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Systematic review and meta-analysis of studies of the timing of
tracheostomy in adult patients undergoing artificial ventilation
Dear Sir,
We read with interest the paper by Griffiths et al published in the
28th May edition of the BMJ. This review and meta-analysis concludes that
tracheostomies should be performed earlier in critically ill patients. As
ENT surgeons we find the potential ramifications of this paper quite
alarming, and note that the authorship does not include a member of our
specialty. Firstly, undertaking an operation which is by no means a minor
procedure and therefore not without potential morbidity in patients who
are already systemically unwell (ASA grades 4 and 5) (1,2). These patients
are often anaemic, have coagulopathies and sepsis amongst other co-
morbidity, points which we felt the authors had failed to discuss, and
factors that have implications for the surgical procedure. Secondly, and
more importantly, it is our experience that many patients listed for
tracheostomy from the ITU are extubated or sometimes die whilst waiting
for their procedure because they often get delayed due to being deemed as
semi-urgent cases. If they were performed immediately, as this paper
suggests, these patients would be subjected to unnecessary procedures. The
post-operative sequelae of tracheostomy are a slow weaning process before
patients can be decannulated followed by potential tracheal stenosis (3-
6). These patients may be able to leave ITU earlier, but this paper does
not tell us about how long they then remain an inpatient before discharge
due to the issues surrounding the patient rehabilitation with a
tracheostomy tube in situ. It is interesting to note that although
duration of ventilation and stay in the ITU were shortened by an earlier
tracheostomy, the mortality was not altered and there is no appreciation
for the morbidity. In fact a paper by Frutos-Vivar et al this year
concluded: “Tracheostomy is a common surgical procedure in the intensive
care unit that is associated with a lower mortality in the unit but with a
longer stay and a similar mortality in the hospital than in patients
without tracheostomy” (7).
The authors have chosen to divide timing of tracheostomy into 2
groups demarcated by 7 days post-intubation, making an artificial
separation which seems invalid. It would have been more interesting to see
the variables measured against days after intubation on a linear scale
i.e. does increasing number of days have a proportional relationship to
the duration of ventilation and stay in ITU? Finally, the paper fails to
mention whether the tracheostomies were performed percutaneously or as a
formal surgical procedure as this has implications for the use of theatres
and the involvement of members of our specialty, but most importantly on
patient outcomes. In conclusion, we would like to advise great caution in
the interpretation of the findings of Griffiths et al and its impact on
the delivery of the tracheostomy service in hospitals.
Mr Carl Philpott
Specialist Registrar in Otolaryngology
Mr Alex Bennett
Specialist Registrar in Otolaryngology
Mr Peter Tassone
Specialist Registrar in Otolaryngology
Departments of Otolaryngology, Norfolk & Norwich University
Hospital & James Paget Hospital, Norfolk
References:
1. McCormick B, Manara AR. Mortality from percutaneous dilatational
tracheostomy. A report of three cases. Anaesthesia 2005;60(5):490-5.
2. Mpe MJ, Mphahlele BV. In-hospital outcome of patients discharged
from the ICU with tracheostomies. South African Medical Journal. Suid
Afrikaanse Tydskrif Vir Geneeskunde 2005;95(3):184-6.
3. Dongelmans DA, van der Meer NJ, Schultz MJ. [Percutaneous
dilatating tracheostomy in intensive-care patients: technique, indications
and complications].[see comment]. Nederlands Tijdschrift voor Geneeskunde
2003;147(48):2370-4.
4. Sue RD, Susanto I. Long-term complications of artificial airways.
Clinics in Chest Medicine 2003;24(3):457-71.
5. Godin DA, Rodriguez KH, Hebert F. Tracheal stenosis. Journal of
the Louisiana State Medical Society 2000;152(6):276-80.
6. Norwood S, Vallina VL, Short K, Saigusa M, Fernandez LG, McLarty
JW. Incidence of tracheal stenosis and other late complications after
percutaneous tracheostomy. Annals of Surgery 2000;232(2):233-41.
7. Frutos-Vivar F, Esteban A, Apezteguia C, Anzueto A, Nightingale P,
Gonzalez M, Soto L, Rodrigo C, Raad J, David CM, Matamis D, G DE,
International Mechanical Ventilation Study G. Outcome of mechanically
ventilated patients who require a tracheostomy.[comment]. Critical Care
Medicine 2005;33(2):290-8.
It is good to have confirmation that early tracheostomies lead to
easier and quicker weaning from artificial ventilation of the lungs.
However, we should not forget that tracheostomies can have both short-term
and long-term complications. For the older patient, the benefits probably
outway the disadvantages. For younger patients, there may be permanent
narrowing of the trachea, leading to problems later in life. In such
patients, I would suggest that a slightly longer time attached to a
ventilator might be a small price to pay for a few decades with a trachea
of a normal diameter. For this reason, I would be inclined to recommend
late tracheostomies in young adults, or indeed to use them only as a last
resort.
Earlier tracheostomy may not be best for the critically ill patient long term
Systematic review and meta-analysis of studies of the timing of
tracheostomy in adult patients undergoing artificial ventilation
Dear Sir,
We read with interest the paper by Griffiths et al published in the
28th May edition of the BMJ. This review and meta-analysis concludes that
tracheostomies should be performed earlier in critically ill patients. As
ENT surgeons we find the potential ramifications of this paper quite
alarming, and note that the authorship does not include a member of our
specialty. Firstly, undertaking an operation which is by no means a minor
procedure and therefore not without potential morbidity in patients who
are already systemically unwell (ASA grades 4 and 5) (1,2). These patients
are often anaemic, have coagulopathies and sepsis amongst other co-
morbidity, points which we felt the authors had failed to discuss, and
factors that have implications for the surgical procedure. Secondly, and
more importantly, it is our experience that many patients listed for
tracheostomy from the ITU are extubated or sometimes die whilst waiting
for their procedure because they often get delayed due to being deemed as
semi-urgent cases. If they were performed immediately, as this paper
suggests, these patients would be subjected to unnecessary procedures. The
post-operative sequelae of tracheostomy are a slow weaning process before
patients can be decannulated followed by potential tracheal stenosis (3-
6). These patients may be able to leave ITU earlier, but this paper does
not tell us about how long they then remain an inpatient before discharge
due to the issues surrounding the patient rehabilitation with a
tracheostomy tube in situ. It is interesting to note that although
duration of ventilation and stay in the ITU were shortened by an earlier
tracheostomy, the mortality was not altered and there is no appreciation
for the morbidity. In fact a paper by Frutos-Vivar et al this year
concluded: “Tracheostomy is a common surgical procedure in the intensive
care unit that is associated with a lower mortality in the unit but with a
longer stay and a similar mortality in the hospital than in patients
without tracheostomy” (7).
The authors have chosen to divide timing of tracheostomy into 2
groups demarcated by 7 days post-intubation, making an artificial
separation which seems invalid. It would have been more interesting to see
the variables measured against days after intubation on a linear scale
i.e. does increasing number of days have a proportional relationship to
the duration of ventilation and stay in ITU? Finally, the paper fails to
mention whether the tracheostomies were performed percutaneously or as a
formal surgical procedure as this has implications for the use of theatres
and the involvement of members of our specialty, but most importantly on
patient outcomes. In conclusion, we would like to advise great caution in
the interpretation of the findings of Griffiths et al and its impact on
the delivery of the tracheostomy service in hospitals.
Mr Carl Philpott
Specialist Registrar in Otolaryngology
Mr Alex Bennett
Specialist Registrar in Otolaryngology
Mr Peter Tassone
Specialist Registrar in Otolaryngology
Departments of Otolaryngology, Norfolk & Norwich University
Hospital & James Paget Hospital, Norfolk
References:
1. McCormick B, Manara AR. Mortality from percutaneous dilatational
tracheostomy. A report of three cases. Anaesthesia 2005;60(5):490-5.
2. Mpe MJ, Mphahlele BV. In-hospital outcome of patients discharged
from the ICU with tracheostomies. South African Medical Journal. Suid
Afrikaanse Tydskrif Vir Geneeskunde 2005;95(3):184-6.
3. Dongelmans DA, van der Meer NJ, Schultz MJ. [Percutaneous
dilatating tracheostomy in intensive-care patients: technique, indications
and complications].[see comment]. Nederlands Tijdschrift voor Geneeskunde
2003;147(48):2370-4.
4. Sue RD, Susanto I. Long-term complications of artificial airways.
Clinics in Chest Medicine 2003;24(3):457-71.
5. Godin DA, Rodriguez KH, Hebert F. Tracheal stenosis. Journal of
the Louisiana State Medical Society 2000;152(6):276-80.
6. Norwood S, Vallina VL, Short K, Saigusa M, Fernandez LG, McLarty
JW. Incidence of tracheal stenosis and other late complications after
percutaneous tracheostomy. Annals of Surgery 2000;232(2):233-41.
7. Frutos-Vivar F, Esteban A, Apezteguia C, Anzueto A, Nightingale P,
Gonzalez M, Soto L, Rodrigo C, Raad J, David CM, Matamis D, G DE,
International Mechanical Ventilation Study G. Outcome of mechanically
ventilated patients who require a tracheostomy.[comment]. Critical Care
Medicine 2005;33(2):290-8.
Competing interests:
None declared
Competing interests: No competing interests