Early versus Late Tracheostomy under Sedation in Critical Care: A Single-Center Retrospective Cohort Study.

Subhash Chandra; Madhukant; Neha Chahar

doi:10.51168/hgy5z171

Authors

Subhash Chandra Assistant Professor, Department of Critical Care Medicine, Mahatma Gandhi Medical College, Jaipur, Rajasthan, India
Madhukant Specialist Medical Officer, Department of Anaesthesia, Indira Gandhi Institute of Cardiac Sciences, Patna, Bihar, India
Neha Chahar Junior Specialist, Department of Anaesthesia, Government Sub-District Hospital Chaksu, Jaipur, Rajasthan, India

DOI:

https://doi.org/10.51168/hgy5z171

Keywords:

Early tracheostomy, Critical care, Mechanical ventilation, Sedation, Ventilator-associated pneumonia

Abstract

Background:

The optimal timing of tracheostomy in critically ill patients requiring prolonged mechanical ventilation remains controversial. Early tracheostomy has been associated with improved clinical outcomes, but its impact on mortality remains uncertain.

Objective:

To compare the clinical outcomes of early (≤7 days) versus late (>7 days) tracheostomy under sedation in critically ill patients requiring prolonged mechanical ventilation.

Methods:

A single-center retrospective cohort study was conducted in the adult intensive care units of a tertiary care hospital in Gurgaon, India, from April 2024 to April 2025. A total of 140 patients were equally divided into early (n = 70) and late (n = 70) tracheostomy groups. Clinical characteristics, duration of mechanical ventilation, sedation duration, intensive care unit (ICU) and hospital stay, ventilator-associated pneumonia (VAP), mortality, and discharge outcomes were compared. Multivariable logistic regression was performed to identify predictors of in-hospital mortality.

Results:

Baseline characteristics were comparable between groups. Early tracheostomy significantly reduced the duration of mechanical ventilation (10.8 ± 4.2 vs. 15.6 ± 5.1 days), sedation (7.2 ± 3.1 vs. 11.4 ± 4.3 days), ICU stay (12.6 ± 5.3 vs. 18.1 ± 6.2 days), and hospital stay (18.9 ± 7.4 vs. 25.3 ± 8.6 days) (all p < 0.001). VAP occurred less frequently in the early group (17.1% vs. 34.3%; p = 0.02). ICU and in-hospital mortality did not differ significantly. APACHE II score independently predicted in-hospital mortality.

Conclusion:

Early tracheostomy was associated with improved clinical recovery and fewer complications but did not significantly reduce mortality.

Recommendation:

Early tracheostomy should be considered for appropriately selected patients expected to require prolonged mechanical ventilation. Larger prospective multicenter studies are needed to validate these findings.

References

1. Wang F, Wu Y, Bo L, Lou J, Zhu J, Chen F, Li J, Deng X. The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials. Chest. 2011 Dec 1;140(6):1456-65.Meng L, Wang C, Li J, Zhang J. Early vs late tracheostomy in critically ill patients: a meta-analysis. Clin Respir J. 2016;10(6):684-92. (PubMed) https://doi.org/10.1378/chest.11-2024

2. Szakmany T, Russell P, Wilkes AR, Hall JE. Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials. British journal of anaesthesia. 2015 Mar 1;114(3):396-405. https://doi.org/10.1093/bja/aeu440

3. Durbin Jr CG, Perkins MP, Moores LK. Should tracheostomy be performed as early as 72 hours in patients requiring prolonged mechanical ventilation?. Respiratory care. 2010 Jan;55(1):76-87. https://doi.org/10.4187/respcare.10550076

4. Chen TJ, Chung YW, Chen PY, Hu SH, Chang CC, Hsieh SH, Wang BC, Chiu HY. Effects of daily sedation interruption in intensive care unit patients undergoing mechanical ventilation: A meta‐analysis of randomized controlled trials. International journal of nursing practice. 2022 Apr;28(2):e12948. https://doi.org/10.1111/ijn.12948

5. Zheng Y, Feng SU, ZHANG GC, Song ZH, Yang SO, Wei LI, Xin XI. Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation. Chinese medical journal. 2012 Jun 1;125(11):1925-30.

6. Blot F, Similowski T, Trouillet JL, Chardon P, Korach JM, Costa MA, Journois D, Thiéry G, Fartoukh M, Pipien I, Bruder N. Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients. Intensive care medicine. 2008 Oct;34(10):1779-87.https://doi.org/10.1007/s00134-008-1195-4

7. 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 May 26;330(7502):1243. https://doi.org/10.1136/bmj.38467.485671.E0

8. Adly A, Youssef TA, El-Begermy MM, Younis HM. Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review. European Archives of Oto-Rhino-Laryngology. 2018 Mar;275(3):679-90. https://doi.org/10.1007/s00405-017-4838-7

9. Durbin Jr CG. Tracheostomy: why, when, and how?. Respiratory care. 2010 Aug;55(8):1056-68. https://doi.org/10.4187/respcare.10551056

10. Mehta S, Burry L, Cook D, Fergusson D, Steinberg M, Granton J, Herridge M, Ferguson N, Devlin J, Tanios M, Dodek P. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. Jama. 2012 Nov 21;308(19):1985-92. https://doi.org/10.1001/jama.2012.13872

11. Zhao J, Zheng W, Xuan NX, Zhou QC, Wu WB, Cui W, Tian BP. The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a Chinese tertiary hospital. BMC anesthesiology. 2024 Jan 23;24(1):39. https://doi.org/10.1186/s12871-024-02411-1

12. Trouillet JL, Luyt CE, Guiguet M, Ouattara A, Vaissier E, Makri R, Nieszkowska A, Leprince P, Pavie A, Chastre J, Combes A. Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: a randomized trial. Annals of internal medicine. 2011 Mar 15;154(6):373-83. https://doi.org/10.7326/0003-4819-154-6-201103150-00002

13. McCredie VA, Alali AS, Scales DC, Adhikari NK, Rubenfeld GD, Cuthbertson BH, Nathens AB. Effect of early versus late tracheostomy or prolonged intubation in critically ill patients with acute brain injury: a systematic review and meta-analysis. Neurocritical care. 2017 Feb;26(1):14-25. https://doi.org/10.1007/s12028-016-0297-z

14. Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. Jama. 2013 May 22;309(20):2121-9. https://doi.org/10.1001/jama.2013.5154