Early vs late tracheotomy in ICU patients.

ENDOTRACHEAL INTUBATION IS THE MOST COMMON PROcedureforairwaycontrolforpatientsrequiringmechanical ventilation. Extubation is performed once patients haveimprovedsothatmechanicalventilationcanbediscontinued.Forpatientswhorequireprolongedmechanicalventilation, replacement of the endotracheal tube with a tracheotomy is often considered. The most common reason for tracheotomyinsertionintheintensivecareunit(ICU)istoprovide accessforprolongedmechanicalventilation.Fromobservational data,between6%and11%ofmechanicallyventilatedpatients receive a tracheotomy after a median of 9 to 12 days; however, there is significantvariabilityaroundbothpatientselectionand timing. Tracheotomy practice is variable in large part because what constitutes prolonged mechanical ventilation (ie, the optimal timing for tracheotomy) is not known. Defining and predicting the need for prolonged ventilation has been a major methodologicalchallenge.Researchontracheotomytiminginvolves evaluating a 2-part study question. First, is it possible to prospectivelyidentifypatientswhowillrequireprolongedmechanicalventilationandcouldpotentiallybenefit fromtracheotomy? Second,does tracheotomyactuallyprovidebenefit for thesepatients? The key challenge is to avoid performing tracheotomy onpatientswhoareclosetoextubation(ie,anunnecessaryprocedure)orwhoarenot likely tosurvive(ie, a futileprocedure), and instead find patients who might benefit. The anticipated benefits of tracheotomy for patients undergoing prolonged ventilation include improved patient comfort due to reduced oropharyngeal and laryngeal stimulation (and possibly less damage to the larynx), which may in turn reduce sedation requirements and possibly delirium. These and other posited advantages, including improved pulmonary toilet and decreased resistance to breathing, might accelerate weaning from mechanical ventilation, decrease the risk ofventilator-associatedpneumonia (VAP), andperhaps shorten the duration of mechanical ventilation. Thus, early tracheotomy in place of longer-term oral endotracheal intubation could conceivably lead to desirable downstream effects including shorter ICU and hospital stays, reduced costs, or even lower mortality. The problem with routinely performing tracheotomy early is that some patients who do not require tracheotomy undergo an unnecessary procedure. In addition, the presence of a tracheotomy may convey a sense of greater medical vulnerability and need, and could result in such patients being transferred to long-term care facilities, when this otherwise might have been avoided. In this issueof JAMA,Terragniandcolleagues report theresults of a trial of tracheotomy timing from 12 Italian ICUs in patients with ongoing severe respiratory failure 24 hours after intubation. Of 600 patients studied, 419 did not significantly improveorworsenaccordingtostandardizedcriteriaevaluated 48 hours after enrollment. These patients were randomized to receivepercutaneoustracheotomyafter6to8days(earlygroup) or after 13 to 15 days (late group) of laryngeal intubation. The primary endpoint was development of VAP; there was a statisticallynonsignificanttrendtowardareductioninVAPwithearly tracheotomy.However,evenif this trendwerereal(andthetrial wasunderpoweredtoconfirmit), theclinicalbenefitwouldappearsmall;earliertracheotomywasnotassociatedwithreductions in mortality (at 28 days or 1 year) or hospital length of stay. Although itmaybeseenas largelynegative, this study is importantandhasseveral strengths. It is the largestpublishedtrial todatetoevaluatetracheotomytiming.MonitoringforVAPwas standardized and assessed by blinded adjudicators in an effort tominimizeascertainmentbias.Comparedwithprevioustrials, thealgorithmusedtopredictwhichpatientswouldrequireprolonged mechanical ventilation was explicit, stepwise, and reasonablyaccurate.This is importantbecause the inability topredict which patients will require ongoing mechanical ventilationhasledtotheprematureterminationofsometrials,whereas unclear patient selection processes have limited the generalizability of others. Even in the current trial by Terragni et al, many of the randomized patients (31% in the early group and 43% in the late group) did not undergo tracheotomy. The reasons they did not were evenly split between actual or impending extubation vs actual or impending death. This reinforces thepointthatastrategyofearlytracheotomyis inevitablyastrategy of more vs fewer tracheotomy procedures. This trial supports the findings of previous studies and meta-analyses suggesting that earlier tracheotomy is unlikely to reduce mortality. Even though ventilator-free days