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My 87 year old grandmother was intubated due to septic shock 11 days ago. She has since regained consciousness, is able to write, is off vasopressors for low BP, and they think the infection is almost gone. She wrote she wanted a tracheostomy so she can communicate better and be transferred to a rehab for ventilator dependent patients. They say they don’t want to do this now and are pushing to extubate and let nature take its course. However, I can’t seem to understand why a tracheostomy is so much more dangerous than that. Are there risks or contraindications that I’m missing here? Does the procedure have a high mortality rate (I’m talking while on the table)?

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First of all, biggest thanks & kudos to MACin CT & PamZ for their insight as RRTs for this forum. Priceless especially in this time of Covid.

Second, Chapdelaine, I’d suggest whomever is your Grans MedicalDPOA clearly speak with her care team as to what may have happened as an effect of her sepsis. Septic shock / sepsis is a very big deal for anyone who goes thru this but especially for elderly patients. My MIL - had been in a SNF then got very ill and hospitalized- had this and although she was able to get various antibiotics to quell the infections, the sepsis affected her organs. It was described to us as she was undergoing “cascading organ failure” with some days pretty ok and others not so. And it all would eventually becomes MODS / Multiple Organ Dysfunction Syndrome. Mil was discharged from hospital to an in-unit hospice that was in its own building separate but adjacent to the hospital. It was a Medicare covered benefit. The reason not to trach/vent was that MODS was happening and would not increase her quality of life or lifespan. It wasn’t that she couldn’t successfully go thru the procedureS but it was more than the procedures would be of no real benefit. It was letting nature take its course; she was made comfortable with medications and high flow O2. The impression I got was that once MODS is happening for someone elderly, they are not expected to live very long. So for MIL, hospice was the next step for her care plan. For us, mil was on pretty serious black box drugs - fenantyl lilipops among other meds - and had had highly contagious infections so being in an in-unit hospice was the best place for her as those places have the medications and staff trained for delivering them; the discharge planner at the hospital took care of all this. It was pretty seamless transfer.
If hospice has not been brought up an an option for your grandmother, please ask about if it’s (hospice) an option to consider.
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My daughter worked rehabs fo 20 years. The ones she worked for did not take trach patients because of the care needed. One reason, infection.

"she can learn to speak with a valve then she is off of the ventilator. Plus she can practice swallowing" Is she going to be able to learn to do this?

For now, I would go with the Doctor's.
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Minor bleeding is a side effect. Pamzimmrrt and I are Respiratory Therapists.. If they remove the tube to see if she can handle it, a re intubation has a higher mortality risk. It sounds like the doctors offering to let nature take its course may mean that they may expect that she may not be around next year. If she gets a trach, then when she is weaned off and she goes into respiratory failure while the trach is still in, the ventilator only has to be hooked up again. Yes she can learn to speak with a valve then she is off of the ventilator. Plus she can practice swallowing. This allows for a more rapid chance to come off of the ventilator.
On the other side of the coin, if she goes to LTC with a ventilator, there is a wait to find a bed and the facility that can take her may be many miles away from home. If she lives in CT, like you, she is at an advantage. There are 2 specialty places in Wallingford and New Britain but it may take about 2 weeks for a bed to open.Generally a ventilator patient going to LTC has a 1 in 3 chance to come off the vent permanently. Also if grandma has been in bed for a month or more then a nursing home may become a permanent reality. She is already at day 11. Her Medicare rehab will start having out of pocket costs within a few weeks. Ask the social worker about it so that you have a clear understanding. Do you feel she may be on the lucky side? Also she is able to communicate. If she is competent, you may have to go with her feelings.
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Not in and of itself,, we do them at the bedside at my hospital much more often than in the OR. BUT it is still surgery, and if they are telling you to "let nature take it's course" that sounds like they don't expect her to last very long either way, I am sorry to say. Before Covid we pushed for trachs at 10 days of intubation, after that the vocal cords become compromised. I am a fan of the trach,, easier to get to rehab and faster to get off the Vent. And they are easily reversed if the Pt improves and gets off the vent!
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