Physiological implications of tracheostomy in critical care-a narrative review

Tracheostomy is a core component of critical care medicine. Although its use is traditionally justified by anticipated improvements in respiratory mechanics and patient comfort, the exact pathophysiological mechanisms are complex. The objective of this narrative review is to examine the physiological changes associated with tracheostomy, focusing on alterations on respiratory mechanics, patient-ventilator interactions, and the implications for speech and swallowing.

A comprehensive literature search of the PubMed (MEDLINE) database was conducted for articles published up to May 2026. The review synthesized data from randomized controlled trials (RCTs), prospective and retrospective observational studies, and relevant systematic reviews involving critically ill adult populations.

Contrary to common clinical belief, transitioning from an endotracheal tube (ETT) to a tracheostomy leads to a marginal reduction in dead space (V_d). The primary respiratory benefit is a reduction in the resistive work of breathing (WOB). Post-tracheostomy dysphagia and dysphonia are highly prevalent and multifactorial, driven by pre-existing laryngeal trauma from intubation and the loss of trans-laryngeal airflow. Evidence demonstrates that early cuff deflation significantly reduces silent aspiration and enhances laryngeal rehabilitation.

The clinical benefits of tracheostomy can be appreciated through an understanding of the physiological effects of tracheostomy. Management of patients with tracheostomy in critical care requires early, multidisciplinary intervention.