Tracheostomy Literature Summaries

TRACHEOSTOMY: OVERVIEW OF EVIDENCE

Summary of evidence for PDT versus open tracheostomy

  • no difference in ICU or hospital mortality
  • no difference in duration of ventilation
  • no difference in nosocomial pneumonia
  • most studies suggest lower rates of complications such as infection, bleeding and scarring

Summary of evidence for early versus late tracheostomy

  • no difference in outcomes if early (< 7 days) or late (>7 days)
  • no difference in short-term mortality or long-term mortality
  • no difference in ventilator-associated pneumonia
  • no difference in duration of mechanical ventilation or sedation (larger meta-analysis by Wang 2011 refutes Griffiths 2005)
  • no difference in duration of stay in ICU or hospital (larger meta-analysis by Wang 2011 refutes Griffiths 2005)
  • no difference in complications

NB. PDT = percutaneous dilatational tracheostomy (Ciaglia technique)

More detail is provided in Tracheostomy literature summaries

PDT VERSUS OPEN TRACHEOSTOMY

1999 – Dulguerov et al, Critical Care Medicine

  • open vs perc.
  • PDT+ Bronch = lowest complication rate in percutaneous group
  • percutaneous group = lower post op but higher perioperative complication rate

2000 – Cheng et al, Ann Otol Rhinol Laryngol

  • meta-analysis (including 4 RCT’s)
  • open vs PDT
  • PDT = lower risk of infection and bleeding
  • PDT + Bronch as safe as open tracheostomy

2000 – Freeman et al, Chest

  • meta-analysis (including 5 RCT’s)
  • open vs PDT
  • no overall difference in mortality rate
  • PDT: quicker, lower post op complications, less bleeding

2006 – Delaney et al, Crit Care Med

  • large SR of 17 RCTs
  • n = 1212
  • PDT vs open
  • PDT: lower wound infection
  • no difference in bleeding and complication rates
  • subgroup analysis suggested PDT had lower bleeding and mortality than open performed in operating theatre

2007 – Higgins et al, Laryngoscope

  • PDT vs open
  • SR of 15 RCTs
  • n = ~1000
  • PDT: less infection, less scarring, trend towards lower complication rate, faster, cheaper, lower conversion rate
  • PDT: higher accidental decannulation
  • no difference in bleeding, subglottic stenosis, death

EARLY VERSUS LATE TRACHEOSTOMY

Young et al, TracMan Study, JAMA 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
  • randomised to tracheostomy at 1-4 days or at >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)

2011 — Wang et al. The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Chest.

  • early or late tracheotomy for critically ill ventilated patients
  • SR of 7 trials
  • n = 1,044
  • no difference in short-term mortality or long-term mortality
  • no difference in ventilator-associated pneumonia
  • no difference in duration of mechanical ventilation or sedation
  • no difference in duration of stay in ICU or hospital
  • no difference in complications

2005 — Griffiths, J et al. “Systematic review and meta-analysis of the timing of tracheostomy in adult patients undergoing artificial ventilation” BMJ 330:1243-1247

  • early vs later tracheostomy or prolonged ventilation
  • n = 406
  • Systematic review of 5 trials
  • no mortality difference
  • no difference in risk of pneumonia
  • significant decrease in duration of mechanical ventilation
  • significant decrease in duration of ICU stay

References and links

LITFL

Journal Articles

  • Cheng E, Fee WE Jr. Dilatational versus standard tracheostomy: ameta-analysis. Ann Otol Rhinol Laryngol. 2000 Sep;109(9):803-7. PubMed PMID:11007080.
  • Clec’h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, Azoulay E, Adrie C, Jamali S, Zaccaria I, Cohen Y, Timsit JF. Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med. 2007 Jan;35(1):132-8. PubMed PMID: 17133180.
  • Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55. Review. PubMed PMID: 16606435; PubMed Central PMCID: PMC1550905.
  • De Leyn P, Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y, Van Meerhaeghe A, Van Schil P; Belgian Association of Pneumology and Belgian Association of Cardiothoracic Surgery. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg. 2007 Sep;32(3):412-21. Epub 2007 Jun 27. Review. PubMed PMID: 17588767. [Free Fulltext]
  • Dulguerov P, Gysin C, Perneger TV, Chevrolet JC. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med. 1999 Aug;27(8):1617-25. PubMed PMID: 10470774.
  • Engels PT, Bagshaw SM, Meier M, Brindley PG. Tracheostomy: from insertion to decannulation. Can J Surg. 2009 Oct;52(5):427-33. Review. PubMed PMID: 19865580; PubMed Central PMCID: PMC2769112.
  • Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. 2000 Nov;118(5):1412-8. PubMed PMID: 11083694. [fulltext]
  • 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. Epub 2005 May 18. Review. PubMed PMID: 15901643; PubMed Central PMCID: PMC558092.
  • Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005 Apr;50(4):497-510. Review. PubMed PMID: 15807912. [Free Fulltext]
  • Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007 Mar;117(3):447-54. Review. PubMed PMID: 17334304.
  • 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.

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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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