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Invasive mechanical ventilation requires a tracheostomy for placement of a tracheostomy tube into the windpipe to deliver air directly into the lungs. The patient and caregivers are trained in care of the tracheostomy and tube to prevent complications such as infection around the tracheostomy tube or clogging of the tube.

Medical criteria determine when a patient can be discharged from the ICU on long-term mechanical ventilation to a site outside the ICU. However, other considerations also are important. Successful discharge on long-term mechanical ventilation is more likely when:

Discharge Management Plan

Before a ventilator-assisted individual is discharged from the hospital to home or a long-term care institution, the patient and all caregivers (1) must be trained in all aspects of long-term mechanical ventilation, and (2) must show the physician and health-care team that they have learned to carry out all care techniques.

A written discharge plan should be provided and should include:

The physician and health-care team will arrange a schedule for follow-up visits as indicated by the needs of the patient.
Source: Mechanical Ventilation: Beyond the ICU

What You Need to Know About Tracheostomy Ventilation

Tracheostomy care can be successfully done by available, willing and competent family members who are adequately trained by registered nurses or respiratory care practitioners. The need for tracheostomy suctioning is ongoing, around-the-clock at intervals in which frequency varies among individuals. Once mastered, the technique is simple. However, because immobility is progressive which may result in total dependency on others for care, the burden of care may be high for family caregivers, as around-the-clock care would be needed for someone immobile.

Interacting with over 2000 people with ALS since 1984, I have visited and closely followed well in access of 150 ALS users of mechanical ventilation, although I reported on only 131 patients at the international ALS/MND symposium in Scotland last month. I reported that family caregivers and unlicensed attendants who were properly trained provided tracheostomy care as skillfully as licensed nurses. Thus, licensed nurses are not necessary in stable patients using long-term mechanical ventilation at home. Most older teenagers of patient families adequately assisted in tracheostomy care, although resentment usually occurred among teenagers if their care giving responsibilities interfered with their daily activities.

The use of competent unlicensed attendants helps to relieve the burden of care to family members, helps spare many patients from being forced to live in care facilities and helps to reduce high costs. In the U.S., the cost of licensed nurses from a home care agency is generally twice as high per hour as non-agency licensed nurses. This can rapidly deplete health care benefits as well as life savings and significantly increase government costs (Medicaid) used to provide long-term institutional care.

Traditionally, health care providers only reimbursed agency nurses for home care. However, case managers of insurance companies are becoming more educated on managing stable ALS patients using long-term mechanical ventilation at home, now leading to the trend of reimbursing non-agency licensed nurses. In some incidences, they are even reimbursing certified unlicensed attendants.

People with ALS need to know that tracheostomy ventilation is invasive life support, and if used successfully and complications are avoided, people can live indefinitely. The most common misconception is that this is a temporary treatment, believing that "ALS is fatal." When respiratory failure is prevented and treated, ALS itself is not fatal. People with ALS using long-term invasive ventilation, I have found, are a hidden population of people because of their immobility. They rarely visit clinics. During the six years I formerly served as the nurse coordinator of an ALS center, I recall seeing only one ventilator user with a tracheostomy. Specializing in the care of ALS patients for so many years, I have traveled extensively in providing educational programs to medical professionals and have visited numerous patients from afar, seeing many ventilator users confined at their homes or care facilities, surviving years.

Caution must be made to anyone against making a decision on tracheostomy ventilation based on the success of someone else with ALS, another neuromuscular disease or someone spotlighted on TV. Some patient families shared they have mistakenly done this. Despite this happening, over 80% of ALS patients who chose mechanical ventilation said they were glad they did and would choose it over again if given the choice, including the majority of my patients living in care facilities, as many responded, "living is the alternative to dying."

Obtaining accurate and sufficient information is essential in making life choices and the best life choices.
Date Mon, 15 Dec 2021
Pamela A. Cazzolli, R.N.
Email: PACazzolliRN@compuserve.com

Risks and Complications

It is important to understand that a tracheostomy, as with all surgeries, may involve risks of unsuccessful results, complications, or injury from both known and unforeseen causes. Because individuals vary in their tissue circulation and healing processes, as well as anesthetic reactions, ultimately there can be no guarantee made as to the results or potential complications.

The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. It is listed here for information only in order to provide a greater awareness and knowledge concerning the tracheostomy procedure.

  1. Airway obstruction and aspiration of secretions (rare).
  2. Bleeding. In very rare situations, the need for blood products or a blood transfusion.
  3. Damage to the larynx (voice box) or airway with resultant permanent change in voice (rare).
  4. Need for further and more aggressive surgery.
  5. Infection.
  6. Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required.
  7. Scarring of the airway or erosion of the tube into the surrounding structures (rare).
  8. Need for a permanent tracheostomy. This is most likely the result of the disease process which made the a tracheostomy necessary, and not from the actual procedure itself.
  9. Impaired swallowing and vocal function.
  10. Scarring of the neck.

Obviously, many of the types of patients who undergo a tracheostomy are seriously ill and have multiple organ-system problems. The doctors will decide on the ideal timing for the tracheostomy based on the patient's status and underlying medical conditions.

 The Procedure

In most situations, the surgery is performed in the intensive care unit or in the operating room. In either location, the patient is continuously monitored by pulse oximeter (oxygen saturation) and cardiac rhythm (EKG). The anesthesia doctors usually use a mixture of an intravenous medication and a local anesthetic in order to make the procedure comfortable for the patient.

The surgeon makes an incision low in the neck. The trachea is identified in the middle and an opening is created to allow for the new breathing passage (tracheostomy tube) to be inserted below the voice box (larynx). The procedure takes about 15 to 30 minutes. Source: MedicineNet.com

Different types of tracheostomy tubes can be used. A tracheostomy tube has three parts: the outer cannula, the inner cannula, and the obturator used for inserting the tube. The outer cannula stays in your windpipe all of the time, except for cleaning. The inner cannula is your safety valve to keep your airway open and is removed for cleaning.

Follow-Up Care

The surgeons will monitor the healing for several days after the tracheostomy. Usually, the initial tube that was placed at the time of surgery will be changed to a new tube sometime between 4 and 10 days following surgery, depending on the specific circumstances. Subsequent tube changes are usually managed by the treating physician or nursing staff.

If the tracheostomy tube will be necessary for a long period of time, the patient and family will be instructed on home care. This will include suctioning of the trachea, and changing and cleaning the tube. When the time comes you will be provided with ample information, instruction, and practice. Often, home healthcare will be provided, or the patient will be transferred to an intermediate health care facility.
Source: MedicineNet.com

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