Use and Timing of Tracheostomy After Severe Stroke
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- intracerebral hemorrhage
- neurocritical care
- subarachnoid hemorrhage
A patient with severe ischemic or hemorrhagic stroke needs to have a tracheostomy performed if he remains unable to breathe and protect his airway sufficiently. This can be caused by very different types of stroke, such as severe acute ischemic stroke (eg, large hemispheric stroke, space-occupying cerebellar stroke, basilar thrombosis, and brain stem infarction), large or brain stem intracerebral hemorrhage and intraventricular hemorrhage, severe cerebral venous and sinus thrombosis, and aneurysmal subarachnoid hemorrhage. The particular type of cerebrovascular pathology is probably less relevant than how extensive the brain damage and its sequelae (brain edema, secondary ischemia) are and what parts of the brain they affect. In particular, compromise of brain regions regulating the level of consciousness (reticular formation in the brain stem, thalami, limbic system), breathing (respiratory centers in the cortex, pons, and medulla), and swallowing (medulla and brain stem connections) may lead to the need of a tracheostomy. There are 2 main scenarios in which tracheostomy after stroke is usually considered.
The first is in a patient requiring stroke unit care with an overall moderate stroke that affects swallowing centers of the brain (such as infarcts of the brain stem or the medulla oblongata) causing dysphagia. In some of those cases, after several noninvasive supportive measures have been sufficiently applied but failed, tracheostomy may be considered to prevent aspiration and bridge swallowing therapy. This approach to that scenario, however, is very controversial.
The second scenario is in a patient with a stroke so severe to demand admission to an intensive care unit (ICU) and mechanical ventilation. There, tracheostomy will be chosen if extubation fails or is deemed not feasible, that is, as part of weaning from the ventilator. The need of tracheostomy, the timing of tracheostomy, and its potential benefits versus risks to the patient with severe stroke remain …