debate regarding the indications , timing and technique for tracheostomy seems to have been raging ever since the procedure itself was first described in ancient egypt . the topic is of global interest , with research from a number of continents published during the past few months . these recently published papers add new information to the ' round table ' discussion that often goes with this controversial and topical subject . the first report , that by griffiths and coworkers , is a well researched systematic review and meta - analysis of five controlled studies that aimed to compare outcomes in critically ill patients undergoing artificial ventilation who received a tracheostomy early or late in their treatment . early tracheostomy was defined as up to 7 days following intubation , and late was defined as any time thereafter , if at all . the results showed that the duration of artificial ventilation was significantly lower in the early group , as was the length of intensive care unit ( icu ) stay . this has obvious implications for icu service provision and patient care , assuming that patients leave the icu to make equal recoveries in the two groups . however , it is difficult to analyze the impact of the results because there was significant heterogeneity between the inclusion and exclusion criteria of the studies . the hospital and 30-day mortality rates were no different between the two groups , and the risk for hospital - acquired pneumonia was also unchanged . a recent retrospective study conducted by chia - lin hsu and coworkers   investigated the optimal timing of tracheostomy formation , its impact on weaning from artificial ventilation , and the outcomes in patients in a medical icu at the 1500-bedded national taiwan university hospital . a total of 163 patients were included and divided into two groups : successful weaning and failure to wean . interestingly , the study discusses rates of associated complications of both percutaneous tracheostomies ( pts ) and surgical tracheostomies ( sts ) . the results showed that patients undergoing tracheostomy more than 3 weeks after intubation had higher icu mortality rates ( 28.3% versus 14.5% ) , higher rates of weaning failure ( 56.4% versus 30.2% ) and longer icu stays ( 14.2 days versus 10.8 days ) . this study also showed no difference in hospital mortality or nosocomial pneumonia during the weaning period . the authors concluded that tracheostomy after 21 days was associated with prolonged weaning , low weaning success rates and prolonged icu stay . in the third study , blot and melot   performed a retrospective analysis of the indications , timing and techniques of tracheostomy in 152 of the 708 french icus contacted . although the study had a relatively low reply rate ( 21.5% ) , it raised several interesting points . first , their definition of early tracheostomy was any time during the first 3 weeks after intubation . second , early tracheostomy was considered more often in nonteaching hospitals than in teaching hospitals . finally , sts were preferred over pts on surgical icus , and vice versa on medical icus . the authors concluded that long - term mechanical ventilation and failed extubation are the major indications for tracheostomy , and that tracheostomy is considered after a mean time of 3 weeks ( later than recommended by several consensus conferences ) . this prospective and retrospective observational study looked into the problem of tracheal stenosis caused by both pt and st individually . the investigators studied 29 patients presenting with tracheal stenosis to a uk national referral centre for tracheal reconstruction . following bronchoscopy preoperatively , they were able to assess the level , length and diameter of tracheal stenosis . this potentially life - threatening complication differs between the two groups in the above parameters , and therefore affects the treatment options available to the patient . the results showed that , compared with st , pt caused tracheal stenosis closer to the vocal cords ( 1.6 cm versus 3.4 cm ; p = 0.04 ) and the onset of tracheal stenosis occurred significantly quicker in the pt group ( 5 weeks versus 28.5 weeks ) . other quoted studies   support the finding that pt resulted in the tracheal wall ' caving in ' due to cartilage fracture significantly more often ( 50% versus < 2% ) . they also conclude that stenosis caused by pt occurred earlier and was more subglottic in nature compared with st . considerable variety in the timing of tracheostomy formation and the technique employed continues to exist , with a number of other publications both supporting and opposing the reports discussed above . intensive care practitioners clearly need further information and research to enable agreement to be reached on optimum tracheostomy care . from these studies , first , early tracheostomy ( < 7 days ) reduces the duration of artificial ventilation . third , patients undergoing tracheostomy after 3 weeks have a higher mortality , longer duration of ventilation , reduced successful weaning and longer icu stay . finally , pt causes more subglottic stenosis , with a quicker onset than with st . the much anticipated tracman study is now underway in the uk and will hopefully shed much more light on some of these issues . the vast majority of acute care hospitals in the uk are without on - site neurosurgical and neurointensive care facilities , necessitating expedient assessment of the brain - injured patient . those with severe traumatic brain injury ( tbi ; i.e. those with glasgow coma scale [ gcs ] score < 9 ) should undergo prompt transfer to a neurosurgical centre unless the prognosis is deemed to be hopeless . for those with mild ( gcs score 1415 ) and moderate ( gcs score 913 ) tbi , with no indication for immediate surgery , it may well be preferable that they stay in the admitting non - neurosurgical centre , given the demand on the all too few neurosurgical intensive care beds in the uk . subsequent monitoring , and therefore management , of this group of patients for secondary neurological deterioration is often suboptimal , given the inability to institute ' gold standard ' techniques such as intracranial pressure and jugular venous saturation monitoring , relying largely on clinical deterioration and computed tomography ( ct ) . a study by jaffres and coworkers   may represent a glimmer of light in this otherwise dark tunnel . in a prospective cohort study ( n = 78 ) set in the emergency room of a french district hospital , consecutive patients admitted with mild or moderate tbi underwent both ct and transcranial doppler ( tcd ) studies within 12 hours of admission . patients were then assessed , based on objective predefined criteria , for neurological deterioration 7 days after admission . the study attempted to correlate deterioration with initial measured variables : tcd , ct of the head , and biochemical , haematological and clinical measures , including a variety of composite scoring systems . seven ( 17% ) patients from the mild tbi group suffered deterioration . using univariate analysis the investigators demonstrated a significant difference in both ct findings and pulsatility index ( pi ) , as measured using tcd , in this subgroup compared with those who did not deteriorate . the injury severity score and maximal head abbreviated injury scale score were also significantly different . in pi and ct scoring were again significantly different in this group , along with the scoring systems mentioned above , initial gcs score and use of vasoactive drugs . jaffres and coworkers   go on to discuss the mechanisms by which pi is inversely related to cerebral perfusion pressure , and suggest that an appropriate combination of ct classification of tbi and measurement of pi on admission may be used to identify those at risk for subsequent deterioration . however , they point out that the feasibility and practicalities of early tcd are not inconsequential and that no threshold value for pi was identified in this small study . less invasive does not necessarily mean less useful , and cuschieri and coworkers    including dr e rivers , who utilized central venous oxygen saturations in early goal - directed therapy for severe sepsis    investigated the correlation between central venous  arterial carbon dioxide difference ( cv  aco2 ) , mixed venous  arterial carbon dioxide difference ( mv  aco2 ) and cardiac index ( ci ) in a group of mechanically ventilated patients with various diagnoses . for inclusion , patients needed to have a pulmonary artery catheter in situ . simultaneous arterial , mixed venous and central venous blood samples were obtained , along with measurement of cardiac indices using the thermodilution technique . the group found excellent correlation between cv  aco2 and mv  aco2 , with a correlation coefficient across all diagnoses and circulation types ( high , low and normal ) of 0.978 . furthermore , both were found to be inversely related to ci , with similar magnitudes of correlation , as compared with thermodilution - derived values . although the relationship between mv  aco2 and ci has long been recognized , as derived from the fick principle , this study suggests an easier and less invasive way to apply the same concept and , in conjunction with centrally derived arteriovenous oxygen differences , this may be very useful in the early assessment of global tissue hypoxia . finally , a thought - provoking review , although one that is not terribly helpful on a practical level , was recently published in chest . hennessy and colleagues carried out a thorough literature search on post - icu outcomes of elderly patients . the elderly population , variously defined as > 65 years , > 70 years , > 75 years or > 85 years , is set to grow massively , and this will undoubtedly have major implications for service provision . although many studies have scrutinized mortality rates from critical illness in the elderly , little is known about health - related quality of life ( hrqol ) and functional status in the survivors . the investigators identified only 16 studies ( involving a total of 3247 patients ) , only one of which was multicentred , addressing this issue . encouragingly , the majority of these studies reported good hrqol and functional status post - icu , although some discordance was evident , suggesting a change in conceptualization of quality of life following critical illness . however , the authors were unable to pool results and draw any significant conclusions because of poor quality study designs and lack of consensus on how to measure hrqol . they urge the need for further research , which must be well designed , prospective and use validated , reliable and responsive measures of hrqol . aco2 = central venous  arterial carbon dioxide difference ; gcs = glasgow coma scale ; hrqol = health related quality of life ; icu = intensive care unit ; mv aco2 = mixed venous  arterial carbon dioxide difference ; pi = pulsatility index ; pt = percutaneous tracheostomy ; st = surgical tracheostomy ; tbi = traumatic brain injury ; tcd = transcranial doppler .
tracheostomies have been around for close to 3000 years , so one would hope that the controversies might have been thrashed out by now , but apparently not . 
 judging by some recent publications it would appear that we still do not know when or how to insert them . 
 monitoring is fundamental to critical care ; two papers describe novel / modified techniques for assessing traumatic brain injury and cardiac output . 
 the intensive care unit imposes a heavy treatment burden , particularly on the elderly . 
 what impact does this have on the lives of the survivors ?