Mechanical ventilation is necessary when a patient is temporarily unable to breathe effectively due to severe illness, injury, or surgery. The ventilator connects to the patient via an Endotracheal Tube (ETT), a flexible plastic tube placed through the mouth or nose and into the windpipe (trachea). The ETT delivers oxygen and breathing assistance. While effective for short-term support, it is not sustainable for patients requiring weeks or months of respiratory assistance. When prolonged ventilator support is anticipated, doctors recommend transitioning to a tracheostomy to avoid ETT complications and facilitate recovery.
Why the Breathing Tube Cannot Stay Indefinitely
The Endotracheal Tube is designed for short-term use. Leaving it in place for more than one to two weeks carries a significant risk of physical harm to the patient’s upper airway. Since the tube passes directly between the vocal cords, constant pressure can cause serious damage, including ulceration, scar tissue (granulomas), and vocal cord paralysis. These injuries can lead to long-term issues such as hoarseness, difficulty swallowing, and problems breathing independently after the tube is removed.
The prolonged presence of the ETT also increases the risk of tracheal damage, potentially causing a narrowing of the windpipe known as tracheal stenosis. Furthermore, the tube provides a direct pathway for bacteria, and pooled secretions above the cuff increase the risk of ventilator-associated pneumonia (VAP). To tolerate the ETT’s discomfort, patients must often be kept deeply sedated. Deep sedation hinders cognitive function and delays physical therapy, introducing further complications.
Functional Improvements for Long-Term Care
Transitioning to a tracheostomy tube significantly improves the patient’s condition and aids recovery by offering several functional advantages over the ETT. The tracheostomy tube is inserted directly into the trachea through a small incision in the neck, bypassing the sensitive vocal cords and upper airway structures. This anatomical difference means the tube is shorter and wider than the ETT, dramatically lowering the resistance against which the patient must breathe. This decreased work of breathing is particularly beneficial when attempting to wean the patient off the ventilator.
The tracheostomy greatly enhances patient comfort, often allowing for a considerable reduction in the sedating medications previously needed to tolerate the ETT. With less sedation, patients become more alert, participate more actively in their care, and engage in physical and occupational therapy sooner. The new airway access also makes it easier and safer for nurses to remove secretions from the lungs, reducing the incidence of ventilator-associated pneumonia.
Communication and Nutrition
The most significant functional improvements relate to communication and nutrition. Since the tracheostomy tube is placed below the vocal cords, a specialized speaking valve can eventually be used to redirect air over the vocal cords. This allows the patient to speak while still on ventilator support. Furthermore, removing the tube from the mouth and throat often allows patients to begin swallowing exercises and potentially resume oral feeding much earlier than with an ETT.
When Doctors Recommend the Transition
The decision to perform a tracheostomy is generally considered when a patient is expected to need mechanical ventilation for more than one to two weeks. This timeframe balances the risks of the surgical procedure against the accumulating damage caused by prolonged ETT use. The patient’s underlying condition is a major factor; those with severe brain injury, extensive trauma, or chronic respiratory failure are often candidates for the transition.
The procedure, called a tracheotomy, involves making a small opening in the neck, typically between the second and third tracheal rings, to insert the tracheostomy tube. It is a common and generally safe procedure performed at the patient’s bedside in the Intensive Care Unit (ICU) or in an operating room. The goal is to provide a more secure and better-tolerated airway for the anticipated period of prolonged recovery.
Recovery and The Path to Breathing Independently
The tracheostomy supports the patient’s rehabilitation process by enabling greater mobility and participation in therapeutic activities. Physical therapists can work with a less-sedated patient who can be moved out of bed, preventing muscle wasting and helping restore strength. Speech-language pathologists can also begin working on swallowing and communication, which are important steps in returning to normal function.
As the patient’s respiratory strength improves, the medical team initiates weaning from the ventilator and the tube. This often involves “capping” or “plugging,” where the tube is temporarily blocked to encourage the patient to breathe naturally through their mouth and nose. If the patient successfully tolerates the capped tube, the final step is decannulation, the complete removal of the tracheostomy tube. Once removed, the stoma (opening in the neck) is covered with a dressing and typically heals and closes on its own within one to two weeks.