Tracheostomy Placement in Patients with High Ventilator Settings: Study of 1,694 Tracheostomies

Early tracheostomy has benefits, including decreased rates of pneumonia, ventilator and ICU days, tracheal stenosis, and mortality. Tracheostomy is often postponed in the setting of unfavorable ventilator settings due to perceived risk. We sought to evaluate whether tracheostomy can be performed in patients with high ventilator requirements without increased adverse events.

Tracheostomies performed between 2014 and 2024 were reviewed. Patients were grouped according to HIGH (FiO2 >50%, PEEP higher than 10, airway pressure release ventilation or pressure-regulated volume control modes, or administered nitric oxide) and LOW ventilator settings. The primary outcome of interest was intraoperative adverse event: hypoxia, loss of airway, need for advanced cardiac life support, bleeding requiring return to operating room, and death. Multivariate logistic regression was performed to identify risk factors for adverse events.

A total of 1,694 tracheostomies were performed during the study period (725 HIGH, 969 LOW). Patients were similar in terms of demographics, baseline data, and injury severity or sepsis. HIGH group patients had higher ventilator settings and use of advanced modes of ventilation. Patients on the HIGH setting had similar percutaneous and ICU-placed tracheostomy rates compared with patients on the LOW setting. There were no differences in individual or composite adverse events between HIGH and LOW ventilator settings (p = 0.814). Multivariate regression demonstrated no increased odds of adverse events with HIGH-setting tracheostomies (odds ratio 0.86, 95% CI 0.36 to 2.03, p = 0.734), but did show an increase in adverse events in HIGH-setting tracheostomies placed in the ICU (odds ratio 2.28, 95% CI 1.09 to 4.81, p = 0.029).

Tracheostomies performed in patients with HIGH ventilator settings are not associated with increased rates of adverse events. Consideration should be made to perform tracheostomies in patients with high ventilator settings in the operating room. Our study supports early tracheostomy placement in patients predicted to require the procedure despite high ventilator settings.