Timing of tracheostomy

PRACTICE MANAGEMENT GUIDELINES FOR THE TIMING OF TRACHEOSTOMY

The EAST Practice Management Guidelines Work Group Michele Holevar, MD (Chair)1, J. C. Michael Dunham, MD (Vice-Chair)2, Thomas V. Clancy, MD3, John J. Como, MD4, James B. Ebert, MD5, Margaret M. Griffen, MD6, William S. Hoff, MD7, Stanley J. Kurek, Jr., DO8, Susan M. Talbert, MD9, Samuel A. Tisherman, MD10
1

Chicago MedicalSchool

2

St. Elizabeth Health Center

3

New Hanover Regional Medical Center
4

MetroHealth Medical Center Elmhurst Memorial Hospital

5

6

University of Florida-Jacksonville
7

St. Luke's Hospital

8

Medical University of South Carolina
9

St. Luke's Roosevelt Hospital
10

University of Pittsburgh

Address for Correspondence and Reprints: Michele Holevar, MDChicago Medical School Mount Sinai Hospital 1500 South California Avenue F938 Chicago, IL 60612 Telephone: 773-257-6484

© Copyright 2006 – Eastern Association for the Surgery of Trauma

PRACTICE MANAGEMENT GUIDELINES FOR TIMING OF TRACHEOSTOMY I. STATEMENT OF THE PROBLEM The ideal time for performing a tracheostomy has not been clearly established. Periods ranging from three days to three weekshave been suggested in the literature. With current operative methods, it has been established that tracheostomy can be performed with a low rate of complications. In a review of 281 tracheostomies as well as another 2862 cases in the literature, Zeitouni et al reported a 0% mortality in their series and a 0.3% mortality in the other series since 197325. The risks of prolonged endotrachealintubation, such as patient discomfort necessitating increased sedation, sinusitis, inadvertent extubation, and laryngeal injury, have become increasingly apparent. Selection of patients who might benefit from conversion of translaryngeal tube to a tracheostomy tube is a complex medical decision. Furthermore, different subgroups may benefit from tracheostomy at different times in their hospital course.Management of patients with a single organ failure (head injury or respiratory failure) may differ from that of the multiply-injured trauma patient. With the lack of clear guidelines for selecting patients for tracheostomy, considerable variability exists in the timing of the procedure, with local practice preferences guiding care, rather than patient considerations. We initiated our review byconverting the need for information about optimal timing of tracheostomy into several answerable questions: 1) Does performance of an "early" tracheostomy provide a survival benefit for the recipients? 2) What patient populations benefit from an "early" tracheostomy? 3) Does "early" tracheostomy reduce the number of days on mechanical ventilation and ICU length of stay? 4) Does "early" tracheostomyinfluence the rate of ventilator-associated pneumonia? II. PROCESS A. IDENTIFICATION OF REFERENCES A computerized search was undertaken using Medline with citations published between the years of 1966 and 2004. Using the search words “tracheostomy” and “timing", and by limiting the search to citations dealing with human subjects and published in the English language, we identified 87 articles. Fromthis initial search, case reports, review articles, editorials, letters to the editor, and pediatric series were excluded prior to formal review. Additional references, selected by the individual subcommittee members, were then included to compile the master reference list of 24 citations.

© Copyright 2006 – Eastern Association for the Surgery of Trauma

Articles were distributed among thesubcommittee members for formal review. A data sheet was completed for each article reviewed which summarized the purpose of the study, hypothesis, methods, main results, and conclusions. The reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research (AHCPR) of the U.S. Department of Health and Human Services. B. QUALITY OF THE REFERENCES...