Deciding Between Intubation and Tracheostomy for Elderly Patients

Intubation or not?

Dear Dr.
Jiang,
I would like to seek your advice regarding my grandmother's condition.
She is currently 78 years old and has a history of hypertension.
Two months ago, she suffered from severe herpes zoster (commonly known as shingles) in her abdomen, which led to a loss of appetite.
A month ago, due to her weakness, she was hospitalized for intravenous fluids, where she was diagnosed with diabetes.
After three days of treatment at a larger hospital, she underwent surgery for peritonitis, during which a perforation in her colon was discovered, resulting in the removal of a section of her colon.
The doctors indicated that her bowel wall was too thin to be reconnected immediately and that we would need to wait for the bowel wall to heal before performing another anastomosis.
Consequently, she was admitted to the intensive care unit and had a breathing tube inserted to assist with suctioning secretions.
Within a week, there was an attempt to remove the breathing tube, but the nurses stated that my grandmother was still unable to cough up secretions on her own, so the tube was reinserted.
Subsequently, she developed a fever due to an infection from the intestinal contents and underwent two cleaning surgeries (approximately one week apart).
During the second cleaning, the doctor mentioned that the breathing tube should not remain in place for too long as it could harm her lungs, and suggested performing a tracheostomy (since it would only require one anesthesia session).
The doctor communicated with the family for a long time, but we strongly opposed the tracheostomy at that time.

This is because two relatives of ours had strokes and later underwent tracheostomy; although they were kept alive, they have been in nursing homes for many years—one for four years and the other for ten years—both still spending their days in a nursing facility.
We do not want our grandmother to spend her later years in such a manner.
While the financial aspect is one concern, it is particularly important to us that she previously expressed her wish not to live in a nursing home.
However, seeing my grandmother with the tube in her mouth, which has caused inflammation of her lips and tongue, and last Saturday (after the third surgery), we discovered that her mouth was bleeding.
The nurse explained that this was due to her discomfort from biting the tube.
They hope the family will agree to the tracheostomy, as the tube cannot remain in place for too long (it has already been three weeks), and it could also alleviate her suffering.
We are now in a dilemma.
On one hand, we fear that if she undergoes a tracheostomy, her wounds may still not heal.
If we do not proceed with treatment, would that not cause her more pain? On the other hand, if her wounds heal and her colon can be reconnected, we wonder if the tracheostomy tube can be removed later, allowing her to breathe independently.
If she cannot breathe or cough on her own, will she have to spend the rest of her life in a nursing home?
I have written so much, and I hope Dr.
Jiang can understand my concerns.
Is a tracheostomy absolutely necessary, or are there other options? Additionally, my grandmother's surgical wound has been healing poorly, and she previously had infected tissue scraped away.
Is this related to her diabetes?
I apologize if I have directed my questions to the wrong specialty, whether it be gastroenterology or pulmonology (regarding the intubation issue).
I would greatly appreciate any assistance you can provide to help my grandmother, as she is my dearest grandmother.
Thank you for your kindness and support!

Jade, 70~79 year old female. Ask Date: 2003/07/28

Dr. Jiang Zhenyuan reply Pulmonology

Basically, if a patient has been intubated for more than two weeks, recommending a tracheostomy is a reasonable course of action.
The benefits include: 1.
It can reduce airway resistance.
2.
It facilitates suctioning, which can actually alleviate the patient's suffering.
However, the idea of creating an incision in the trachea may be difficult for family members to accept.
As for the patient's prognosis, we can only take it one step at a time and do our best.
Essentially, respiratory therapy is an adjunctive treatment that allows time to address the underlying disease, so treating the underlying condition is the fundamental approach.
Dr.
Wu Ying-Hsun

Reply Date: 2003/07/28

More Info

Deciding between intubation and tracheostomy for elderly patients, especially in complex medical situations like your grandmother's, is indeed a challenging and emotional decision. Your grandmother's medical history, including hypertension, recent abdominal surgery, and the complications arising from her condition, adds layers of complexity to her care.

Intubation is typically a temporary measure used to secure the airway and provide mechanical ventilation. It is often employed in acute situations where a patient cannot breathe adequately on their own. However, prolonged intubation can lead to complications, such as damage to the vocal cords, trachea, or lungs, as you've observed with your grandmother's discomfort and oral injuries from the endotracheal tube.

On the other hand, a tracheostomy involves creating an opening in the neck to place a tube directly into the trachea. This procedure is generally recommended when a patient requires prolonged respiratory support, typically more than two weeks. The benefits of a tracheostomy include easier access for suctioning secretions, reduced airway resistance, and improved comfort for the patient. It can also facilitate better oral hygiene and allow for easier weaning off mechanical ventilation in some cases.

Your concerns about the long-term implications of a tracheostomy are valid, especially given your family's previous experiences. It is crucial to understand that while a tracheostomy can improve comfort and reduce the risk of complications associated with prolonged intubation, it does not guarantee a return to normal respiratory function or quality of life. Each patient's situation is unique, and outcomes can vary widely based on underlying health conditions, the reason for respiratory failure, and the patient's overall prognosis.

Regarding your grandmother's healing process, diabetes can significantly impact wound healing. Elevated blood sugar levels can impair the body's ability to heal and increase the risk of infections, which may explain the ongoing issues with her surgical site. Managing her diabetes effectively is crucial to improving her overall health and recovery prospects.

In making this decision, it is essential to have open and honest discussions with her healthcare team. They can provide insights into her current condition, the potential benefits and risks of a tracheostomy versus continued intubation, and what to expect in terms of recovery and quality of life. You might also consider involving a palliative care team, which can help address your grandmother's comfort and quality of life concerns, regardless of the medical interventions being considered.

Ultimately, the decision should align with your grandmother's wishes and values, as well as the family's understanding of her prognosis and potential outcomes. It is a difficult situation, but ensuring that her care aligns with her preferences and quality of life considerations is paramount.

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