Early vs Late Tracheotomy for Prevention of Pneumonia in Mechanically Ventilated Adult ICU Patients: A Randomized Controlled Trial | Critical Care Medicine | JAMA | JAMA Network
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Caring for the Critically Ill Patient
April 21, 2010

Early vs Late Tracheotomy for Prevention of Pneumonia in Mechanically Ventilated Adult ICU Patients: A Randomized Controlled Trial

Author Affiliations

Author Affiliations: Anestesia e Rianimazione 1 (Drs Terragni, Faggiano, Urbino, Filippini, Mascia, and Ranieri), Anestesia e Rianimazione 3 (Dr Berardino), Ospedale S. Giovanni Battista, and Cancer Epidemiology Unit, CPO Piemonte, CeRMS (Drs Pagano, Evangelista, and Ciccone), Università di Torino, Turin, Italy; Terapia Intensiva, Policlinico A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy (Dr Antonelli); Anestesia e Rianimazione, Ospedale San Gerardo di Monza, University of Milano-Bicocca, Milan, Italy (Dr Fumagalli); Anestesia e Rianimazione, Azienda Ospedaliera Universitaria San Martino, Genoa, Italy (Dr Pallavicini); Anestesia e Rianimazione, Azienda Ospedaliera CTO, Turin, Italy (Dr Miletto); Anestesia e Rianimazione, Policlinico P. Giaccone, Università di Palermo, Palermo, Italy (Dr Mangione); Anestesia e Rianimazione, Policlinico Universitario, Università di Messina, Messina, Italy (Dr Sinardi); Anestesia e Rianimazione, Ospedale E. Agnelli, Pinerolo, Turin, Italy (Dr Pastorelli); Anestesia e Rianimazione, Ospedale SS Antonio e Biagio, Alessandria, Italy (Dr Vivaldi); Anestesia e Rianimazione, Azienda Ospedaliera Universitaria, Università di Modena, Modena, Italy (Dr Pasetto); and Anestesia e Rianimazione, Azienda Ospedaliera Universitaria, Università di Udine, Udine, Italy (Dr Della Rocca).

JAMA. 2010;303(15):1483-1489. doi:10.1001/jama.2010.447
Abstract

Context Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources.

Objective To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days.

Design, Setting, and Patients Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater.

Intervention Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy).

Main Outcome Measures The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive.

Results Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15).

Conclusion Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia.

Trial Registration clinicaltrials.gov Identifier: NCT00262431

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