- No high-quality studies have definitively answered the question of whether routine, early tracheostomy improves clinical outcomes:
- Studies are difficult to design
- Doctors are poor at predicting which patients may undergo successful extubation within the next few days, thereby avoiding unnecessary tracheostomy
- Accumulated evidence and expert opinion suggest early tracheostomy does not improve survival or even shorten hospital stay
- The largest trial to explore the question is the TRACMAN trial:
Population
Intervention
Conclusion
- Intubated and ventilated patients expected to require at least seven further days of ventilation
- Excluded those with potential indications for early tracheostomy (airway obstruction, neurological illness, TBI)
- Early (within four days of admission) vs. late (on/after day 10) tracheostomy
- Primary outcome 30-day mortality
- No difference in mortality at any point over the two-year follow-up
Early group: - Non-significant trend towards shorter duration of mechanical ventilation
- Significantly fewer days of sedation administration
Late group: - Only 43% of the patients in the late group went on to receive a tracheostomy (many not intubated)
- 6.3% complication rate for the tracheostomies that were performed
- Eight RCTs with a total of 1,977 participants
- Early tracheostomy (two to 10 days after intubation) vs. late tracheostomy (> 10 days after intubation) for critically ill adult patients
- Results from seven RCTs (n = 1903) showed lower mortality rates in the early as compared with the late tracheostomy group (risk ratio (RR) 0.83, P value 0.03)
- However due to low quality evidence review concluded results "no more than suggestive of the superiority of early over late tracheostomy"