Tracheostomy is a frequently performed surgical procedure in critically ill patients, being done in about 24% patients in ICU 1.  For patients who require prolonged mechanical ventilation, replacement of endotracheal intubation with a tracheostomy is often considered 2. The benefits of tracheostomy over prolonged intubation are 3-5: Greater airway security, Better oral hygiene, Reduced work of breathing and improved clearance of pulmonary secretions, Reduced use of sedation, Easier nursing care, Reduced trauma to the oropharynx & larynx, and Improved patient comfort. It has also been reported that patients, who had prolonged tracheal intubation, and consequent late tracheostomy, had more complications, namely airway injuries and ventilator associated pneumonia 6. However, tracheostomy is not risk-free, and complications related to it include bleeding, wound infection, subcutaneous emphysema and tracheal stenosis 7. In a study of patients intubated and with tracheostomies cared for in an ICU, the incidence of airway problems was 10-fold greater in patients with tracheostomies 8. Of even more concern in this report was that the importance of these airway problems was greater, including several deaths, in the patients with tracheostomies.
Below are listed important advantages of both (Reprinted from Ref.6)

Selection of patients who might benefit from conversion of a trans laryngeal 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 multiple injury trauma patients. 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. The decision to proceed to tracheostomy is often made only if the patient cannot be extubated within 10–14 days or more. In 1989, the American College of Chest Physicians Consensus Statement on Artificial Airways in Patients Receiving Mechanical Ventilation considered trans laryngeal intubation to be the preferred technique for patients requiring up to 10 days of mechanical ventilation 2. For those with anticipated need for artificial airway for more than 21 days, tracheostomy was recommended. For all other patients, the decision regarding the timing of tracheostomy was left to daily assessment and physician preference. Several studies demonstrated that early tracheostomy (ET) might shorten the duration of ventilation, and the length of ICU stay, and that ET might reduce the incidence of ventilation-associated pneumonia (VAP) and even mortality in critically ill patients 9-10. However, these advantages remain controversial.
Three meta-analyses have been published regarding the effect of the timing of tracheostomy on the prognosis of prolonged mechanically ventilated patients 11-13. Of these studies, two studies 11-12 defined ET as a tracheotomy conducted up to 7 days and one study 13 up to 10 days after the initiation of trans laryngeal intubation; these studies assessed the influence of tracheostomy early or late on the incidence of mortality, the duration of mechanical ventilation (MV) and ICU stay and other important clinical outcomes in critically ill adult patients. However, inconclusive results were presented concerning several outcomes among the three meta-analyses. The most recent meta-analysis on this subject 14 concluded that, “ET as an intervention in critically ill adult patients did not reduce short-term or long-term mortality compared to late tracheostomy (LT)/ prolonged intubation (PI); moreover, incidence of VAP and duration of MV and ICU stay were also unaffected. Future RCTs are needed to define which subgroups of critically ill adult patients are most likely to benefit from this intervention."
Practice Management Guidelines for timing of Tracheostomy was presented at the 21st Annual meeting of the Eastern Association for the Surgery of Trauma (EAST) in 2008, and later published in the journal of Trauma, October 2009 issue, and they had suggested a 3-tier level of recommendations based on review of 24 studies on the subject. These references may be classified as follows: Class I: Prospective randomized controlled trials (PRCT) (7 references); Class II: Clinical studies in which the data were collected prospectively, and retrospective analyses that were based on clearly reliable data. Types of studies classified as such included observational studies, cohort studies, prevalence studies, and case-control studies (5 references); Class III: Studies based on retrospectively collected data. Evidence used in this class included clinical series and database or registry review (12 references).
The proposed 3-tier level of recommendations is as follows 15 :
Level I
There is no mortality difference between patients receiving early tracheostomy (3–7 days) and late tracheostomy or extended endotracheal intubation.
Level II
Early tracheostomy decreases the total days of mechanical ventilation and ICU LOS in patients with head injuries. Therefore, it is recommended that patients with a severe head injury receive an early tracheostomy.
Level III
Early tracheostomy may decrease the total days of mechanical ventilation and ICU LOS in trauma patients without head injuries. Early tracheostomy may decrease the rate of pneumonia in trauma patients. Therefore, it is recommended that early tracheostomy should be considered in all trauma patients who are anticipated to require mechanical ventilation for >7 days, such as those with neurologic impairment or prolonged respiratory failure.
One of the purported advantages of tracheostomy is in facilitating weaning from mechanical ventilation 16. This may be due to lower resistance to breathing, less dead space, better secretion removal, improved patient comfort, or need for less sedation. However, no prospective, systematic study of this issue has been performed. Patients may just appear to wean faster with a tracheostomy because the patient with an ETT “needs” to be attached to a mechanical ventilator while a “trached” patient does not. These factors are unlikely to explain why patients appear to wean faster following tracheostomy17.
Conclusion
Unfortunately, early tracheostomy has not been found to provide a survival benefit for its recipients. Of six prospective, randomized, controlled trials, 3,5,8,18,19 only one has demonstrated a reduction of mortality. In the otorhinolaryngology literature, however, the performance of tracheostomy to protect the larynx from intubation damage has been recommended within 3 days of intubation. This recommendation is based on the fact that the visually observed mucosal damage to the larynx and vocal cords is maximal in 3–7 days. If the tube is removed from the larynx within several days, complete healing of these injuries is the rule20. If trans laryngeal intubation is continued, the visually assessed damage progresses, with scar formation, and functional abnormalities (voice changes) occur with increasing frequency if the tube is left in place longer than 1 week 21.
Patients with respiratory failure who cannot be weaned within 7–10 days are candidates for tracheostomy. Most severely injured trauma patients requiring intubation longer than 5 days will require airway support and will benefit from early tracheostomy 5. Patients with supratentorial intracranial bleeds who do not awaken within 3–5 days will most likely require a tracheostomy if they survive 8. Delay of tracheostomy in these groups of patients is associated with longer hospital length of stay and more pneumonia. Future investigations should be performed in a prospective, randomized manner with a sufficient number of patients to enable clinicians to draw valid, concrete conclusions as to the optimal methods of evaluating these patients. Prospective randomization will decrease the baseline differences between the groups and allow more concrete conclusions to be drawn. Consensus as to what constitutes “early” versus “late” tracheostomy should be established, so that various studies can be compared. Multi-institutional studies of sufficient sample sizes of specific patient populations, such as the head injured, should identify objective criteria to aid the individual physician in determining which subgroups of patients are likely to require prolonged ventilation and might subsequently benefit from an early tracheostomy. Given the current condition of shrinking resources, future studies should also routinely include cost-effectiveness analysis.
References:

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