Tracheotomy: Why and When
Abstract & Commentary
By Saadia R. Akhtar, MD, MSc, Idaho Pulmonary Associates, Boise, is Associate Editor for Critical Care Alert.
Dr. Akhtar reports no financial relationship to this field of study.
Synopsis: Tracheotomy at 6-8 days of intubation compared to 13-15 days of intubation did not reduce the incidence of ventilator-associated pneumonia.
Source: Terragni PP, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: A randomized controlled trial. JAMA 2010;303:1483-1489.
Terragni et al performed this 4-year-long multicenter randomized controlled trial to determine whether early (6-8 days) vs late (13-15 days) tracheotomy would reduce ventilator-associated pneumonia (VAP) incidence. Twelve Italian ICUs took part. Eligible patients were mechanically ventilated for 24 hours and had no evidence of pulmonary infection; exclusion criteria included COPD, prior tracheotomy, anatomic neck deformity, soft-tissue infection of the neck, certain cancers, and pregnancy.
At 48 hours after enrollment, an attending physician not involved in the patient's care reviewed each case to determine whether specific a priori-defined conditions such as significant improvement in respiratory status had occurred; if patients remained eligible, they were randomized to early vs late tracheotomy. Similar criteria were reviewed in the 24 hours prior to the scheduled tracheotomy; patients who did not go on to receive the procedure were still included in an intention-to-treat analysis. Use of semi-recumbent position and protocols for spontaneous breathing trials and sedation were required at all centers. Usual demographics and severity of illness scores, perioperative complications of tracheotomy, presence of VAP (defined by the Clinical Pulmonary Infection Score) up to 28 days, ventilator- and ICU-free days at 28 days, hospital length of stay, and overall survival (at day 28 and 1 year) were measured.
Of 600 enrolled patients, 419 were eligible for randomization and 264 received tracheotomy. All tracheotomies were percutaneous bedside procedures with a complication rate of 39% in both groups (usually stoma site inflammation or infection or minor bleeding). VAP incidence was not significantly different; 30 (14%) of 145 patients in the early group vs 44 (21%) of 119 patients in the late group developed VAP (the trend did favor the early group and the ultimate results suggest the trial may have been underpowered to prove this). The early tracheotomy group had more ventilator- and ICU-free days, and higher incidence of liberation from the ventilator and ICU discharge; there was no difference in hospital length of stay or overall survival.
Commentary
Tracheotomy provides a stable airway for long-term mechanical ventilatory support and management of pulmonary secretions. The optimal timing of tracheotomy for patients requiring ongoing mechanical ventilation remains unknown. Traditionally, experts have recommended considering tracheotomy at 2-3 weeks of intubation; observational studies suggest that in recent practice tracheotomy is performed earlier, on average at about 10 days.1 A key challenge in considering tracheotomy is that other than in some specific instances (for example, high cervical cord injury) there is no clear way early on to accurately identify patients who will need prolonged mechanical ventilation; this is illustrated in this study by the fact that only about two-thirds of patients randomized to receive tracheotomy (69% in the early group and 57% in the late group) actually required it.
Another critical question that remains is whether and when tracheotomy provides significant benefit that would justify its use. Tracheotomy for intubated patients is believed to generally increase patient comfort, may decrease need for sedatives, and may facilitate weaning and ultimate liberation from mechanical ventilation. However, there are no robust data to support this. There is very limited evidence to suggest that tracheotomy may decrease risk of VAP; Rumbak et al's 2004 study of tracheotomy in selected patients within 48 hours of initiation of mechanical ventilation revealed significant reductions in VAP incidence, ICU length of stay, and hospital mortality.2 Unfortunately, the selection criteria used in the study were not clearly defined and the key results (impact of early tracheotomy on VAP or mortality) have not been replicated. Some studies like Terragni et al's suggest earlier ventilator liberation or decreased ICU length of stay with early tracheotomy, but the importance of these is unclear when overall hospital length of stay and mortality are not impacted. The Terragni et al study differs greatly from and cannot be fairly compared to the Rumbak et al study; for instance, it may be argued that Terragni et al's "early" tracheotomy was not early enough to provide benefit.
Terragni et al's trial though is an important addition to the relatively small body of work on this topic. This study has several strengths including its size, overall design (randomization, clear definition for VAP, intention-to-treat analysis), and especially the use of clear, a priori-defined criteria for patient selection for tracheotomy. Further investigations of earlier tracheotomy using a similar approach to study design are warranted.
For now, I suggest that we continue our current practice of considering tracheotomy at 10+ days, recognizing that early tracheotomy may simply lead to a greater rate of tracheotomy without clear outcome benefit.
References
- Groves DS, Durbin CG Jr. Tracheostomy in the critically ill: Indications, timing and techniques. Curr Opin Crit Care 2007;13:90-97.
- Rumbak MJ, et al. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004;32:1689-1694.
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