Airway obstruction

• To secure and clear the airway in upper respiratory tract obstruction
• This can be an actual obstruction, typically caused by a cancer, swelling of the airway, infection, inflammation or trauma
• This can also be potential obstruction, typically where an airway is predicted to get worse and possibly become actually obstructed. This might be predicted after major head and neck surgery for example

Providing an artificial airway for ventilation

• Invasive ventilation needs an interface between the ventilator tubing and the patient's trachea. This can be via an oral (or nasal) tracheal tube, which has to cross the larynx. The presence of a trans-laryngeal tube is very stimulating, usually requiring sedation. In the critically-ill, invasive ventilation may be required for many days, weeks or months, with some patients requiring long-term or indefinite invasive ventilatory support
• Although requiring an invasive procedure to insert the tube, a tracheostomy is relatively well tolerated and typically does not require sedation. There are other physiological advantages discussed later. A tracheostomy is the best way of invasively ventilating a patient in the medium to long term, providing a secure airway without directly interfering with the larynx
• Tracheostomy can facilitate weaning from artificial ventilation in acute respiratory failure and prolonged ventilation. This means an overall gradual reduction in the support delivered by the ventilator
• Tracheostomy can enable long-term mechanical ventilation of patients, either in an acute ICU setting or sometimes chronically in hospitals or in the community

'Protecting' the airway

• Some patients are at high risk of aspirating secretions or gastric contents into the airway. This includes those with impaired or incompetent laryngeal, pharyngeal or tongue movement or sensitivity. For example; neuromuscular disorders, unconsciousness, head injuries, stroke or following prolonged disuse such as after trans-laryngeal intubation
• No tube system completely eliminates the risks of aspiration
• A tracheostomy tube with the cuff inflated reduces the risk and offers a degree of protection against aspiration
• Sub-glottic suction systems can help to reduce secretions that enter the airway
• The benefits of cuff deflation on laryngeal rehabilitation are increasingly being realised. Adequate control of oral secretions and early cuff deflation can increase laryngeal function and cough strength, which in themselves can mitigate aspiration risks. Continual positive pressure flowing up from the lower airways (when a cuff is deflated) can also reduce the chances of aspiration
• Using a cuff for protection against aspiration is a multidisciplinary decision, involving the patient, medical teams, speech and language therapists and physiotherapists

Respiratory secretion management

• To facilitate the removal of bronchial secretions where there is poor cough effort with sputum retention
• Tracheostomy allows positive and/or negative pressure ('cough assist' devices) to be applied directly to the lungs
• Suction is possible directly into the trachea to help clear secretions as part of a comprehensive nursing and physiotherapy package of care