JAMA 2010;303:1537-1538

Endotracheal intubation is the most common procedure for airway control for patients requiring mechanical ventilation. Extubation is performed once patients have improved so that mechanical ventilation can be discontinued. For patients who require prolonged mechanical ventilation, replacement of the endotracheal tube with a tracheotomy is often considered. The most common reason for tracheotomy insertion in the intensive care unit (ICU) is to provide access for prolonged mechanical ventilation. From observational data, between 6% and 11% of mechanically ventilated patients receive a tracheotomy after a median of 9 to 12 days; however, there is significant variability around both patient selection and timing.

Tracheotomy practice is variable in large part because what constitutes prolonged mechanical ventilation (ie, the optimal timing for tracheotomy) is not known. Defining and predicting the need for prolonged ventilation has been a major methodological challenge. Research on tracheotomy timing involves evaluating a 2-part study……

JAMA 2010;303:1483-1489

Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources.

Objective
To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days.

Design, setting and patients
Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater.

Intervention
Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy).

Main outcome measures
The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive.

Results
Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15).

Conclusion
Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia.

Critical Care 2010, 14:R26

Mechanical ventilation of patients may be accomplished by either translaryngeal intubation or tracheostomy. While numerous ICU studies have compared various outcomes between the two techniques, there is no definitive consensus that tracheostomy is superior. Comparable studies have not been performed in a respiratory care center (RCC) setting.

Methods
This was a retrospective observational study of 985 tracheostomy and 227 translaryngeal intubated patients who received treatment in a 24-bed RCC between November 1999 and December 2005. Treatment and mortality outcomes were compared between tracheostomized and translaryngeal intubated patients, and the factors associated with positive outcomes in all patients were determined.

Results
Duration of RCC (22 vs. 14 days) and total hospital stay (82 vs. 64 days) and total mechanical ventilation days (53 vs. 41 days) were significantly longer in tracheostomized patients (all P<0.05). The rate of in-hospital mortality was significantly higher in the translaryngeal group (45% vs. 31%, P<0.05). There were no significant differences in weaning success between the groups (both were over 55%), nor RCC mortality. Due to significant baseline between group heterogeneity, case match analysis was performed. This analysis confirmed the whole cohort findings, except for the fact that there was only a trend for in-hospital mortality to be higher in the translaryngeal group (P=0.08). Stepwise logistic regression revealed that patients with a lower median severity of disease (APACHE II score <18) who were properly nourished (albumin >2.5 g/dL) or had normal metabolism (BUN <40 mg/dL) were more likely to be successfully weaned and survive (all P<0.05). Patients who were tracheostomized were also significantly more likely to survive (P<0.05)

Conclusions
These findings suggest that the type of mechanical ventilation does not appear to be an important determinant of weaning success in an RCC setting. Focused care administered by experienced providers may be more important for facilitating weaning success than the ventilation method used. However, our findings do suggest that tracheostomy may increase the likelihood of patient survival.

Crit Care Med 2008; 36:2547-2557

Tracheostomy is common in intensive care unit patients, but the appropriate timing is controversial.

Objective
To determine whether earlier tracheostomy is associated with greater long-term survival.

Design
Retrospective cohort analysis.

Setting
Acute care hospitals in Ontario, Canada (n = 114).

Patients
All mechanically ventilated intensive care unit patients who received tracheostomy between April 1, 1992 and March 31, 2004, excluding extreme cases (<2 or >=28 days) and children (<18 yrs).

Measurements
For crude analyses, tracheostomy timing was classified as early (<=10 days) vs. late (>10 days) with mortality measured at multiple follow-up intervals. Proportional hazards analyses considered tracheostomy as a time-dependent variable to adjust for measurable confounders and possible survivor treatment bias. We used stratification, propensity score, and instrumental variable analyses to adjust for patient differences.

Results
A total of 10,927 patients received tracheostomy during the study, of which one-third (n = 3758) received early and two-thirds late (n = 7169). Patients receiving early tracheostomy had lower unadjusted 90-day (34.8% vs. 36.9%; p = 0.032), 1 yr (46.5% vs. 49.8%; p = 0.001), and study mortality (63.9% vs. 67.2%; p < 0.001) than patients receiving late tracheostomy. Multivariable analyses treating tracheostomy as a time-dependent variable showed that each additional delay of 1 day was associated with increased mortality (hazard ratio 1.008, 95% confidence interval 1.004-1.012), equivalent to an increase in 90-day mortality from 36.2% to 37.6% per week of delay (relative risk increase 3.9%; number needed to treat, 71 patients to save one life per week delay).

Limitations
This analysis provides guidance regarding timing but not patient selection for tracheostomy.

Conclusions
Physicians performing early tracheostomy should not anticipate a large potential survival benefit. Future research should concentrate on identifying which patients will receive the most benefit

Eur Arch Otorhinolaryngol. 2008 Apr 12

A prospective study was designed to compare two single-dilator percutaneous tracheotomy techniques, the Ciaglia BlueRhino and the Percutwist technique. One hundred and ninety adult patients were included, 166 with the BlueRhino, a conical shaped, flexible rubber dilator, and 24 with the Percutwist, a screw like dilating device. The procedure was performed under fiberscopy in the intensive care unit (ICU). Age, body mass index (BMI), indication for tracheotomy, surgical landmarks, duration of the procedure and surgical complications were recorded. Median age and indications were similar for the two groups. Dilation was successful in all patients. The mean time for surgery was shorter with the Ciaglia technique: 8 +/- 3 versus 12 +/- 5 min with the Percutwist technique (P = 0.004). There was no significant difference related to weight, BMI, duration of tracheotomy and complications between both groups. One posterior tracheal wall puncture was observed with the Ciaglia technique and four with the Percutwist technique. No serious complications were noted with either technique. The Percutwist technique represents an alternative to the more established Ciaglia BlueRhino technique. The Ciaglia technique is a safe and more rapid procedure for bedside tracheotomy.

Anesth Analg 2003;96:229-232

PercuTwist is a new technique for percutaneous tracheostomy in that stoma dilation is achieved with a unique screwlike dilating device. We describe the technique itself and our first clinical experiences with PercuTwist.

This is the original movie made by Rusch. Approx. 14 minutes.

Critical Care Medicine 2007;35:132-138

To examine the association between the performance of a tracheostomy and intensive care unit and postintensive care unit mortality, controlling for treatment selection bias and confounding variables.

Design
Prospective, observational, cohort study.

Setting
Twelve French medical or surgical intensive care units.

Patients
Unselected patients requiring mechanical ventilation for >=48 hrs enrolled between 1997 and 2004.

Measurements and Main Results
Two models of propensity scores for tracheostomy were built using multivariate logistic regression. After matching on these propensity scores, the association of tracheostomy with outcomes was assessed using multivariate conditional logistic regression. Results obtained with the two models were compared. Of the 2,186 patients included, 177 (8.1%) received a tracheostomy. Both models led to similar results. Tracheostomy did not improve intensive care unit survival (model 1: odds ratio, 0.94; 95% confidence interval, 0.63-1.39; p = .74; model 2: odds ratio, 1.12; 95% confidence interval, 0.75-1.67; p = .59). There was no difference whether tracheostomy was performed early (within 7 days of ventilation) or late (after 7 days of ventilation). In patients discharged free from mechanical ventilation, tracheostomy was associated with increased postintensive care unit mortality when the tracheostomy tube was left in place (model 1: odds ratio, 3.73; 95% confidence interval, 1.41-9.83; p = .008; model 2: odds ratio, 4.63; 95% confidence interval, 1.68-12.72, p = .003).

Conclusions
Tracheostomy does not seem to reduce intensive care unit mortality when performed in unselected patients but may represent a burden after intensive care unit discharge.

Critical Care 2006, 10:R99

Translaryngeal intubated and ventilated patients often need sedation to treat anxiety, agitation and/or pain. Current opinion is that tracheotomy reduces sedation requirements. We determined sedation needs before and after tracheotomy of intubated and mechanically ventilated patients.

Methods
We performed a retrospective analysis of the use of morphine, midazolam and propofol in patients before and after tracheotomy.

Results
Of 1,788 patients admitted to our intensive care unit during the study period, 129 (7%) were tracheotomized. After the exclusion of patients who received a tracheotomy before or at the day of admittance, 117 patients were left for analysis. The daily dose (DD; the amount of sedatives for each day) divided by the mean daily dose (MDD; the mean amount of sedatives per day for the study period) in the week before and the week after tracheotomy was 1.07 ± 0.93 DD/MDD versus 0.30 ± 0.65 for morphine, 0.84 ± 1.03 versus 0.11 ± 0.46 for midazolam, and 0.62 ± 1.05 versus 0.15 ± 0.45 for propofol (p < 0.01). However, when we focused on a shorter time interval (two days before and after tracheotomy), there were no differences in prescribed doses of morphine and midazolam. Studying the course in DD/MDD from seven days before the placement of tracheotomy, we found a significant decline in dosage. From day -7 to day -1, morphine dosage (DD/MDD) declined by 3.34 (95% confidence interval -1.61 to -6.24), midazolam dosage by 2.95 (-1.49 to -5.29) and propofol dosage by 1.05 (-0.41 to -2.01). After tracheotomy, no further decrease in DD/MDD was observed and the dosage remained stable for all sedatives. Patients in the non-surgical and acute surgical groups received higher dosages of midazolam than patients in the elective surgical group. Time until tracheotomy did not influence sedation requirements. In addition, there was no significant difference in sedation between different patient groups.

Conclusion
In our intensive care unit, sedation requirements were not further reduced after tracheotomy. Sedation requirements were already sharply declining before tracheotomy was performed.