The impact of early percutaneous tracheotomy on reduction of the incidence of ventilator associated pneumonia and the course and outcome of ICU patients

The aim of the study. The primary objec-tive of this study was to determine the differences in the incidence of respiratory infections and septic episodes in patients who underwent early percutaneous trache-otomy (ET) and in patients who underwent translaryngeal intubation i.e late trache-otomy (LT). Secondary objectives were to determine the differences in the early mortality of patients, duration of mechani-cal ventilation and length of Intensive care unit (ICU) stay.

Materials and methods. The study included 72 surgical and trauma patients older than 18 years of age, treated at the ICU of the University Clinical Hospital Mostar who had undergone translaryngeal intubation and were mechanically ventilated for at least 48 hours. The basic criterion for inclu-sion in the study was expected duration of mechanical ventilation of at least 14 days. Forty-eight hours after enrollment, patients were randomly divided into two groups. The first group of patients underwent ET after 2-4 days of mechanical ventilation; the second group underwent LT if they ex-hibited longer episodes of hypoxemia after 15 days. 

Results. The ET group of patients spent less time in mechanical ventilation and ICU. The ET group had a lower rate of VAS pneumonia (p=0.137), sepsis episodes (p=0.029) and mortality rate (p=0.056). Conclusion. The results of our study sup-port ET being performed 2–4 days from the start of mechanical ventilation. De-spite a lack of power, we found significant benefits of ET regarding the incidence of pneumonia, sepsis, hospital mortality, du-ration of mechanical ventilation and length of ICU stay

tracheotomy, mechanical ventila-tion, intensive care unit, ventilator-associat-ed pneumonia, treatment outcome, compli-cations 

1. Rogers JM. Intubation vs. Tracheotomy. Can Med Assoc J. 1922;12:238–40.

2. Durbin CG. Tracheostomy: Why, when, and how? Respiratory Care 2010;55:1056-8.

3. Cox CE, Carson SS, Holmes GM, Howard A, Carey TS. Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993-2002. Crit Care Med 2004;32:2219-26.

4. Adesina O, Soufi S, Alhamad M, Walsmann G, Shilbi M. Early Versus Late Tracheostomy in Critically Ill Patients. Chest [serial online] October 2011 [Cited 2017 May 17]. Available from: URL:http://journal.publications.chestnet.org/article.aspx?articleid=1045937

5. Zheng Y, Sui F, Chen XK, Zhang GC, Wang XW, Zhao S, et al. Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation. Chin Med J (Engl) 2012;125:1925-30.

6. Koch T, Hecker B, Hecker A, Brenck F, Preuß M, Schmelzer T, et al. Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study. Langenbecks Arch Surg 2012;397:1001-8.

7. Ahmed N, Kuo YH. Early versus late tracheostomy in patients with severe traumatic head injury. Surg Infect (Larchmt) 2007;8:343-7.

8. Mahafza T, Batarseh S, Bsoul N, Massad E, Qudaisat I, Al- Layla AE. Early vs. late tracheostomy for the ICU patients: Experience in a referral hospital. Saudi J Anaesth 2012;6:152-4

9. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percu-taneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004;32:1689-94.

10. Brook AD, Sherman G, Malen J, Kollef MH. Early versus late tracheostomy in patients who require prolonged mechanical ventila-tion. Am J Crit Care. 2000;9:352-9.

11. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.

12. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med 2003;29:530-8.

13. Seneff MG, Zimmerman JE, Knaus WA, Wagner DP, Draper EA. Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest 1996;110:469-76.

14. Heffner JE, Brown LK, Barbieri CA, Harpel KS, DeLeo J. Prospective validation of an acute respiratory distress syndrome predictive score. Am J Respir Crit Care Med 1995;152:1518-25.

15. Troche G, Moine P. Is the duration of mechanical ventilation predictable? Chest 1997;112:745-51.

16. Terragni PP, Antonelli M, Fumagalli R, Faggiano C, Berardino M, Pallavicini FB, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010;303:1483-9.

17. Diaz-Prieto A, Mateu A, Gorriz M, Ortiga B, Truchero C, Sampietro N, et al. A randomized clinical trial for the timing of trache-otomy in critically ill patients: factor precluding inclusion in a single center study. Crit Care 2014;18:585-99.

18. Durbin CG Jr. Early complications of tracheostomy. Respir Care 2005;50:511-5.

19. Liu CC, Livingstone ED, Dort JC. Early versus late tracheostomy: a systematic review and meta-analysis. Otolaryngology-Head AND Neck Surgery 2015;152:219-27.

20. Nseir S, Di Pompeo C, Jozefowicz E, Cavestri B, Brisson H, Nyunga M, et al. Relatioship between tracheotomy and ventilator –associ-ated pneumonia: a case control study. Eur Respir J 2007;30:314-20.

21. Blot F, Similowski T, Trouillet JL, Chardon P, Korach JM, Costa MA, et al. Early tracheotomy versus prolonged endotracheal intuba-tion in unselected severely ill ICU patients. Intensive Care Med 2008;34:1779-87.

22. Bouderka MA, Fakhir B, Bouaggad A, Hmamouchi B, Hamoudi D, Harti A. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma 2004;57:251-4.

23. Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery 1990;108:655-9.

24. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330:1243.

25. Young D, Harrison DA, Cuthbertson BH, Rowan K; TracMan Collaborators. Effect of early versus late tracheotomy placement on survival in patients receiving mechanical ventilation. JAMA 2013;309:2121-9.

26. Clec'h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, et al. Tracheotomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity a propensity analysis. Crit Care Med 2007;35:132-8.

27. Scales DC , Thiruchelvam D, Kiss A, Redelmeier DA. The effect of trachostomy timing during critical care illness on long term sur-vival. Crit Care Med 2008;36:2547-57.

28. Dunham CM, Ransom KJ. Assesment of early tracheostomy in trauma patients: a systematic review and meta –analysis. Am Surg 2006;72:276–81.

29. Frutos-Vivar F, Esteban A, Apezteguía C, Anzueto A, Nightingale P, González M, et al. Outcome of mechanically ventilated patients who required tracheostomy. Crit Care Med 2005;33:290–8.

30. Wang F, Wu Y, Bo L, Lou J, Zhu J, Chen F, et al. The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Chest. 2011;140:1456-65.