Delayed tracheotomy recommended in ICU patients
MedWire News: The timing of tracheotomy does not appear to affect the risk for ventilator-associated pneumonia (VAP) in intensive care unit (ICU) patients requiring mechanical ventilation, report researchers.
V. Marco Ranieri (University of Turin, Italy) and colleagues say that early tracheotomy may have increased the rate of unnecessary treatment, and support delaying tracheotomy for about 2 weeks.
The team randomly assigned 209 ICU patients who needed mechanical ventilation to undergo tracheotomy after 6–8 days of laryngeal intubation and 210 to undergo the procedure after 13–15 days. In total, 145 and 119 patients in the early and late tracheotomy groups, respectively, ultimately underwent the procedure.
There was a nonsignificant trend toward reduced VAP risk among patients in the early tracheotomy group, with 14% versus 21% of late tracheotomy patients developing VAP – the primary endpoint.
There were significant differences for some secondary endpoints, however, with early tracheotomy patients having significantly more ventilator-free days within the first 28 days, at 11 versus 6 days in the late tracheotomy group. Also, 77% versus 68% of patients were successfully weaned from ventilation, 48% versus 39% were discharged from the ICU, and 74% versus 68% survived to day 28.
But randomization to the early tracheotomy group increased patients’ chances of actually undergoing the procedure, Ranieri et al note in the Journal of the American Medical Association.
Most procedure cancellations, in both groups, were due to patients dying, being in a moribund state, or no longer requiring ventilation, suggesting that some patients in the early tracheotomy group underwent an unnecessary procedure. Unnecessary tracheotomy could also have contributed to the good outcomes in the early treatment group.
Given that 39% of patients overall suffered complications potentially related to tracheotomy, the researchers support delaying tracheotomy to the later time.
In an accompanying editorial, Damon Scales (Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada) and Niall Ferguson (Mount Sinai Hospital, Toronto) noted that early tracheotomy may improve other factors not measured in the current study, such as patient comfort.
But they cautioned: “If the only remaining benefit of earlier tracheotomy might be improved patient comfort, but the procedure does not reduce VAP, hospital length of stay, or mortality, these factors need to be weighed against procedural risks and other disadvantages.”
The editorialists stressed: “Perhaps the most important finding from the study by Terragni et al is that despite best efforts to predict which patients will require prolonged mechanical ventilation, many patients were successfully managed without tracheotomy.”
“This creates a compelling argument for waiting at least 2 weeks to be certain that a patient has an ongoing need for mechanical ventilation or assistance with pulmonary toilet before proceeding to tracheotomy.”
They concluded: “Sometimes physicians just need to wait.”
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By Eleanor McDermid