Early Tracheostomy No Benefit to Patients

Karyn Hede

May 21, 2013

Tracheostomy within the first 4 days after hospital admission has become common for critically ill patients who have trouble breathing. Clinicians often perceive potential benefits with early tracheostomy for those patients expected to need prolonged mechanical ventilation, including reduced sedation, improved comfort, and faster weaning from the ventilator. However, evidence for the use of early tracheostomy has been lacking.

Now, a study published in the May 22/29 issue of JAMA suggests that early tracheostomy has no survival benefit and that by waiting at least 10 days, the procedure could be avoided altogether in approximately one third of patients.

Duncan Young, DM, from John Radcliffe Hospital, Oxford, United Kingdom, and colleagues compared early vs late tracheostomy in 909 adult patients at 72 hospitals in the United Kingdom between 2004 and 2011. Patients were randomly assigned to receive early tracheostomy within 4 days of admission or late tracheostomy after 10 days if the procedure was still deemed necessary.

Short-term and long-term mortality rates were nearly identical for both groups. After 30 days, 139 patients (30.8%; 95% confidence interval [CI], 26.7% - 35.2%) in the early group and 141 patients (31.5%; 95% CI, 27.3% - 35.9%) in the late group had died. Similarly, after 2 years, about half the individuals in both groups had died (51.0% [95% CI, 46.4% - 55.6%] in the early group vs 53.7% [95% CI, 49.1% - 58.3%] in the late group).

Moreover, by waiting, many of the patients assigned to the late group were able to avoid the tracheostomy procedure entirely. Of the 455 patients randomly assigned to the early group, 91.9% (95% CI, 89.0% - 94.1%) received a tracheostomy, compared with 44.9% (95% CI, 40.4% - 49.5%) of the 454 patients in the late group. For the 622 patients who received tracheostomies, 23 (5.5%) of 418 patients in the early group and 16 (7.8%) of 204 patients in the late group developed procedure-related complications, including bleeding that required intravenous fluids or another treatment. There was no difference in the length of the hospital stay between groups.

"The implications, for clinical practice and for patients, from this study are found from the results in the late group," the authors write. "Not only were there no statistically significant difference in mortality between the 2 groups but, through waiting, an invasive procedure was avoided in a third of patients."

In an accompanying editorial, Derek C. Angus, MD, MPH, from the Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania, notes that this is the second randomized trial to show no benefit from early tracheostomy. "Therefore, until development of a robust tool to predict prolonged need of ventilation, tracheostomy generally should be delayed until at least 10 days after initiating mechanical ventilation," he writes.

The study was funded by the UK Intensive Care Society and the Medical Research Council. The authors have disclosed no relevant financial relationships.

JAMA. 2013;309:2121-2129.

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