Early Percutaneous Tracheotomy Versus Prolonged Intubation of Mechanically Ventilated Patients After Cardiac Surgery Early tracheostomy in severe traumatic brain injury: evidence for decreased mechanical ventilation and increased hospital mortality. [Tracheostomy in the intensive care unit]. Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients A randomized clinical trial for the timing of tracheotomy in critically ill patients: factors precluding inclusion in a single center study Early tracheostomy for primary airway management in the surgical critical care setting Factors Influencing Choice Between Tracheostomy and Prolonged Translaryngeal Intubation in Acute Respiratory Failure: A Prospective Study Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. Multicenter, randomized, prospective trial of early tracheostomy. Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients* [Analysis of early tracheostomy and its impact on development of pneumonia, use of resources and mortality in neurocritically ill patients]. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Prolonged tracheal intubation in the trauma patient. Early versus late tracheostomy in patients who require prolonged mechanical ventilation. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. [Clinical study on the comparison of prophylactic tracheotomy with emergent tracheotomy after inhalation injury].
BACKGROUND Whether early percutaneous tracheotomy in patients who require prolonged mechanical ventilation can shorten mechanical ventilation duration and lower mortality remains controversial . OBJECTIVE To compare the outcomes of severely ill patients who require prolonged mechanical ventilation r and omly assigned to early percutaneous tracheotomy or prolonged intubation .  DESIGN Prospect i ve , r and omized , controlled , single-center trial ( Clinical Trials.gov registration number : NCT00347321 ) . SETTING Academic center . PATIENTS 216 adults requiring mechanical ventilation 4 or more days after cardiac surgery . INTERVENTION Immediate early percutaneous tracheotomy or prolonged intubation with tracheotomy 15 days after r and omization . MEASUREMENTS The primary end point was the number of ventilator-free days during the first 60 days after r and omization . Secondary outcomes included 28- , 60- , or 90-day mortality rates ; duration s of mechanical ventilation , intensive care unit stay , and hospitalization ; sedative , analgesic , and neuroleptic use ; ventilator-associated pneumonia rate ; unscheduled extubations ; comfort and ease of care ; and long-term health-related quality of life ( HRQoL ) and psychosocial evaluations . RESULTS There was no difference in ventilator-free days during the first 60 days after r and omization between early percutaneous tracheotomy and prolonged intubation groups ( mean , 30.4 days [ SD , 22.4 ] vs. 28.3 days [ SD , 23.7 ] , respectively ; absolute difference , 2.1 days [ 95 % CI , -4.1 to 8.3 days ] ) nor in 28- , 60- , or 90-day mortality rates ( 16 % vs. 21 % , 26 % vs. 28 % , and 30 % vs. 30 % , respectively ) . The duration s of mechanical ventilation and hospitalization , as well as frequencies of ventilator-associated pneumonia and other severe infections , were also similar . However , early percutaneous tracheotomy was associated with less intravenous sedation ; less time of heavy sedation ; less haloperidol use for agitation , delirium , or both ; fewer unscheduled extubations ; better comfort and ease of care ; and earlier resumption of oral nutrition . After a median follow-up of 873 days , between-group survival , psychosocial evaluations , and HRQoL were similar . LIMITATION The prolonged intubation group had more ventilator-free days during days 1 to 60 than what was hypothesized ( mean , 23.0 days [ SD , 17.0 ] ) . CONCLUSION Early tracheotomy provided no benefit in terms of mechanical ventilation and length of hospital stay , rates of mortality or infectious complications , and long-term HRQoL for patients who require prolonged mechanical ventilation after cardiac surgery . However , the well-tolerated procedure was associated with less sedation , better comfort , and earlier resumption of autonomy . PRIMARY FUNDING SOURCE French Ministry of Health OBJECTIVE In the past , the authors performed a comprehensive literature review to identify all r and omized controlled trials assessing the impact of  early tracheostomy on severe brain injury outcomes . The search produced only two trials , one by Sugerman and another by Bouderka . SUBJECTS AND METHODS The current authors initiated an Institutional Review Board-approved severe brain injury r and omized trial to evaluate the impact of early tracheostomy on ventilator-associated pneumonia rates , intensive care unit (ICU)/ventilator days , and hospital mortality . Current study results were compared with the other r and omized trials and a meta- analysis was performed . RESULTS Early tracheostomy pneumonia rates were Sugerman-48.6 % , Bouderka-58.1 % , and current study -46.7 % . No early tracheostomy pneumonia rates were Sugerman-53.1 % , Bouderka-61.3 % , and current study -44.4 % . Pneumonia rate meta- analysis showed no difference for early tracheostomy and no early tracheostomy ( OR 0.89 ; p = 0.71 ) . Early tracheostomy ICU/ventilator days were Sugerman-16 ± 5.9 , Bouderka-14.5 ± 7.3 , and current study -14.1 ± 5.7 . No early tracheostomy ICU/ventilator days were Sugerman-19 ± 11.3 , Bouderka-17.5 ± 10.6 , and current study -17 ± 5.4 . ICU/ventilator day meta- analysis showed 2.9 fewer days with early tracheostomy ( p = 0.02 ) . Early tracheostomy mortality rates were Sugerman-14.3 % , Bouderka-38.7 % , and current study -0 % . No early tracheostomy mortality rates were Sugerman-3.2 % , Bouderka-22.6 % , and current study -0 % . R and omized trial mortality rate meta- analysis showed a higher rate for early tracheostomy ( OR 2.68 ; p = 0.05 ) . Because the r and omized trials were small , a literature assessment was undertaken to find all retrospective studies describing the association of early tracheostomy on severe brain injury hospital mortality . The review produced five retrospective studies , with a total of 3,356 patients . Retrospective study mortality rate meta- analysis demonstrated a larger mortality for early tracheostomy ( OR 1.97 ; p < 0.0001 ) . CONCLUSION For severe brain injury , analyses indicate that ventilator-associated pneumonia rates are not decreased with early tracheostomy . Further , this study implies that mechanical ventilation is reduced with early tracheostomy . Both the r and omized trial and retrospective meta- analysis indicate that risk for hospital death increases with early tracheostomy . Findings imply that early tracheostomy for severe brain injury is not a prudent routine policy During the last 22 months , a total number of 85 tracheostomies have been performed in our ICU , 40 of which have been surgical , and 45 percutaneous to patients under mechanical ventilation .  This period has coincided with the learning process of the technique of percutaneous tracheostomy by our staff . The choice of the type of tracheostomy was not taken at r and om , but guided by clinical criteria . Our results confirm a lower rate of infection of the estoma in percutaneous tracheostomies than in surgical ones ( 5 percutaneous and 29 surgical , p < 0.001 ) . The most serious complication was a tracheal perforation in a percutaneous tracheostomy . 17 of the 85 patients died in ICU , and 33 of the 68 patients who were discharged , survived the hospital , 27 of whom left with a closed tracheostomy . The other 6 permanent tracheostomies had been performed surgically and corresponded to 4 patients with worsening EPOC , one neurological patient and another patient suffering from anoxic encephalopathy . No  percutaneous tracheostomy  was left as permanent . The patients who benefitted especially from the tracheostomy presented the following characteristics :  acute respiratory insufficiency  with prolonged intubation , neurological patients , and worsening EPOC . The  tracheostomy in persistent vegetative status allowed their moving to more suitable areas . Our study proves the existence of a learning curve in the practice of  percutaneous tracheostomy . This aspect should be taken into account by other groups who are interested in including this technique in their services Objective Although several advantages are attributed to tracheotomy in ICU patients requiring mechanical ventilation ( MV ) , true benefits and the optimal timing of tracheotomy remain controversial . In this study , we compared early tracheotomy ( ET ) with prolonged intubation ( PI ) in severely ill patients requiring prolonged MV . Design Prospect i ve , r and omized study . Setting Twenty-five medical and surgical ICUs in France . Patients Patients expected to require MV > 7 days . Measurements and results Patients were r and omised to either ( open or percutaneous ) ET within 4 days or PI . The primary end-point was 28-day mortality . Secondary end-points were : the incidence of ICU-acquired pneumonia , number of d1-d28 ventilator-free days , time spent in the ICU , 60-day mortality , number of septic episodes , amount of sedation , comfort and laryngeal and tracheal complications .  A sample size of 470 patients was considered necessary to obtain a reduction from 45 to 32 % in 28-day mortality . After 30 months , 123 patients had been included ( ET = 61 , PI = 62 ) in 25 centres and the study was prematurely closed . All group characteristics were similar upon admission to ICU . No difference was found between the two groups for any of the primary or secondary end-points . Greater comfort was the sole benefit afforded by tracheotomy after subjective self- assessment by patients . Conclusions The trial did not demonstrate any major benefit of tracheotomy in a general population of ICU patients , as suggested in a previous meta- analysis , but was underpowered to draw any firm conclusions . The potential advantage of ET may be restricted to selected groups of patients Introduction We investigated the potential benefits of early tracheotomy performed before day eight of mechanical ventilation ( MV ) compared with late tracheotomy ( from day 14 if it still indicated ) in reducing mortality , days of MV , days of sedation and ICU length of stay ( LOS ) . Methods R and omized controlled trial ( RCT ) including all-consecutive ICU admitted patients requiring seven or more days of MV . Between days five to seven of MV , before r and omization , the attending physician ( AP ) was consulted about the expected duration of  MV  and acceptance of tracheotomy according to r and omization . Only accepted patients received tracheotomy as result of r and omization . An intention to treat analysis was performed including patients accepted for the AP and those rejected without exclusion criteria . Results A total of 489 patients were included in the RCT . Of 245 patients r and omized to the early group , the procedure was performed for 167 patients ( 68.2 % ) whereas in the 244 patients r and omized to the late group was performed for 135 patients ( 55.3 % ) ( P < 0.004 ) . Mortality at day 90 was similar in both groups ( 25.7 % versus 29.9 % ) , but duration of sedation was shorter in the early tracheotomy group median 11 days ( range 2 to 92 ) days compared to 14 days ( range 0 to 79 ) in the late group ( P < 0.02 ) . The AP accepted the protocol of r and omization in 205 cases ( 42 % ) , 101 were included in early group and 104 in the late group . In these subgroup of patients ( per- protocol analysis ) no differences existed in mortality at day 90 between the two groups , but the early group had more ventilator-free days , less duration of sedation and less LOS , than the late group . Conclusions This study shows that early tracheotomy reduces the days of sedation in patients undergoing MV , but was underpowered to prove any other benefit . In those patients selected by their attending physicians as potential c and i date s for a tracheotomy , an early procedure can lessen the days of MV , the days of sedation and LOS . However , the imprecision of physicians to select patients who will require prolonged MV challenges the potential benefits of early tracheotomy . Trial registration Controlled-Trials.com IS RCT N22208087 . Registered 27 March 2014 During a 12‐month period , 264 patients with multiple injuries who required mechanical ventilation were admitted to the surgical intensive care unit . One hundred twenty patients ( 46 % ) were disengaged from the ventilator , and 38 patients ( 14 % ) died . Of the remaining 106 patients ( 40 % ) 51 patients ( group I ) were to receive tracheostomy within 1 to 7 days , and 55 patients ( group II ) underwent late ( 8 or more days after admission ) tracheostomy . Multiple variables in four categories ( admission , operative , ventilatory , and outcome ) were analyzed prospect ively to define the impact that early tracheostomy had on duration of mechanical ventilation , intensive care stay , and hospital stay . Morbidity and mortality rates of the procedures were assessed . Early tracheostomy , in a homogeneous group of critically ill patients , is associated with a significant decrease in duration of mechanical ventilation , as well as shorter intensive care unit and hospital stays , compared with translaryngeal endotracheal intubation . There were no deaths attributable to tracheostomy , and overall morbidity of the procedures was 4 % . We conclude that early tracheostomy has an overall risk equivalent to that of endotracheal intubation . Furthermore , early tracheostomy  shortens days on the ventilator and intensive care unit and hospital days and should be considered for patients in the intensive care unit at risk for more than 7 days of intubation One of the problems of prolonged ventilatory therapy in acute respiratory failure ( ARF ) is the need to choose between tracheostomy after 48 to 72 hours of translaryngeal ( TL ) tracheal intubation or the continuous use of the TL tube for a period of 10 days . Too often the choice has been based on retrospective studies or personal preference . To investigate this problem prospect ively , 52 adults in ARF were divided sequentially into 2 groups on their 3rd day of TL intubation . Patients in group I ( G-I ) retained the TL tube for a total of 11 days ; those in group II ( G-II ) were tracheostomized on the 3rd day . The following factors were used to evaluate the efficiency and complications in each group : patient 's epidemiologic variables , daily pulmonary functions , severity of respiratory infections , and scores of post-intubation airway lesions . No consistent statistically significant differences between the two procedures were seen in the pulmonary functions or the range of individual patient variables . However , with an early tracheostomy , there was an eightfold greater incidence of contamination of the airway by new organisms , airway lesions were more frequent and severe , and the need for the tracheal tube was extended . To identify the epidemiologic variables and the pulmonary functions that discriminate between patients with serious airway lesions and those with mild lesions , and to evaluate the ability of these variables to differentiate the patients who died from those who survived , the distribution of all factors was compared in the two categories . The epidemiologic variables separated the patients according to their airway lesions only , while the difference in pulmonary functions was statistically significant only between the patients who died and those who survived CONTEXT Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation ; however , there is considerable variability in the time considered optimal for performing tracheotomy . This is of clinical importance because timing is a key criterion for performing a tracheotomy  and patients who receive one require a large amount of health care re sources . OBJECTIVE To determine the effectiveness of early tracheotomy ( after 6 - 8 days of laryngeal intubation ) compared with late tracheotomy ( after 13 - 15 days of laryngeal intubation ) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days . DESIGN , SETTING , AND PATIENTS R and omized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection , who had been ventilated for 24 hours , had a Simplified Acute Physiology Score II between 35 and 65 , and had a sequential organ failure assessment score of 5 or greater . INTERVENTION Patients who had worsening of respiratory conditions , unchanged or worse sequential organ failure assessment score , and no pneumonia 48 hours after inclusion were r and omized to early tracheotomy ( n = 209 ; 145 received tracheotomy ) or late tracheotomy ( n = 210 ; 119 received tracheotomy ) . MAIN OUTCOME MEASURES The primary endpoint was incidence of ventilator-associated pneumonia ; secondary endpoints during the 28 days immediately following r and omization were number of ventilator-free days , number of ICU-free days , and number of patients in each group who were still alive . RESULTS Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group ( 14 % ; 95 % confidence interval [ CI ] , 10%-19 % ) and in 44 patients in the late tracheotomy group ( 21 % ; 95 % CI , 15%-26 % ) ( P = .07 ) . During the 28 days immediately following r and omization , the hazard ratio of developing ventilator-associated pneumonia was 0.66 ( 95 % CI , 0.42 - 1.04 ) , remaining connected to the ventilator was 0.70 ( 95 % CI , 0.56 - 0.87 ) , remaining in the ICU was 0.73 ( 95 % CI , 0.55 - 0.97 ) , and dying was 0.80 ( 95 % CI , 0.56 - 1.15 ) . CONCLUSION Among mechanically ventilated adult ICU patients , early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00262431 OBJECTIVES Determine the effect of early ( days 3 - 5 ) or late ( days 10 - 14 ) tracheostomy on intensive care unit length of stay ( ICU LOS ) , frequency of pneumonia , and mortality , and evidence of short-term or long-term pharyngeal , laryngeal , or tracheal injury in head trauma , non-head trauma , and critically ill nontrauma patients . STUDY DESIGN R and omized , prospect i ve . SETTING Five Level I trauma centers . METHODS Data were obtained prospect ively and included Acute Physiology and Chronic Health Evaluation III score ( AIII ) , Glasgow Coma Scale score , Emergency Room Trauma Score , Injury Severity Score , Acute Injury Score , type of endotracheal tube or tracheostomy , level of positive end-expiratory pressure , and peak inspiratory pressure .  Patients were to undergo laryngoscopy for detection of injury according to the Lindholm criteria at the time of endotracheal tube or tracheostomy removal and be reevaluated at 3 to 5 months after discharge . RESULTS One hundred fifty-seven patients were entered , 127 to early r and omization ( 3 - 5 days ) and 28 to late r and omization ( 10 - 14 days ) ; however , only 112 patients with early and 14 with late r and omization had completed data forms for the primary study goals . An additional 22 patients from the early entry groups were rer and omized late . Early r and omization data : the AIII score was higher ( p < 0.05 ) in the head trauma tracheostomy ( 65 + /- 4 ) than in the nontracheostomy group ( 51 + /- 4 ) and in the nontrauma tracheostomy ( 92 + /- 6 ) than in the nontracheostomy group ( 68 + /- 7 ) , but was equivalent in the non-head trauma group . Glasgow Coma Scale score , Emergency Room Trauma Score , Injury Severity Score , Acute Injury Score , positive end-expiratory pressure , and peak inspiratory pressure were not significantly different in any of the groups . There were no significant differences in ICU LOS , frequency of pneumonia , or death in any of the groups after either early or late tracheostomy compared with continued endotracheal intubation . Only 83 patients underwent postextubation laryngoscopy . There were no significant differences between the groups ; however , there were trends to more vocal cord ulceration and subglottic inflammation in the continued intubation group . No patient was seen in this study with late vocal cord or laryngeal stenosis ; there were no tracheal-innominate artery fistulae . Seven of the patients with abnormal findings at extubation had normal 3- to 5-month postextubation laryngoscopy . CONCLUSION Physician bias limited patient entry into the study . Although there were higher AIII scores in the head trauma early tracheostomy patients , there were no differences in the primary end points of ICU LOS , pneumonia , or death in any of the groups studied . Long-term endoscopic follow-up was poor , but no known late tracheal stenosis was seen BACKGROUND Tracheostomy should be considered to replace endotracheal intubation in patients requiring prolonged mechanical ventilation ( MV ) . However , the optimal timing for tracheostomy is still a topic of debate . The present study aim ed to investigate whether early percutaneous dilational tracheostomy ( PDT ) can reduce duration of MV , and to further verify whether early PDT can reduce sedative use , shorten intensive care unit ( ICU ) stay , decrease the incidence of ventilator associated pneumonia ( VAP ) , and increase successful weaning and ICU discharge rate . METHODS A prospect i ve , r and omized controlled trial was carried out in a surgical ICU from July 2008 to June 2011 in adult patients anticipated requiring prolonged MV via endotracheal intubation . Patients meeting the inclusion criteria were r and omly assigned to the early PDT group or the late PDT group on day 3 of MV . The patients in the early PDT group were tracheostomized with PDT on day 3 of MV . The patients in the late PDT group were tracheostomized with PDT on day 15 of MV if they still needed MV . The primary endpoint was ventilator-free days at day 28 after r and omization . The secondary endpoints were sedation-free days , ICU-free days , successful weaning and ICU discharge rate , and incidence of VAP at day 28 after r and omization . The cumulative 60-day incidence of death after r and omization was also analyzed . RESULTS Total 119 patients were r and omized to either the  early PDT group ( n = 58 ) or the  late PDT group ( n = 61 ) . The ventilator-free days was significantly increased in the early PDT group than in the late PDT group ( ( 9.57 ± 5.64 ) vs. ( 7.38 ± 6.17 ) days , P < 0.05 ) . The sedation-free days and ICU-free days were also significantly increased in the early PDT group than in the late PDT group ( 20.84 ± 2.35 vs. 17.05 ± 2.30 days , P < 0.05 ; and 8.0 ( interquartile range ( IQR ) : 5.0 - 12.0 ) vs. 3.0 ( IQR : 0 - 12.0 ) days , P < 0.001 respectively ) . The successful weaning and ICU discharge rate was significantly higher in early PDT group than in late PDT group ( 74.1 % vs. 55.7 % , P < 0.05 ; and 67.2 % vs. 47.5 % , P < 0.05 respectively ) . VAP was observed in 17 patients ( 29.3 % ) in early PDT group and in 30 patients ( 49.2 % ) in late PDT group ( P < 0.05 ) . There was no significant difference between the two groups in the cumulative 60-day incidence of death after r and omization ( P = 0.949 ) . CONCLUSIONS The early PDT result ed in more ventilator-free , sedation-free , and ICU-free days , higher successful weaning and ICU discharge rate , and lower incidence of VAP , but did not change the cumulative 60-day incidence of death in the patients ' anticipated requiring prolonged mechanical ventilation BACKGROUND Tracheostomy is a commonly performed procedure in ventilator dependent patients . Many critical care practitioners believe that performing a tracheostomy early in the postinjury period decreases the length of ventilator dependence as well as having other benefits such as better patient tolerance and lower respiratory dead space . We conducted a r and omized , prospect i ve , single institution study comparing the length ventilator dependence in critically ill multiple trauma patients who were r and omized to two different strategies for performance of a tracheostomy . We hypothesized that earlier tracheostomy would reduce the number of days of mechanical ventilation , frequency of pneumonia and length of intensive care unit ( ICU ) stay . METHODS Patients were eligible if they were older than 15 years and either a Glasgow Coma Score ( GCS ) > 4 with a negative brain computed tomography ( CT ) ( no anatomic head injury ) , or a GCS > 9 with a positive head CT ( known anatomic head injury ) . Patients who required tracheostomy for facial/neck injuries were excluded . Patients were r and omized to an intention to treat strategy of tracheostomy placement before day 8 or after day 28 . RESULTS The study was halted after the first interim analysis . There were 60 enrolled patients , who had comparable demographics between groups . There was no significant difference between groups in any outcome variable including length of ventilator support , pneumonia rate , or death . CONCLUSION A strategy of tracheostomy before day 8 postinjury in this group of trauma patients did not reduce the number of days of mechanical ventilation , frequency of pneumonia or ICU length of stay as compared with the group with a tracheostomy strategy involving the procedure at 28 days postinjury or more Background Long-term ventilation in intensive care units ( ICUs ) is associated with several problems such as increased mortality , increased rates of ventilator-associated pneumonia ( VAP ) , and prolonged time of hospitalization , and thus leads to enormous healthcare expenditure . While the influence of tracheostomy on VAP incidence , duration of ventilation , and time of hospitalization has already been analyzed in several studies , the timing of the tracheostomy procedure on patient ’s mortality is still controversial . The aim of our study was to investigate whether early tracheostomy improved outcome in critically ill patients . Material s and methods Within 2 years , 100 critically ill , predominantly surgical patients entered this prospect i ve r and omized study . A percutaneous dilatational tracheostomy was performed either early ( ≤4 days , 2.8 days median ) or late ( ≥6 days , 8.1 days median ) after intubation . Results We could demonstrate that mortality was not significantly reduced in the early tracheostomy ( ET ) group in contrast to the late tracheostomy ( LT ) group . ET was associated with decreased VAP incidence ( ET 38 % vs. LT 64 % ) , decreased duration of ventilation ( ET 367.5 h vs LT 507.5 h ) , and shorter time of hospitalization both in hospital ( ET 31.5 days vs LT 68 days ) and in ICU ( ET 21.5 days vs LT 27 days ) . Conclusion Despite many advantages like reduced time of ventilation and hospitalization , early tracheostomy is not associated with decreased mortality in critically ill patients Objective : The timing of tracheotomy in patients requiring mechanical ventilation is unknown . The effects of early percutaneous dilational tracheotomy compared with delayed tracheotomy in critically ill medical patients needing prolonged mechanical ventilation were assessed . Design : Prospect i ve , r and omized study . Setting : Medical intensive care units . Patients : One hundred and twenty patients projected to need ventilation > 14 days . Interventions : None . Measurements and Main Results : Patients were prospect ively r and omized to either early percutaneous tracheotomy within 48 hrs or delayed tracheotomy at days 14–16 . Time in the intensive care unit and on mechanical ventilation and the cumulative frequency of pneumonia , mortality , and accidental extubation were documented . The airway was assessed for oral , labial , laryngeal , and tracheal damage . Early group showed significantly less mortality ( 31.7 % vs. 61.7 % ) , pneumonia ( 5 % vs. 25 % ) , and accidental extubations compared with the prolonged translaryngeal group ( 0 vs. 6 ) . The early tracheotomy group spent less time in the intensive care unit ( 4.8 ± 1.4 vs. 16.2 ± 3.8 days ) and on mechanical ventilation ( 7.6 ± 2.0 vs. 17.4 ± 5.3 days ) . There was also significantly more damage to mouth and larynx in the prolonged translaryngeal intubation group . Conclusions : This study demonstrates that the benefits of early tracheotomy outweigh the risks of prolonged translaryngeal intubation . It gives credence to the practice of subjecting this group of critically ill medical patients to early tracheotomy rather than delayed tracheotomy OBJECTIVE We analyze the most suitable time to perform tracheostomy in neurocritically ill patients . We compare morbimortality and use of re sources between those patients in which tracheostomy was done early ( < or= 9 days ) and those in which it was perform later ( > 9 days ) , in a selected group of patients . MATERIAL AND METHODS We made an observational prospect i ve study involving a group of patients diagnosed as traumatic brain injury ( TBI ) or stroke , whose tracheostomy was performed during their stay at the Intensive Care Unit . We compared two groups : a ) early tracheostomy ( during first 9 days of ICU stay ) ; b ) late tracheostomy ( made on 10th day or later ) . As variables , we studied : demographic data , severity of illness at admission , admittance department , diagnosis , length of intubation , length of mechanical ventilation ( LMV ) , sedation and antibiotic treatment needs , ventilator-associated pneumonia ( VAP ) events , ICU length of stay and mortality . We calculated relative risk of suffering from pneumonia and made a multivariate logistic regression to establish which factors were associated with an increased risk of developing pneumonia . Statistical signification p < or= 0.05 . RESULTS We analyzed 118 patients , 60 % with TBI .  Mean length of intubation before tracheostomy was 12 days and mean LMV was 20 days . 94 VAP events were diagnosed in 81 patients ( 68.6 % ) . Early tracheostomy group showed lower length of mechanical ventilation and ICU stay , lower length of sedation and antibiotic treatment , and less pneumonia events ( p<0,001 ) . The precocity of tracheostomy did n't have any influence either on hospital length of stay ( p=0.844 ) , ICU mortality ( p=0.924 ) or in-hospital mortality ( p=0.754 ) . At the TBI group  mean age was lower ( p < 0.001 ) , tracheostomy was made later ( p=0.026 ) , and patients needed a longer sedation ( p=0.001 ) and a longer antibiotic treatment ( p=0.002 ) . Length of intubation ( p=0.034 , OR 1.177 ) and ICU length of stay ( p=0.003 , OR 1.100 ) were factors independently associated with development of pneumonia . Relative risk of suffering from pneumonia when tracheostomy was made after 9 days of ICU stay was 1.55 ( IC 95 % : 1.10 - 2.16 ) . The number needed to treat ( NNT ) for early tracheostomy avoiding one pneumonia event was 3.13 . VAP was not associated with a higher ICU ( p=0.558 ) or in-hospital mortality ( p=0.370 ) . CONCLUSIONS Early tracheostomy ( < or= 9 days ) provides significant advantages in neurocritically ill patients : it shortens length of mechanical ventilation and ICU stay and decreases antibiotic and sedatives requirements . Although later tracheostomy is not directly related with mortality , it increases considerably the risk of suffering from pneumonia , particularly in patients with TBI . These clinical circumstances should be evaluated individually in each patient , so the best time to perform tracheostomy in neurocritically ill patients could be established BACKGROUND To see if early tracheostomy ( fifth day ) reduces duration of mechanical ventilation , ICU stay , incidence of pneumonia and mortality in comparison with prolonged intubation ( PI ) in patients with head injury . METHODS Patients were prospect ively included in this study if they met the following criteria : isolated head injury , Glasgow coma scale ( GCS ) score < or = 8 on first and fifth day , with cerebral contusion on CT scan . On the fifth day , r and omization was done in two groups :  early tracheostomy group ( T group , n = 31 ) and prolonged endotracheal intubation group ( I group , n = 31 ) . We evaluated total time of mechanical ventilation , ICU stay , pneumonia incidence and mortality . Complications related to each technique were noted . Analysis of data were performed using Yates and Kruskall Walis tests . p < 0.05 was considered significant . RESULTS The two groups were comparable in term of age , sex , and Simplified Acute Physiologic Score ( SAPS ) . The mean time of mechanical ventilatory support was shorter in T group ( 14.5 + /- 7.3 ) versus I group ( 17.5 + /- 10.6 ) ( p = 0.02 ) . After pneumonia was diagnosed , mechanical ventilatory time was 6 + /- 4.7 days for ET group versus 11.7 + /- 6.7 days for PEI group ( p = 0.01 ) . There was no difference in frequency of pneumonia or mortality between the two groups . CONCLUSION In severe head injury early tracheostomy decreases total days of mechanical ventilation or mechanical ventilation time after development of pneumonia A prospect i ve study of the complications and consequences of  translaryngeal endotracheal intubation and tracheotomy was conducted on 150 critically ill adult patients . Adverse consequences occurred in 62 percent of all endotracheal intubations and in 66 percent of all tracheotomies during placement and use of the artificial airways . The most frequent problems during endotracheal intubation were excessive cuff pressure requirements ( 19 percent ) , self-extubation ( 13 percent ) and inability to seal the airway ( 11 percent ) . Patient discomfort and difficulty in suctioning tracheobronchial secretions were very uncommon . Problems with tracheotomy included stomal infection ( 36 percent ) , stomal hemorrhage ( 36 percent ) , excessive cuff pressure requirements ( 23 percent ) and subcutaneous emphysema or pneumomediastinum ( 13 percent ) . Complications of tracheotomy  were judged to be more severe than those of endotracheal intubation . Follow-up studies of survivors revealed a high prevalence of tracheal stenosis after tracheotomy ( 65 percent ) and significantly less after endotracheal intubation ( 19 percent)(p < 0.01 ) . Thirty-nine of 41 ( 95 percent ) patients with endotracheal intubation  and 20 of 22 ( 91 percent ) patients with  tracheotomy  had laryngotracheal injury at autopsy . Ulcers on the posterior aspect of the true vocal cords were found at autopsy in 51 percent of the patients who died after endotracheal intubation . There was no significant relationship between the duration of endotracheal intubation or tracheotomy  and the over-all amount of laryngotracheal injury at autopsy , although patients with prolonged endotracheal intubation followed by tracheotomy had more laryngeal injury at autopsy ( P = 0.06 ) and more frequent tracheal stenosis ( P = 0.05 ) than patients with short-term endotracheal intubation followed by tracheotomy .  Adverse effects of both endotracheal intubation and tracheotomy are common . The value of tracheotomy when an artificial airway is required for periods as long as three weeks is not supported by data obtained in this study Over a 15-month period , 74 trauma patients who were expected to require extended intubation were studied prospect ively to evaluate the appropriateness of tracheostomy . Patients were r and omized to receive either early ( 34 ) or late ( 40 ) tracheostomies . The patients also were grouped to determine the difference of early versus late tracheostomy on the development of laryngotracheal pathology and respiratory infections ; length of intubation and type of patient injury were studied as possible differential factors . Fifteen per cent ( 11/74 ) of the patients developed major laryngotracheal pathology as identified by endoscopy , and respiratory infections developed in 54 % ( 40/74 ) , but there was no significant difference in the complication incidence between the early and late tracheostomy groups . Significantly more complications occurred in rigid-posture , head-injured patients than in any other trauma grouping , but there was no significant difference in the complication incidence between the two tracheostomy groups within that classification . We conclude that patients can undergo translaryngeal intubation for up to 2 weeks without significantly increasing complications relative to transtracheal intubation OBJECTIVES To compare the clinical outcomes of early versus late tracheostomy in patients who require prolonged mechanical ventilation . METHODS A prospect i ve observational study was done . The sample was a cohort of 90 patients who had tracheostomy in the medical intensive care unit of a university-affiliated teaching hospital . Primary outcome measures were duration of mechanical ventilation and total cost of hospitalization .  Tracheostomy was defined as early if performed by day 10 of mechanical ventilation and late if performed thereafter . RESULTS Fifty-three patients had early tracheostomy ( mean + /- SD = day 5.9 + /- 7.2 of ventilation ) , and 37 patients had late tracheostomy ( mean + /- SD = day 16.7 + /- 2.9 ) ( P < .001 ) . The mean ( + /- SD ) duration of mechanical ventilation was 28.3 + /- 28.2 days in the early-tracheostomy group versus 34.4 + /- 17.8 days in the late-tracheostomy group ( P = .005 ) . Total cost of hospitalization was significantly lower in the early-tracheostomy group ( mean + /- SD = $ 86,189 + /- $ 53,570 ) than in the late-tracheostomy group ( mean + /- SD = $ 124,649 + /- $ 54,282 ) ( P = .001 ) . Male sex ( adjusted odds ratio = 3.84 ; 95 % CI = 2.32 - 6.34 ; P = .007 ) and higher ratios of PaO2 to fraction of inspired oxygen ( adjusted odds ratio = 1.01 ; 95 % CI = 1.00 - 1.01 ; P = .03 ) were associated with early tracheostomy . The timing of tracheostomy was not associated with hospital mortality . CONCLUSION Early tracheostomy is associated with shorter lengths of stay and lower hospital costs than is late tracheostomy among patients in the medical intensive care unit . Prospect i ve clinical trials are necessary to determine the optimal timing of tracheostomy in that setting IMPORTANCE Tracheostomy is a widely used intervention in adult critical care units . There is little evidence to guide clinicians regarding the optimal timing for this procedure . OBJECTIVE To test whether early vs late tracheostomy would be associated with lower mortality in adult patients requiring mechanical ventilation in critical care units . DESIGN AND SETTING An open multicentered r and omized clinical trial conducted between 2004 and 2011 involving 70 adult general and 2 cardiothoracic critical care units in 13 university and 59 nonuniversity hospitals in the United Kingdom . PARTICIPANTS Of 1032 eligible patients , 909 adult patients breathing with the aid of mechanical ventilation for less than 4 days and identified by the treating physician as likely to require at least 7 more days of mechanical ventilation . INTERVENTIONS Patients were r and omized 1:1 to early tracheostomy ( within 4 days ) or late tracheostomy ( after 10 days if still indicated ) . MAIN OUTCOMES AND MEASURES The primary outcome measure was 30-day mortality and the analysis was by intention to treat . RESULTS Of the 455 patients assigned to early tracheostomy , 91.9 % ( 95 % CI , 89.0%-94.1 % ) received a tracheostomy and of 454 assigned to late tracheostomy , 44.9 % ( 95 % CI , 40.4%-49.5 % ) received a tracheostomy . All-cause mortality 30 days after r and omization was 30.8 % ( 95 % CI , 26.7%-35.2 % ) in the early and 31.5 % ( 95 % CI , 27.3%-35.9 % ) in the late group ( absolute risk reduction for early vs late , 0.7 % ; 95 % CI , -5.4 % to 6.7 % ) . Two-year mortality was 51.0 % ( 95 % CI , 46.4%-55.6 % ) in the early and 53.7 % ( 95 % CI , 49.1%-58.3 % ) in the late group ( P = .74 ) . Median critical care unit length of stay in survivors was 13.0 days in the early and 13.1 days in the late group ( P = .74 ) . Tracheostomy-related complications were reported for 6.3 % ( 95 % CI , 4.6%-8.5 % ) of patients ( 5.5 % in the early group , 7.8 % in the late group ) . CONCLUSIONS AND RELEVANCE For patients breathing with the aid of mechanical ventilation treated in adult critical care units in the United Kingdom , tracheostomy within 4 days of critical care admission was not associated with an improvement in 30-day mortality or other important secondary outcomes . The ability of clinicians to predict which patients required extended ventilatory support was limited . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N28588190 OBJECTIVE To compare prophylactic with emergent tracheostomy in 93 patients with inhalation injury , so as to explore the clinical significance of prophylactic tracheostomy . METHODS Tracheostomy was applied in all patients with moderate and severe inhalation injury . The patients with obvious dyspnea , low oxygen pressure and decreased oxygen saturation before the operation were set to be emergent tracheostomy group  ( ET , n = 21 ) , while those without dysfunction of ventilation and gas exchange , as prophylactic group ( PT , n = 72 ) . The average operation starting time was 4.31 + /- 3.04 PBH and 34.47 + /- 2.79 PBH in PT and ET groups , respectively . RESULTS There were evident decrease of blood oxygen pressure and oxygen saturation and increase of respiratory and heart rates before the tracheostomy in ET group , but all these signs improved after the operation . In contrary , the vital signs in PT group exhibited stable perioperatively . Assisted respiration with respirator was applied in 20 cases ( 95.24 % ) in ET and in 65 cases ( 90.28 % ) in PT groups within 2 post-operative days ( POD ) . CONCLUSION Early and prophylactic tracheostomy should be advocated in patients suspected to be with moderate or severe inhalation injury .  Emergent tracheostomy must be avoided and respiratory assistance should be employed as early as possible
Introduction The optimal timing of tracheotomy in critically ill patients remains a topic of debate .
We performed a systematic review to clarify the potential benefits of early versus late tracheotomy .