Data on possible advantages of tracheostomy over translaryngeal tube in lowering the risk for ventilator-associated pneumonia are controversial. In a prospective study on ventilator-associated pneumonia in 880 patients receiving mechanical ventilation at a non-teaching community hospital, Ibrahim et al. [44] found that 15 % of these patients developed pneumonia. Logistic regression analysis showed that tracheostomy, together with multiple central venous line insertions, reintubation, and use of antacids, was independently associated with the development of pneumonia.

In contrast, a 4-year period trial performed in 12 Italian ICUs on the effectiveness of early tracheostomy (after 6–8 days of laryngeal intubation, n = 145) versus late tracheostomy (after 13–15 days of laryngeal intubation, n = 119) in reducing the incidence of ventilator-associated pneumonia showed that pneumonia was present in 14 % of patients in the early tracheostomy group and in 21 % of patients in the late tracheostomy group (p = 0.07) [25].

Skin and soft tissue infection of the anterior aspect of the neck (Fig. 15.2) is usually circumscribed, but it may be complicated by local or systemic dissemination.

Aspiration may be a complication in tracheostomized subjects, particularly if the cuff is left inflated while the patient is eating [45]. A number of studies have investigated the influence of tracheostomy on the swallowing reflex in patients with tracheostomy. Physiologically, subjects with tracheostomy are more likely to aspirate because the tracheostomy tube partially blocks laryngeal movements, preventing its elevation during deglutition. Tracheostomy tubes, particularly when the cuff is inflated, may compress the esophagus and interfere with swallowing [45]. Additionally, prolonged translaryngeal intubation can result in swallowing disorders even after the tracheal tube is converted to a tracheostomy [46].

Elpern et al. [47] found that 50 % of 83 patients receiving long-term mechanical ventilatory support had evidence of aspiration. In 77 % of these patients, aspiration was clinically silent. Advanced age was found to be a risk factor for aspiration in this population.

In non-ventilated patients, some small studies have investigated the role of tracheostomy cuff inflation on aspiration. In 12 ICU patients who had been weaned from mechanical ventilation, Amathieu et al. [48] showed that the swallowing reflex was progressively more difficult to elicit with increasing cuff pressure and, when activated, the resulting motor swallowing activity and efficiency at elevating the larynx was depressed. In 12 tracheostomized patients who undergone fluoroscopic swallowing studies after ventilator weaning, Davis et al. [49] showed that when the cuff was inflated, the aspiration rate was 2.7 times higher than when the cuff was deflated. In this study, logistic regression analysis revealed that the cuff status and the type of substance ingested were both predictors of aspiration, suggesting that feeding with the cuff deflated may be the preferred method and that solid foods are safer than liquids. Conversely, different findings were reported by Suiter et al. [50] in a study on the effects of tracheostomy cuff status and use of one-way speaking valve on the physiology of swallowing in 14 spontaneously breathing patients under three conditions: cuff inflated, cuff deflated, and one-way valve in place. Aspiration was not significantly affected by cuff status, i.e., inflation or deflation, whereas one-way valve placement significantly reduced aspiration for the liquid bolus.

In the light of these findings, in non-ventilated patients with tracheostomy, the evidence is inconclusive as to whether the cuff status predisposes to aspiration of food or fluids at the level of the larynx. However, performing swallowing studies may be a useful method for assessing which substances will be better tolerated by an individual patient. Clinicians who perform swallowing studies in tracheostomized patients should also include evaluations with a one-way speaking valve in place before making any decisions regarding the use of the valve as a means to reduce aspiration.

Obstruction of the tracheostomy tube is a life-threatening emergency. Usual manifestations of respiratory distress due to an obstructed tracheostomy tube include agitation, dyspnea, tachypnea, accessory muscle use, hypoxemia, or hypercapnia. The most common cause of tracheostomy tube obstruction is dried mucous plug. For preventing tube obstruction from mucous plugs, airway suctioning should be performed when indicated. Further, inhaled humidification and a proper patient hydration are essential for maintaining a patent airway. Finally, the use of tracheostomy tubes with an inner cannula can prevent tube obstruction by allowing regular inspection and cleaning or replacement of the inner cannula. Managing subjects having a tracheostomy without an inner cannula outside of an ICU may be hazardous (Fig. 15.3).

Use of an inappropriate model of tracheostomy tube could lead to the occlusion of the tube against the tracheal wall (Fig. 15.4a). Generally, a tracheostomy tube should extend at least 2–3 cm beyond the stoma and lie in the center of the tracheal lumen, at least 2 cm above the carina. The selection of a proper tube should be individualized and the angulation selected to avoid problems of tube occlusion (Fig. 15.4b).

Persons living with a tracheostomy generally express a high level of satisfaction with their lives. However, various areas of dissatisfaction have been identified among ventilator users. A proper assessment of healthcare quality of life may be helpful to better understand the needs of tracheostomized persons and improve their types of life. Healthcare professionals should be aware of early and late complications that may develop in these persons and use a multidisciplinary strategy to optimize their clinical management.