does critically ill patient get benefit from early tracheostomy?

1. By:
Mohamed Abuelnaga
Suez canal university

2. Early tracheostomy :
-may decrease the duration of mechanical
ventilation, sedation exposure, and intensive care
stay, possibly resulting in improved clinical
outcomes.
Late tracheostomy:
-may prevent early unnecessary tracheostomy
The evidence is conflicting

4. in 1989, a Consensus Conference on Artificial
Airways in Patients Receiving Mechanical
Ventilation made the following guidelines :
1. For anticipated need of the artificial airway up
to 10 days, the translaryngeal route is preferred.
2. For anticipated need ofthe artificial airway for
greater than 21 days, tracheotomy is preferred.

7.  These two independent
retrospective European postal
surveys showed that the timing
for performing tracheostomy is
not fully standardized in Europe
either.

9. A retrospective analysis of 118 trauma patients
who underwent tracheostomy for airway and
pulmonary management was undertaken.
Timing of the procedure was defined as early (0-3
days), intermediate (4-7 days), and late > 7 days).
Our study suggests that early tracheostomy may
decrease pulmonary septic complications in
trauma patients.
Although no change in length of stay can be
attributed to the early performance of
tracheostomy, preventing pneumonia in the
intensive care unit setting with its resulting high
expense is beneficial.

11.  Results:
 Rumbak et al reported that in patients
predicted to require mechanical ventilation
for 2 or more weeks, early (within the first 48
hours) tracheostomy had significantly less 30
day mortality rate, ventilator- associated
pneumonia, and accidental extubations, than
prolonged translaryngeal intubation (<14
days).

16.  There is a growing volume of
published data that suggests that
relatively early tracheostomy (possibly
>7 days) may indeed decrease ICU
days, ventilator days, and/or
ventilator-associated pneumonia, all
outcomes that translate into a direct
patient benefit.

18. Conclusion:
in mechanically ventilated adult ICU patients,
there was no statistically significant
difference in the rates of VAP with early
tracheotomy (after 6-8 days of laryngeal
intubation) versus late tracheotomy (after 13-
15 days of laryngeal intubation).

21. In this study , the medical records of patients
who underwent tracheostomy in the medical
ICU of a tertiary medical centre from July
1998 to June 2001 were reviewed.

22. Conclusion:
"In critically ill adult patients requiring prolonged mechanical
ventilation, tracheotomy performed at an early stage(within the first
week) may shorten the duration of artificial ventilation and length of
stay in intensive care "(level 1B)

23. The TracMan study , an open multi-centred randomised
clinical trial conducted between 2004 and 2011 involving 70
adult general and two cardiothoracic ICUs units in 13
university and 59 non-university hospitals, was carried out in
the United Kingdom to assess the impact of early (day 1-4 of
ICU admission) versus late (day 10 or later) tracheostomy.
The study included 909 patients randomised to early(n=455)
or late (n=454) tracheostomy.

24. Patient characteristics were similar across both groups, with
respiratory failure the most common cause of admission to
the ICU.
There was no significant difference in mortality between the
early and late tracheostomy groups at 30 days (139 versus 141
deaths) or at 2 years post randomisation, with a 74% follow up
rate.
There was also no significant difference in ICU or hospital
length of stay and no significant difference in antibiotic
use.
However, mean days of sedation were predictably reduced
to 6.6 days in the early group compared with 9.3 days in the
late group.

25. Systematic review and meta-analysis of randomized trials
Patients allocated to tracheostomy within 10 days of start of
mechanical ventilation was compared with placement of
tracheostomy after 10 days if still required

26.  4482 publications were identified and 14 trials
enrolling 2406 patients were included
 Primary outcomes were mortality within 60 days, and
duration of mechanical ventilation, sedation, and
intensive care unit stay.
 Secondary outcomes were the number of
tracheostomy procedures performed, and incidence
of VAP and mortality at longest follow-up.

34.  1- as a meta-analysis our research is retrospective
and subject to the methodological soundness of
the individual studies.
 2-We have tried to keep the probability of bias to
a minimum by developing a detailed protocol a
priori, carrying out a thorough search for published
and unpublished data, and using explicit criteria
for study selection, data collection, and data
analysis.

35.  As a result, we consider that our robust
approach has resulted in recommendations
directly applicable to clinical practice.
 Secondly, our review includes trials from
1976 to 2012. There has been an enormous
change in clinical practice during this
period, which could account for the
negative findings.

36.  Thirdly, there is little guidance on the prediction of
prolonged mechanical ventilation and the timing of
tracheostomy insertion is based on this assessment.
 Overall, all of the included studies have different
definitions of early tracheostomy and prolonged
mechanical ventilation.
 Consequently, we can only provide data on the
safety and effectiveness of early tracheostomy on
reduction of mortality compared with standard

37.  It is clear that continued research is needed to find
appropriate tools to predict the duration of mechanical
ventilation on the ICU.
 Future research should be aimed at standardizing the
definitions of early tracheostomy and examining if it
would be beneficial in certain patient groups
 The safety and late complication rates of tracheostomy
are poorly understood and further efforts should be
directed to examine the wider socio-economic
consequences of the procedure.

38. 1- early tracheostomy does not carry any
mortality advantage in the heterogeneous patient
population included in this work.
2- early tracheostomy does not help to reduce
length of ICU stay or incidence of VAP.
3-early tracheostomy leads to reduction in the
duration of sedative use when performing early
tracheostomy, although this is not accompanied
by a reduction in duration of mechanical
ventilation.
4-early tracheostomy leads to unnecessarily high
procedural rate with associated increased
morbidity and possibly financial cost.

39. 1-tracheostomy before Day 10 of mechanical
ventilation should be avoided.
2-Further research with adequately powered
and methodologically sound clinical trials
should address the questions if any particular
subgroups of critically ill patients would
benefit from the procedure and to
understand the longer term effects of the
intervention.

41. In our own ICU, we usually perform tracheostomy as
soon as any of the following indications is met:
1. The specific diagnosis and clinical scenario clearly
suggest with reasonable certainty that the need for
mechanical ventilation will exceed 10 to 14 days
2. The patient has objectively proven by nerve
conduction studies and/or EMG, and by neurologic
examination, to have severe polyneuropathy and/or
myopathy with profound muscle weakness that
cannot be reasonably expected to recover in a few
days, or with moderate weakness only but the
patient has failed one weaning attempt.

42. 3. Any patient with thick secretions who has
already failed an attempt to extubate because of
those secretions or in whom the physician is
reluctant to attempt extubation because of a weak
cough and limited respiratory reserve.
4. Any patient with morbid obesity and known
severe sleep apnea who fails one weaning attempt
using Bi-PAP.
5. Any patient who fails 2 weaning attempts or has
a life threatening complication with the first failure,
ie, arrhythmias, angina, exceedingly difficult
reintubation, transient ischemic attack, etc.

43. 6. The patient has severe and irreversible
neurologic deficit that interferes with
breathing, for example, a high C-spine
transection and/or a neurologic event that
results in a profoundly impaired level of
consciousness such as a thalamic stroke.
7. Known upper airway obstruction caused by,
but not limited to, pharyngeal tumor with ball-
valve effect, fractured arytenoid cartilages, or
paralyzed vocal cords