Early tracheotomy: the end of the controversy?

Abstract

The expected benefit of a tracheotomy is the reduction in complications associated with prolonged intubation such as laryngotracheal injuries, ventilator-associated pneumonia, sinusitis, discomfort, sedation-analgesia and risk of self-extubation. Retrospective and non-randomized studies have reported a decrease in duration of mechanical ventilation and even in mortality may occur if tracheotomy is performed early, before the seventh day post-intubation. In 2004, a randomized trial including severely critically ill patients in 3 ICUs found very positive results, reopening the controversy. Since this date, at least nine randomized trials have been conducted. The last three trials, TracMan, ETOC and the Italian trial, reached their terms, and their results are now available. They have shown no particular benefit for early tracheotomy as opposed to late tracheotomy in terms of mortality, ventilation duration (except for the Italian trial) length of the hospitalization stay and ventilator-associated pneumonia. However, two of them have confirmed a decrease in sedation analgesia. These three studies involving more than 1,500 patients, associated with five other globally negative trials, allow closing the controversy. There is no interest to perform an early tracheotomy, neither in terms of vital prognosis nor in terms of the duration of mechanical ventilation, however critically ill the patient is. Because benefits of tracheotomy are of “secondary importance”, it is now mandatory to determine for which patients this invasive procedure is relevant and why.