Tracheotomy is performed during the ventilation of patients who present with difficulty weaning. The contribution of precocious tracheotomy in ICU (intensive care unit) patients is still debated in comparison with prolonged intubation. The main purpose of our study was to assess if tracheotomy compared to prolonged intubation, reduces the duration of ventilation, frequency of nosocomial pneumopathy (NP), length of stay and mortality in a medical ICU.
Patients and methods
It was a retrospective and comparative study, conducted during seven years (2001-2007) in the medical intensive care unit at Ibn Rochd University hospital. We included patients who presented with neurological injuries or respiratory failure and required mechanical ventilation (MV) for more than three weeks. We divided them into 2 groups: Tracheotomy Group (TG, n=30) (the tracheotomy was performed between the eighth day and the fifteenth day, after the first period of tracheal intubation; and Intubation Group (IG, n=30) (patients are intubated throughout the period of hospitalization until extubation or death). Tracheotomy was performed using a surgical technique in the ICU by a critical care physician with low pressure tracheotomy tube cuffs. We measured duration of ventilation, frequency of NP, length of stay in ICU, incidence of each technique and mortality in ICU. NP is a ventilator associated pneumonia, defined by fever (>38.3 °C), leukocytosis or leucopenia, purulent bronchial secretions, and a new or persistent infiltrate on chest radiography after 48 hours stay in ICU, and confirmed by bronchalveolar lavage. The two groups were similar in mean age (40 ± 9 vs. 42 ± 11 years), sex-ratio (1.2 vs. 1.4), gravity score (SAPS II and APACHE II) (table 1) and diagnosis (figure 1). The parameters in each group were compared using Chi-2 test and Fischer's exact test when necessary for qualitative variables. We compared qualitative variables using Student's t test. P < 0.05 was considered significant. All data were analyzed with SPSS 11.0 for Windows.
A total of 60 patients, who required MV, were recruited in our study. The mean age was 41 ± 11 years. Cerebral hemorrhage and chronic obstructive pulmonary disease were the predominant diagnoses, 23 % respectively (figure 1).
Table 1. Patient characteristics on admission.
(n = 30)
(n = 30)
|Age (years)||40.03 ± 10.15||41.7 ± 12.41||0.53|
|SAPS II||28.13 ± 3.57||29.97 ± 5.83||0.64|
|APACHE II||12.13 ± 2.54||14.67 ±10.26||0.17|
Tracheotomy Group (TG),Intubation Group (IG)
Table 2. Comparison of ventilatory and nosocomial pneumopathy data.
|TG (n = 30)||IG (n = 30)||P|
|Number of weaning tentative||1.31 ± 0.47||1.18 ± 0.40||0.37|
|Total length of mechanical ventilation (day)||27.03 ± 3.31||31.63 ± 6.05||0.001|
|Nosocomial Pneumopathy (NP) n (%)||16 (53.3)||21 (70)||0.18|
|Appearance of NP (day)||11.12 ± 2.72||8.8 ± 1.50||0.003|
|Number of days of mechanical ventilation after NP||10 ± 2.36||15.04 ± 11.17||0.23|
Tracheotomy Group (TG),Intubation Group (IG)
Tracheotomy is frequently performed in the ICU. It is recommended to: improve respiratory mechanics, nutrition, patient comfort and clearance of secretion, to reduce laryngeal ulceration, enhance mobility and speech and it enables care of the patient outside the ICU. (1) The optimal time to perform a tracheotomy remains controversial. Early tracheotomy in critically ill medical patients who undergo ≥ 14 days of ventilation may have significant benefits over delayed tracheotomy. These include reduction in mortality rate, frequency of pneumonia, duration of mechanical ventilation, and length of time in intensive care. (2) In surgical ICU patients, Bouderka concluded that early tracheotomy decreases the total days of the ventilator and mechanical ventilatory time after pneumonia in isolated severe head injury. It did not reduce either ICU stay or the frequency of pneumonia or mortality. (3) Our study demonstrates that early tracheotomy has advantages over prolonged intubation in medical ICU patients who required ventilation > 14 days. The first group spent significantly less time on ventilation and had delayed nosocomial pneumopathy. The last finding in our study is not found in others papers. In critically ill adult patients who require prolonged mechanical ventilation, performing a tracheostomy at an earlier stage than is currently practiced may shorten the duration of artificial ventilation and length of stay in intensive care. On the one hand, we think that, in the tracheotomy group, the number of tracheal aspirations is less frequent and easy. On the other hand, ventilator weaning is precocious, which decreases alveolar aggressions due to the mechanical ventilation.
Laryngo-tracheal injuries constitute an important element for specifying the optimal moment for performing tracheotomy, in patients requiring prolonged ventilation. Several authors affirm that the greater the duration of intubation, the greater the impact and gravity of these injuries. Rumbak concluded, through a prospective and randomized survey, that the maximum of these lesions occur with tardive tracheotomy, showing the profit of precocious tracheotomy as soon as possible. (2) Otherwise, Stauffer in a prospective survey including 150 patients showed that prolonged intubation provokes less tracheal complications than tracheotomy (62% versus 66%), particularly tracheal stenosis (19% versus 65%). (4) Tracheomalacia as well as esotracheal fistulas are more frequent with tracheotomy than with intubation. (5) Maxillary sinusitis occurs more often with intubation than with tracheotomy. (6) The tracheotomy mortality is minimal, Rodriguez (7) reported 0%, and Berlauk 3%. (8) A recent meta-analysis concluded that critically ill adult patients who require prolonged mechanical ventilation, performing a tracheostomy at an earlier stage than is currently practiced may shorten the duration of artificial ventilation and length of stay in intensive care. (9)
It seems that tracheotomy in medical ICU patients leads to decreased duration of ventilation, delayed nosocomial pneumopathy without modifying its frequency and the mean duration of hospitalization or death.
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