Quick Tip for Families in Intensive Care: Can a Tracheostomy Be Done with High PEEP (Positive End-Expiratory Pressure) in Intensive Care?

“Can a tracheostomy be done with high PEEP (Positive End-Expiratory Pressure) in intensive care?” That is what I’m going to answer today.

My name is Patrik Hutzel from intensivecarehotline.com, and this is another quick tip for families in intensive care.

One of our members and clients who has their son in intensive care has the following question, “My son remains ventilated with FiO2 (Fraction of Inspired Oxygen) down to 40%, but with high PEEP. A tracheostomy is scheduled for Friday, though he may still be borderline for the procedure due to high PEEP with 14.” PEEP stands for positive-end expiratory pressure. It’s the pressure left in the lungs at the end of the breath to help keep the airways and alveoli, also known as air sacs, open, so gas exchange can continue.

Lower PEEP, ideally less than 10, is usually preferred before a tracheostomy because it means the lungs are more stable and can tolerate the procedure more safely. Ongoing and continued coordination with ENT specialists, anesthetists and respiratory therapists are essential to optimize readiness for the tracheostomy procedure. So, that’s the situation with our member’s son in ICU.

I know if you’re watching this, it’s probably because your loved one is ventilated in ICU and the ICU team is either talking about a tracheostomy, or they’re delaying it using high PEEP as the main or one of the reasons. So, let me break this down for you in simple terms as I always do here at intensivecarehotline.com.

What is PEEP and why does it matter? PEEP stands for positive-end expiratory pressure. It’s the pressure left in the lungs at the end of exhalation, designed to keep the air sacs alveoli open. This is critical when someone’s lungs are very sick, like in ARDS (Acute Respiratory Distress Syndrome), pneumonia or COVID, because it helps with oxygenation. Generally speaking, a PEEP of 5 to 10 cmH2O (centimeters above water) is considered safe and stable. But, once your loved one needs a PEEP of 12, 14, or even higher, it means their lungs are still in trouble and dependent on that pressure to stay open.

When the ICU team says, “We’re not sure if a tracheostomy can be done at PEEP 14.” They’re not wrong, but they’re not telling you the full story either. This is what I’ve been saying on this channel for over a decade now, that ICU teams are not even telling you half of the story of what you actually need to know.

So, can a tracheostomy done with high PEEP?

Yes, it absolutely can, but it’s not ideal, so let me explain. A tracheostomy is often done when your loved one has been ventilated for more than 10 to 14 days, if your loved one is not waking up or it’s not strong enough to come off the ventilator. They’re failing spontaneous breathing trials or CPAP (continuous positive airway pressure) trials. The breathing tube in the mouth, also known as endotracheal...