Early vs Late Tracheotomy for Prevention of Pneumonia in Mechanically Ventilated Adult ICU Patients A Randomized Controlled Trial

Anestesia e Rianimazione 1, Ospedale S. Giovanni Battista, Università di Torino, Turin, Italy.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 04/2010; 303(15):1483-9. DOI: 10.1001/jama.2010.447
Source: PubMed


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.
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.
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.
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).
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.
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).
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. Identifier: NCT00262431.

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    • "Therefore, patients with a predicted prolonged intubation would benefit from a tracheostomy made within the first week of intubation. Recent studies from Germany 11 , 12 , USA 13 , Spain 14 and Italy 15 , have shown an improvement in secondary outcomes as length of stay at the ICU, days of mechanical ventilation, ventilator associated pneumonia but not in mortality. "
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    ABSTRACT: Introduction: There are no established guidelines for selecting patients for early tracheostomy. The aim was to determine the factors that could predict the possibility of intubation longer than 7 days in critically ill adult patients. Methods: This is cohort study made at a general intensive care unit. Patients who required at least 48 hours of mechanical ventilation were included. Data on the clinical and physiologic features were collected for every intubated patient on the third day. Uni- and multivariate statistical analyses were conducted to determine the variables associated with extubation. Results: 163 (62%) were male, and the median age was 59±17 years. Almost one-third (36%) of patients required mechanical ventilation longer than 7 days. The variables strongly associated with prolonged mechanical ventilation were: age (HR 0.97 (95% CI 0.96-0.99); diagnosis of surgical emergency in a patient with a medical condition (HR 3.68 (95% CI 1.62-8.35), diagnosis of surgical condition-non emergency (HR 8.17 (95% CI 2.12-31.3); diagnosis of non-surgical-medical condition (HR 5.26 (95% CI 1.85-14.9); APACHE II (HR 0.91 (95% CI 0.85-0.97) and SAPS II score (HR 1.04 (95% CI 1.00-1.09) The area under ROC curve used for prediction was 0.52. 16% of patients were extubated after day 8 of intubation. Conclusions: It was not possible to predict early extubation in critically ill adult patients with invasive mechanical ventilation with common clinical scales used at the ICU. However, the probability of successfully weaning patients from mechanical ventilation without a tracheostomy is low after the eighth day of intubation.
    Full-text · Article · Sep 2013
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    • "The reported incidence of pneumonia in the other methods for prevention of pneumonia (including early and late tracheotomy, pharmacological treatment and conventional methods) is between 14% and 25%. The incidence of pneumonia in this study was 14% and 25% in intervention and control groups, respectively.18,19,22 "
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    ABSTRACT: Objective: To evaluate the role of flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) on pneumonia prevention of tracheostomy patients in intensive care unit. Methodology: This clinical trial was conducted on 67 head-injury patients who needed tracheostomy. The eligible patients were divided into two groups of different methods for removing the airway secretions. In intervention group, FB and BAL was added to routine conventional methods for airway clearance. Patients were followed for signs and symptoms of pneumonia. Results : The risk of nosocomial pneumonia decreased from 35% to 14% in intervention group. The days of hospital stay were significantly reduced with bronchoscopic method. Conclusions: Flexible Bronchoscopy is recommended to all ICU admitted patients that have tracheostomy tube and high volume of secretion in their airways. It can not only prevent the pneumonia formation decrease the morbidity and mortality rate but it can even shorten the ICU stay time and consequently reduce the costs of treatment.
    Full-text · Article · Feb 2013 · Pakistan Journal of Medical Sciences Online
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    • "Additional measures to decrease VAP include daily vacation sedation to examine readiness for extubation, management of upper airway secretions with closed aspiration systems, and strict control of endotracheal-tube cuff pressures, policies related to hand hygiene, head elevation at 45 • , oral hygiene with chlorhexidine preparations, along with stress ulcer prophylaxis with H2 or proton-pump inhibitors [19]. Though neurological patients experience more early tracheotomies in general [1], this practice has not been associated with improved patient outcomes, particularly mortality or onset of VAP [20] [21]. Accumulation of fluid in the pleural space and bacterial infection may result in empyema. "
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    ABSTRACT: Pulmonary complications are prevalent in the critically ill neurological population. Respiratory failure, pneumonia, acute lung injury and the acute respiratory distress syndrome (ALI/ARDS), pulmonary edema, pulmonary contusions and pneumo/hemothorax, and pulmonary embolism are frequently encountered in the setting of severe brain injury. Direct brain injury, depressed level of consciousness and inability to protect the airway, disruption of natural defense barriers, decreased mobility, and secondary neurological insults inherent to severe brain injury are the main cause of pulmonary complications in critically ill neurological patients. Prevention strategies and current and future therapies need to be implemented to avoid and treat the development of these life-threatening medical complications.
    Full-text · Article · Oct 2012 · Critical care research and practice
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