Critically evaluate the timing of elective tracheostomy in ICU patients.
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 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 shorten time on ventilator
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 2013 – 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
Any reasonable approach acceptable
Lack of evidence to support early v late trache overall. Selected patients e.g. 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
This question is identical to Question 13 from the first paper of 2013, with the exception that in 2013 they specifically asked about adult Intensive Care patients. The discussion section for that question is reproduced below with minimal modification, in keeping with the college's own complete verbatim replication of their 2013 model answer, complete even with their reference to the "recent RCT Trac Man", a 2013 publication which in early 2013 was not yet published and in late 2017 is no longer recent.
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 2013 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, modern data expected of the candidates would probably come from the 2015 meta-analysis article by Andriolo et al and Szakmany et al, or the 2016 meta-analysis by Meng et al. All of them 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),
Rationale for early tracheostomy:
Rationale for delaying tracheostomy:
Cochrane review by Andriolo et al (2015):
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.
Meng, Liang, et al. "Early vs late tracheostomy in critically ill patients: a systematic review and meta‐analysis." The clinical respiratory journal 10.6 (2016): 684-692.