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Todd Fraser wrote 07-26-2010 12:28:45 pm
"A recent JAMA article (Terragni et al. JAMA, April 21, 2010--Vol 303, No. 15) compared the early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients. From 2004 to 2008, a total of 600 adult patients were enrolled from 12 Italian ICUs. Of 209 patients randomly assigned to early tracheotomy (6-8 days), 145 received tracheotomy, as did 119 of 210 randomly assigned to late tracheotomy(13-15 days). In the early tracheotomy group, ventilator-associated pneumonia developed in 30 patients (14%; 95% confidence interval [CI], 10% - 19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15% - 26%; P = .07). The hazard ratio (HR) for ventilator-associated pneumonia during the 28 days immediately after randomization was 0.66 (95% CI, 0.42 - 1.04). During the same period, the HR for remaining connected to the ventilator was 0.70 (95% CI, 0.56 - 0.87); for remaining in the ICU, 0.73 (95% CI, 0.55 - 0.97); and for death, 0.80 (95% CI, 0.56 - 1.15). The authors concluded that in intubated and mechanically ventilated adult ICU patients with a high mortality rate, early tracheotomy (performed after 6-8 days of endotracheal intubation) did not result in a significant reduction in incidence of VAP compared with late tracheotomy (performed after 13-15 days of endotracheal intubation). Although the number of ICU-free and ventilator-free days was higher in the early tracheotomy group than in the late tracheotomy group, long-term outcome di

Todd Fraser wrote 04-26-2011 06:11:57 pm
An interesting paper on this topic just released, finding that there was no increase in ventilator free days, reduction in mortality or reduction in VAP with early trachy.

This seems to be one of those things that is sooo attractive in theory, but is having a very hard time proving itself in the literature

Michael Corkeron wrote 10-20-2010 10:11:28 pm
Timing of tracheostomy remains a vexed issue with wide variation in practice and some forcefully held opinions. The evidence is mixed and beset by issues of definition of "early", endpoints (is incidence of VAP a meaningful endpoint?), heterogeneity and power. Hard to know what the differences really are given the existing evidence base.

I think one of the instructive aspects of the question whether early tracheostomy reduces ICU resource utilisation is the institution-dependent aspects of this practice. If you are in a hospital in which early discharge is facilitated by trache there may be very positive influences on LOS; conversely if there are conservative policies re ward admission with trache in situ it may reduce ventilation time (still not enough data to call this, but this is a repeated trend in studies) but have little impact on ICU LOS . The quality of follow up care on the ward is crucial as to risk-benefit of the procedure. It should not need to be said that operators need clear physiological minima that need to be met before the patient is deemed suitable for the procedure, though again these are typically historically /clinically based.

This is a great example of where a point intervention in the ICU needs to be seen in context of the institution, and changes in care processes have to be adopted with a whole-of-admission approach, and audited similarly.

The existing evidence re the procedure itself needs thus to be seen in context. I have worked

Todd Fraser from Australia wrote 07-08-2013 07:07:39 pm
Another interesting recent publication on this topic in our Journal Club just recently seems to suggest there is little benefit in insertion of a tracheostomy very early, and we still are very bad at predicting how long someone will be intubated.