Tracheostomy Practices in Neurocritical Care

Excerpt

Historically, the outcomes of patients requiring mechanical ventilation for acute brain injury were poor, with a high percentage being reported dead or fully dependent at 6 months after admission [1]. These data led to a certain amount of therapeutic nihilism, and a tendency to early withdrawal of life support [2, 3] that neurocritical care as a field has worked hard to reverse [4]. Outcomes of mechanically ventilated patients with severe acute brain injury have improved [5], but a current review of tracheostomy practices nationally in patients with severe acute brain injury [6] suggests the possible evolution of two different treatment environments. Tracheostomy in patients with severe acute brain injury is a marker for treatment—it signifies an ongoing commitment to care and is not performed when there is the intention to discontinue supportive measures. Conversely, tracheostomy is often—but not always required in severely brain-injured patients until their airway protective reflexes, pharyngeal tone, and levels of activation and cognition have improved enough to at least clear secretions and maintain a patent upper airway [7, 8]. …