Question 13

College Answer

Introduction

Tracheostomy is performed in critically ill adults requiring prolonged invasive ventilation as a strategy to reduce respiratory tract injury, improve patient confort and/or to facilitate weaning. Timing of tracheostomy has been a subject of debate and may be considered as “early” at <10 days or “late” >10 days although these definitions may vary.

Rationale

There has been debate as to whether “early” trache may confer advantages of reduced morbidity and mortality 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

Many studies and meta-analyses of variable quality have evaluated this issue. 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.

Cochrane Review 2012 considered 4 studies (latest 2010) to meet inclusion criteria. Conclusions were that quality of evidence to date was poor and results conflicting. Recent RCT Tracman Study from UK – tracheostomy at 1-4 days v >10 days invasive ventilation. Early tracheostomy associated with shorter duration of sedation but increased number of procedures and associated complications with no beneficial effect on overall mortality not ICU/hospital LOS.

Studies have evaluated patients with respiratory failure and not those intubated for neurological injury.

Own Practice

Any reasonable approach acceptable.

Summary

Lack of evidence to support early v late trache overall. Selected patients eg neurotrauma, GBS, stroke may benefit from early. 
Probably best decided on case by case basis.

Involves invasive procedure with attendant risks and complications and needs appropriate expertise.

Discussion

The timing of tracheostomy is well discussed in a recent meta-analysis. Sure, its PLOS, and sometimes people only value the advice they have to pay for, but I think it is of a high quality. The model answer makes reference to TracMan, a trial which had not yet been published at the time of the exam, and so could not have been expected as a part of an answer to this question. If this question were repeated in future papers (eg. Question 13 from the second paper of 2017)  modern data expected of the candidates would probably come from the 2015 meta-analysis article by  Andriolo et al and Szakmany et al, which arrived at essentially the same conclusions (in three words, early vs late tracheostomy makes no difference to any parameters of interest when you homogenise the ICU population). 

Introduction:

• Typically tracheostomy is performed on patients with difficulty weaning.
• Some argument exists whether patients who are likely to require prolonged weaning should have this procedure early, and whether this improves their outcome
• No agreement exists regarding the definition of what is late and what is early tracheostomy
  • the 10 day cutoff is mentioned by the college, and it probably comes from TracMan.
• No agreement exists as to the selection of patients who might benefit

Rationale for early tracheostomy:

• Early tracheostomy exposes the patient to the various advantages of tracheostomy, which are:
  • decreased dead space
  • decreased airway injury
  • lower airway resistance and improved work of breathing
  • decreased sedation requirements and improved comfort
  • avoidance of complications of prolonged intubation
  • earlier oral feeding
  • decreased incidence of VAP
  • decreased length of ICU stay
  • avoidance of the perils of prolonged intubation
• The argument is that the earlier this is performed, the better.

Rationale for delaying tracheostomy:

• The counter-argument is that patients who would have otherwise been successfully extubated would undergo an unnecessary tracheostomy. Such a practice would expose them to the risks of tracheostomy, which are:
  • bleeding and wound infection
  • potential for periprocedure complications, such as tracheo-oesophageal fistula
  • tracheomalacia and tracheal stenosis
  • potential for dislodgement and airway failure
• Some patients may end up being extubated after a prolonged intubation
• A long period of intubation allows these patients to be more easily identified. 
• Risks of prolonged intubation are probably overstated
• Futile care may be perpetuated by tracheostomy. 
• Length of ICU stay is largely a financial rather than medical consideration, and some might argue that it is inappropriate to let such matters influence decisions regarding patient care.

Evidence:

Cochrane review  by Andriolo et al (2015):

•   n=1977, of which 909 were from TracMan.
• There was a statistically significant mortality benefit associated with early tracheostomy (47% vs 53%); the NNT was 11. This mortality benefit was seen at the longest reported follow-up, rather than at 30 days.
• The early group had a higher chance of being discharged from the ICU on day 28.
• There was no statistically significant effect on the duration of mechanical ventilation.
• The early group had decreased duration of sedation.
• Data regarding risk of pneumonia could not be subjected to meta-analysis due to heterogeneity.

Own practice:

• An impression of the likelihood of a patient requiring tracheostomy can form early in their stay (eg. poor neurological recovery, permanent loss of airway reflexes, or existing chronic lung disease). Such patients should be offered tracheostomy early, and to delay it would expose them to the risks of of prolonged intubation. Each case should be evaluated according to its own unique features, and risk must be weighed against benefit.

Summary:

• Broadly speaking, early tracheostomy does not influence outcome in ICU patients.
• Some ICU patients may still benefit from an early tracheostomy, but features which identify them are not well established, and the decision still relied on case-by-case analysis and clinical experience.

Huang, Huibin, et al. "Timing of Tracheostomy in Critically Ill Patients: A Meta-Analysis." PloS one 9.3 (2014): e92981.

Young, Duncan, et al. "Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial." Jama 309.20 (2013): 2121-2129.

Longworth, Aisling, et al. "Tracheostomy in special groups of critically ill patients: Who, when, and where?." Indian Journal of Critical Care Medicine 20.5 (2016): 280.

Baron, David Marek, et al. "Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury." Wiener klinische Wochenschrift (2016): 1-7.

Hosokawa, Koji, et al. "Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials." Critical Care 19.1 (2015): 1-12.

Gomes Silva, Brenda Nazaré, et al. "Early versus late tracheostomy for critically ill patients." Cochrane Database Syst Rev 3 (2012).

Andriolo, B. N., et al. "Early versus late tracheostomy for critically ill patients." Cochrane Database Syst Rev 1 (2015).

Szakmany, T., et al. "Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials." British journal of anaesthesia 114.3 (2015): 396-405.