Monday September 01, 2008
Early vs Late Tracheostomy !

It is a common understanding that all prolong ventilated patients eventually require tracheostomy but so far there is no strong evidence-based guidelines for early vs late tracheostomy, and the appropriate timing is still controversial.

Earlier, one study looked into a total of 163 relevant ICU patients and suggests that: "Tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality". 1

Another meta-analysis of five studies with 406 patients was published in BMJ and found that "In adult ICU patients, who require prolonged mechanical ventilation, performing an early tracheostomy, may shorten ventilator days and length of stay in ICU but does not alter mortality or the risk of pneumonia". 2

But one very large study failed to show marked benefit. This month a retrospective cohort analysis of about 11,000 patients from 114 acute care hospitals in Ontario, Canada has been published to determine whether earlier tracheostomy is associated with greater long-term survival. 3

Measurements: For crude analyses, tracheostomy timing was classified as early ( less than10 days) vs. late ( more than 10 days) with mortality measured at multiple follow-up intervals.

Results: A total of 10,927 patients received tracheostomy during the study, of which one-third (n = 3758) were early and two-thirds late (n = 7169)

Patients receiving early tracheostomy had little lower unadjusted 90-day (34.8% vs. 36.9%), 1 yr (46.5% vs. 49.8%), and study mortality (63.9% vs. 67.2%)

Conclusions: Physicians performing early tracheostomy should not anticipate a large potential survival benefit. Future research should concentrate on identifying which patients will receive the most benefit.


Refrences: Click to get abstract/article.

1. Timing of Tracheostomy as a Determinant of Weaning Success in Critically Ill Patients: A Retrospective Study - Crit Care. 2005; 9 (1): R46-R52
2. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation - BMJ 2005;330:1243 (28 May)
3. The effect of tracheostomy timing during critical illness on long-term survival - Critical Care Medicine. 36(9):2547-2557, September 2008