threw out our system, but it is the survivors that truly suffer. Our perspectives have to change. Our vision has to broaden our system has to evolve. Our discussions have to mature. Incentives have to update. Our choices upon admission, and the risks considered have to include the price to be paid in the weeks and years to follow? Next episode, I will have a special consultant Patrick, share with us his role in helping the masses of decondition patients with new tracheostomy as they leave the ICU.

Transcribed by https://otter.ai

References
Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., Veale, K., Rodriguez, L., & Hopkins, R. (2007). Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine.

El-Anwar, M., Nofal, A., Shawadfy, M., Maaty, A., & Khazbak, A. (2017). Tracheostomy in the intensive care unit: a university hospital in a developing country study. International Archives of Otorhinologarngology, 21(1).

Hickmann, C., Montecinos-Munoz, N., Castanares-Zapatero, Arriagada-Garrido, R., Jeria-Blanco, U., Gizzatullin, T., Roeseler, J., Dugernier, J., Wittebole, X., & Laterre, P. (2021) Acute effects of sitting out of bed and exercise on lung aeration and oxygenation in critically ill subjects. Respiratory Care, 66(2).

<Keough, E., Lopez-Rodriaguez, L., Carriedo, D., Goncalves, G., Barreiro, E., & Lorente, J. (2019). Ventilator-induced diaphragm dysfunction: translation mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Medicine, 7(48).

Mehta, A., Walkey, A., Everett, D., & Douglas, I. (2019). One-year outcomes following acute respiratory failure. Critical Care Medicine, 47(11).

Saccheri, C., Morawiec, E., Delemazure, J., Mayaux, J., Dube, B., Similowski, T., Demoule, A., & Dres, M. (2020). ICU-acquired weakness, diahpragm dysfunction, and long-term outcomes of critically ill patients. Annals of Intensive Care, 10(1).

Spataro E, Durakovic N, Kallogjeri D, Nussenbaum B. Complications and 30-day hospital readmission rates of patients undergoing tracheostomy: A prospective analysis. Laryngoscope. 2017;127(12):2746–53.

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