Delayed tracheostomy in critically ill does not increase mortality

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1. Critically ill patients who underwent tracheostomy  within the first 4 days after admission did not experience a reduction in all cause mortality at 30 days when compared to patients who underwent delayed tracheostomy (after 10 days). 

2. The ability of physicians to accurately predict which patients requir prolonged mechanical ventilation remains limited.

Evidence Rating Level: 1 (Excellent)

Study Rundown: This study demonstrated no significant difference in 30-day all cause mortality, mean days of respiratory support, mean critical care admission, antibiotic use, or 1- and 2-year mortality rates between patients undergoing early versus delayed tracheostomy. Thus, this study suggests that early tracheostomy (before 4 days after admission) should be avoided as it does not provide benefit for the patient despite its inherent risks.

This study corroborates previous studies by again showing no mortality benefit for early tracheostomy. These studies also indicate that physicians are unreliable in predicting which patients will require prolonged mechanical ventilation. As a result of this unreliable means of assessment, patients who are overestimated in their need for mechanical ventilation undergo early tracheostomy and are subjected to an unnecessary invasive procedure. Moreover, patients who have an underestimated need for prolonged mechanical ventilation are exposed to prolonged endotracheal intubation, which increases risk of tracheal stenosis. With the addition of this study to a growing literature, future research should investigate a reliable prediction tool that will decrease both unnecessary tracheostomies and prolonged exposure to endotracheal intubation.

Click to read the study, published today in JAMA

Click to read an accompanying editorial in JAMA

Relevant Reading: Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation

In-Depth [open, multicenter randomized clinical trial]: This study randomized 909 critically ill patients at hospital admission who were expected to need at least 7 additional days of mechanical ventilation into early (n= 455) or late (n= 454) tracheostomy intervention. The primary outcome, all cause 30-day mortality, was not significant different between the two groups (p=0.89). Mortality in the intensive care unit (p=>.99), at discharge (p=.63), and at 1- and 2-year follow up (p= .38 and .42 respectively), were also not significantly different. The mean duration of critical care admission was 13.0 days for the early tracheostomy group and 13.1 days for the late tracheostomy group (p=0.74). The early tracheostomy group had a mean of 13.6 days of respiratory support compared to 15.2 days in the late tracheostomy group (p=0.06). Of 622 patients who underwent tracheostomy, 6.3% experienced complications, of which the most common was bleeding.

By Brittany Hasty and Rif Rahman

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