Timing of Tracheostomy
Reviewed and revised 13/7/2013
OVERVIEW
- Tracheostomy is performed in critically ill adults requiring prolonged invasive ventilation as a strategy to:
— reduce respiratory tract injury
— improve patient comfort, and/or
— to facilitate weaning - Timing of tracheostomy has been a subject of debate and may be considered as “early” at 10 days although these definitions may vary
- If it is clear that prolonged ventilation is inevitable (e.g. neuromuscular disorder such as GBS), it is reasonable to perform tracheostomy early
- However, clinicians appear to be poor at predicting which patients will need tracheostomy
RATIONALE
- There has been debate as to whether “early” trache may confer advantages of reduced morbidity and mortality
- Transoral endotracheal tubes are poorly tolerated, risk dislodgement, require more sedation and limit communication.
- Disadvantages of tracheostomy include airway trauma, bleeding and death and this may be increased by doing an “early” tracheostomy in patients who may otherwise die or be extubated before 10 days
- Early tracheostomy is a consideration in patients with neurological issues (brain injury, GBS, CVA etc.) and shortens time on ventilator and time in ICU
EVIDENCE
Overview
- Many studies and meta-analyses of variable quality have evaluated this issue
- Older observational studies and single center RCTs lent towards early tracheostomy having some benefits
- TrachMan is the first multi-center RCT to study tracheostomy timing
- Methodological issues include differences in “early” and “late” timing, prediction of which patients will require “long-term” ventilation, exclusion/inclusion of specific patient groups and diagnosis of end-points such as VAP
- Studies have evaluated patients with respiratory failure and not those intubated for neurological injury
Prior to 2012 (based on meta-analyses by Griffiths 2005 and Wang 2011) the weight of evidence suggested no difference in outcomes if early (< 7 days) or late (>7 days), including:
- short-term mortality or long-term mortality
- ventilator-associated pneumonia
- duration of mechanical ventilation or sedation (larger meta-analysis by Wang 2011 refutes Griffiths 2005)
- LOS in ICU or hospital (larger meta-analysis by Wang 2011 refutes Griffiths 2005)
- complications
Cochrane Systematic Review 2012
- considered 4 studies (latest 2010) to meet inclusion criteria
- concluded that quality of evidence to date was poor and results conflicting
TracMan Study 2013 (the first multi-center study assessing tracheostomy timing)
- MC RCT 87 UK ICUs
- n = 909 patients with respiratory failure expected to stay >/=7 days in ICU
- tracheostomy at 1-4 days v >10 days invasive ventilation
- Early tracheostomy associated with:
— shorter duration of sedation (6.6 vs 9.3 days in the deferred group)
— increased number of procedures and associated complications
— no beneficial effect on overall mortality (139 vs 141 deaths at 30 days, no difference at 2 years either) or ICU/hospital LOS - commentary and criticisms
— only 45% of patients in the late group actually underwent tracheostomy (no longer needed a tube!), whereas 92 % of early-group actually received a tracheostomy
— 7% of tracheostomy patients had significant bleeding
— underpowered due to ‘study fatigue’
— did not include patients requiring tracheostomy for reasons other than respiratory failure (e.g. neurological disorders)
AN APPROACH
- Overall lack of evidence to support early or late tracheostomy
- Tracheostomy is an invasive procedure with attendant risks and complications and needs appropriate expertise
- Given that clinicians are poor at predicting the need for tracheostomy, an early strategy inadvertently leads to a large increase in the number of unnecessary tracheostomies
- In general, tracheostomy should be delayed until at least 10 days after initiating mechanical ventilation
- Selected patients eg neurotrauma, GBS, stroke may benefit from early tracheostomy
- Timing of tracheostomy must be decided on a case-by-case basis
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
- Angus DC. When should a mechanically ventilated patient undergo tracheostomy? JAMA. 2013 May 22;309(20):2163-4. doi: 10.1001/jama.2013.6014. PubMed PMID: 23695486.
- Gomes Silva BN, Andriolo RB, Saconato H, Atallah AN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev. 2012 Mar 14;3:PMID: 22419322.
- Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005 May 28;330(7502):1243. PMC558092.
- Wang F, Wu Y, Bo L, Lou J, Zhu J, Chen F, Li J, Deng X. The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Chest. 2011 Dec;140(6):1456-65. Epub 2011 Sep 22. Review. PubMed PMID: 21940770.
- Young D, Harrison DA, Cuthbertson BH, Rowan K; TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013 May 22;309(20):2121-9. doi: 10.1001/jama.2013.5154. PubMed PMID: 23695482.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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