“Why are the surgeons so quick to trach?”

The title question was asked of me by a pulmonary intensivist about a month ago.  My pulmonary colleague simply said, “The evidence doesn’t seem that great for it, so I don’t see the harm in waiting.  We keep people on the ventilator for a month sometimes in the MICU without a trach.” I was fascinated because I hadn’t really given the subject a great deal of thought (probably because I am one of those dreaded surgeons!), and the good news was that it drove me back to the literature to see what we really know.  I try my best to practice based upon evidence, acknowledging that in burns and critical care that evidence is limited at times.  And while I was pretty certain that a patient who has been on the ventilator for a month deserves a tracheostomy, I wasn’t sure when the best timing really is.

A great deal of the early literature on the benefits of early tracheostomy came from the trauma world; while early trach didn’t influence mortality in trauma patients, duration of mechanical ventilation and ICU stay were both shortened.  A recent propensity analysis in patients with traumatic brain injury confirmed these findings, but also added decreased rates of pneumonia, DVT, and decubitus ulcer to the benefits of early trach.

A 2005 systematic review that included a more broad ICU population demonstrated again that duration of mechanical ventilation and ICU stay were shortened, albeit with no reduction in mortality.  This lack of mortality benefit has been repeatedly confirmed, and was also shown with the 2012 Cochrane review of early versus late tracheostomy.  The Cochrane review appropriately noted the generally low quality of most studies in this area and the need for multicenter RCTs to provide definitive information.

Two posters at the recent Critical Care Congress addressed the issue of early tracheostomy, one in pediatric patients, the other in adults (but bringing a new angle in to the discussion).  As someone who does care for critically ill children who can and do have prolonged ventilator courses, the reduction in length of stay with early (<14 days) tracheostomy in pediatric ICU patients was notable to me.  However, I also recognize that their patient population in a “regular” PICU is very different from the pathophysiology of our pediatric burn population.  The Hopkins study that evaluated quality of life is the one that I find the most compelling, and is the most likely to inform my practice.  The simple fact that adult patients who underwent tracheostomy reported better quality of life than ventilated patients who did not, much less that early trach showed a significant quality of life benefit over late trach, encourages me to look at 10 days as a “fish or cut bait” point for tracheostomy, both in the Burn unit as well as the oncology ICU.

Now if I could just overcome my irrational fear of percutaneous tracheostomy…but that’s a blog for another day.