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Early Tracheostomy Gives Better Outcomes for Critically Ill

Patients
By Will Boggs MD July 21, 2014
NEW YORK (Reuters Health) - Early tracheostomy appears to offer better outcomes than late or no tracheostomy for patients in
the ICU, according to a meta-analysis of 15 trials.

Tracheostomy provides airway security, enhanced patient comfort, and easier weaning from mechanical ventilation, but the
procedure is not free of risk, and optimal timing for placement remains controversial.

Dr. Ilias I. Siempos from Brigham and Women's Hospital in Boston and colleagues conducted a systematic review and meta-
analysis to investigate whether early tracheostomy (within the first week of mechanical ventilation) has any mortality benefit
compared with late or no tracheostomy in critically ill patients who need mechanical ventilation.

In the 13 trials that reported all-cause mortality, assignment to early tracheostomy was associated with a 28% lower risk of all-
cause mortality in the ICU, compared with assignment to late/no tracheostomy (p=0.04), according to the June 27th Lancet
Respiratory Medicine online report.

The mortality reduction was even greater (32%) in the eight trials that had a low risk of bias (p=0.02).

In mechanically ventilated patients, the incidence of ventilator-associated pneumonia was 40% lower in patients assigned to the
early group vs the late/no tracheostomy group (p=0.01).

Tracheostomy-related complications did not differ between the early and late/no tracheostomy groups, but patients assigned to
the early tracheostomy group had a two-day shorter time to mobility than patients assigned to the late/no tracheostomy group
(p<0.001).

By one year, there was no difference in mortality between the tracheostomy groups.

"Our findings are not in line with those of recent trials in which early tracheostomy offered no survival benefit compared with
postponing tracheostomy for at least 10 days after the start of mechanical ventilation," the researchers conclude.

"However," they add, "the scarcity of a beneficial effect on long-term mortality and the potential complications associated with
tracheostomy need careful consideration; thus, further studies focusing on long-term outcomes are warranted."

Dr. Victoria A. McCredie and Dr. Neill K. J. Adhikari from Sunnybrook Health Sciences Center and the University of Toronto wrote
a commentary related to this report. In a joint email to Reuters Health, they wrote, "Physicians should interpret the finding of lower
ICU mortality in the early tracheostomy group with caution. One of the main challenges is that at the beginning of an ICU
admission, the ability of physicians to predict who will actually need mechanical ventilation beyond one week is modest.
Therefore, a commitment to early tracheostomy represents a commitment to performing tracheostomies in more patients, a
strategy that has similar long-term outcomes compared to waiting longer to perform the procedure in a more select group of
patients."

"Until a robust tool exists that reliably predicts the need for prolonged ventilation, we suggest that tracheostomy should be
delayed until at least after the first week of initiating mechanical ventilation," they added.

And, Dr. McCredie and Dr. Adhikari pointed out in their email, "like any invasive procedure, tracheostomy confers short- and long-
term procedural risks, including infection, tracheal injury, loss of airway, bleeding, and rarely death. These complications should
be made explicit during the consent process."

Dr. Siempos did not respond to a request for comments.

SOURCE: http://bit.ly/1tePjXJ

Lancet Respir Med 2014.

Reuters Health Information 2014

Cite this article: Early Tracheostomy Gives Better Outcomes for Critically Ill Patients. Medscape. Jul 18, 2014.