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
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
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.
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.
| INTENSIVE | RAGE | Resuscitology | SMACC
