Tracheostomy: how do you get the timing right?

One of the earliest references in history to a procedure that vaguely resembles a tracheostomy is alluded to in the Rig Veda, with the description of the healing of a throat incision.¹ The Egyptians, ancient pioneers of “modern” medicine as we know it today, were past masters of many different surgical procedures in their time and may have documented the first ever tracheostomy in history.  Alexander the Great, the historical hero that he was, did not hesitate to stab the windpipe of one of his fellow soldiers, who was choking on a piece of bone.¹

In more recent times, the debate on what is a good time to perform a tracheostomy continues to captivate intensivists. To say that the evidence has been contradictory would perhaps be an understatement.

The putative benefits of tracheostomy include ease of tracheal suctioning and patient mobilization, reduction or earlier cessation of sedation, and facilitation of speech and oral intake. Besides, even more importantly, a shorter tube may help with spontaneous breathing due to a lower airflow resistance and reduced work of breathing, enabling earlier weaning and liberation from mechanical ventilation. One of the early randomized controlled trials (RCT) compared tracheostomy within the first 48 hours of ventilation to a later tracheostomy between days 14–16.² This study revealed marked benefits of an early tracheostomy, including reduced mortality, a lower incidence of pneumonia, and less duration on ventilation and in the ICU. However, the findings of many later studies have been more sobering. Several meta-analysts have also thrown in their weight trying to find an answer to this vexing question. Griffiths et al., in their meta-analysis of five RCTs, found no significant difference in mortality or the incidence of pneumonia. However, an early tracheostomy resulted in a reduced duration of mechanical ventilation and stay in the ICU.³ However, Wang et al. did not find any reduction in the duration of mechanical ventilation nor in the length of ICU or hospital stay with an early tracheostomy.⁴ A Cochrane review of more recent studies revealed a lower mortality at the longest time of follow-up with early tracheostomy; however, the authors cautioned that high-quality information is not available on the subject, and their findings may only be “suggestive”.⁵

The TracMan study is the largest, multi-center, RCT that has been conducted to evaluate the possible benefit of an early tracheostomy.⁶ Critically ill patients from 70 general intensive care units across the UK were eligible if they were within 4 days of ICU admission, and, would require at least 7 days of mechanical ventilation according to clinician judgment. An early tracheostomy was performed within the first 4 days of admission to the critical care unit; patients randomized to the control group were subjected to a tracheostomy after 10 days if it was still considered necessary by the clinician.

In the early group, 84.6% of patients underwent a tracheostomy as planned; however, among patients randomized to the late group, only 45% received a tracheostomy. Eighty-nine (19.6%) of patients in the late group were discharged from the ICU by day 10, while 78 (17.2%) were still in ICU, but off ventilator support. Thus, 167 out of the 448 patients who were allocated to the late group could be weaned off ventilation and extubated by day 10. This staggering statistic suggests that clinicians could easily misjudge the duration of ventilation and the requirement for tracheostomy. All-cause mortality at 30 days, the primary outcome for which the study was powered for, did not differ significantly between groups. The secondary outcomes, including survival rates at ICU and hospital discharge, and at 1- and 2-year follow-up were also not significantly different. Furthermore, the duration of ventilation and the duration of ICU stay were similar between groups. The sole advantage observed with an early tracheostomy was less use of sedation among 30-day survivors. The targeted sample size could not be achieved as the recruitment rate slowed down over time.  Besides, the TracMan trial included only 5% of patients with a primary neurological illness, a subgroup of patients who might probably benefit from an early tracheostomy.

At the end of the day, what should our timing strategy be in patients who, according to our judgment may require long-term ventilator support?

In my opinion, there are relatively few patients who might benefit from a tracheostomy within the first 3–5 days of ventilation; perhaps patients with neurological illnesses may be able to be liberated from mechanical ventilation early and cared for in a ward with an early tracheostomy. This may be important, especially when the cost of care is an important consideration. It is also important to consider the clinical situation while contemplating tracheostomy. If reducing the level of ventilator support seems unlikely, there may not be much point in performing a tracheostomy. This applies to patients who may require high levels of PEEP, FiO₂ or inspiratory pressures. Attempting a tracheostomy in this setting may lead to worsening of gas exchange and is more likely to cause harm. A tracheostomy should perhaps also be deferred if the prospect of a reasonably meaningful recovery seems unlikely.

References

1. Colice GL (1994) Historical background. In: Tobin MJ (ed) Principles and practice of mechanical ventilation. McGraw-Hill, New York, pp 1-37
2. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004 Aug;32(8):1689–94.
3. 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;330(7502):1243.
4. 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.
5. 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
6. 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