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

• 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:CD007271. doi: 10.1002/14651858.CD007271.pub2. Review. PubMed PMID: 22419322. [Free Ful Text]
• 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.
• 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.