By:Mohamed AbuelnagaSuez canal university

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

in 1989, a Consensus Conference on ArtificialAirways 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.

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

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.

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).

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.

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).

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.

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

The TracMan study , an open multi-centred randomisedclinical 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.

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.

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

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.

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.

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.

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

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.

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.

1-tracheostomy before Day 10 of mechanicalventilation 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.

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.

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.

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