Résumé:
Extubation failure after invasive mechanical ventilation occurs frequently. Several large-scale cohort studies have reported rates of failure between 14% and 18%, and 35% of patients had not been weaned at three months. To facilitate weaning, tracheostomy is a procedure commonly used in ICU patients whose liberation from mechanical ventilation is unsuccessful. French expert guidance considers tracheostomy in adult ICUs as a procedure planned mainly as anticipation for prolonged weaning or after failed extubation; the panel suggests considering tracheostomy as an option when weaning extends >7 days after the first spontaneous breathing trial failure, and in acquired reversible neuromuscular disorders . In 2018, French national insurance data on 77,132 critically ill patients indicated that 3,688 (4.8%) had undergone tracheostomy. Tracheostomy rates reported in large cohorts ranged from 21% for all patients with separation attempts to 63% for patients in prolonged weaning.
Tracheostomy presents many advantages. Its purposes are well-known to clinicians: the ability to maintain mechanical ventilation and secure airway access, reduced work of breathing via decreased upper-airway resistance, improved patient comfort, decreased sedative exposure, liberation of the mouth to restore phonation and swallowing and promote mobilization. Nevertheless, these advantages should be weighed against uncommon but at times severe complications. Across contemporary cohorts, post-tracheostomy ventilator weaning typically takes about 12 days (IQR 7–20) in COVID-19 series, with 21% mortality and 93% of survivors weaned and 86% decannulated. In a general ICU cohort tracheostomized for complex weaning, hospital mortality was 24%, 37.5% had a poor outcome (death or discharge with tracheostomy), 62.5% were alive and decannulated at hospital discharge, and the median time from intubation to decannulation was 42 days.
The management of tracheostomized patients is specific and requires adequate knowledge of the available devices, upper-airway physiology, and the mechanisms of phonation and swallowing. Many steps of weaning and bedside care remain insufficiently described, markedly heterogeneous, and largely practice-based. In light of these considerations, updated, standardized guidelines for post-tracheostomy ventilator weaning and decannulation in ICU patients are needed.
We are presenting updated, evidence-aligned guidelines for adult ICU tracheostomy care, from ventilator weaning through restoration of phonation and swallowing to decannulation. The guidelines are designed for the multidisciplinary teams managing tracheostomy across the ICU-to-ward continuum (intensivists, ICU physiotherapists, respiratory therapists, nurses, speech-language pathologists, otolaryngologists, thoracic surgeons, and rehabilitation professionals). They should also inform researchers and hospital leaders responsible for pathway design and policy, and serve as a teaching resource for trainees as well as for patients and families.
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