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St. Louis, MO
Dr. Kollef is Associate Professor of Medicine, Pulmonary and Critical Care Division, Washington University School of Medicine, and Medical Critical Care Director, Respiratory Care Services, Barnes-Jewish Hospital.
Correspondence to: Marin H. Kollef, MD, FCCP, Washington University School of Medicine, Box 8052, 660 South Euclid Ave, St. Louis, MO 63110; e-mail: kollefm{at}msnotes.wustl.edu
Tracheostomy formation is one of the most commonly performed surgical procedures in the critically ill patient who requires prolonged mechanical ventilation.1 2 Relative to translaryngeal intubation, tracheostomy potentially affords greater patient comfort, more effective pulmonary toilet, increased airway security, and less airway resistance.3 4 5 The latter may be especially important in patients experiencing unrecognized narrowing of their endotracheal tube lumens due to the adherence of airway secretions.6 Among patients with appropriate anatomy, tracheostomy can be safely performed at the bedside using a percutaneous technique.7 8 Despite the common use of tracheostomy for patients requiring prolonged mechanical ventilation, there are still several fundamental unanswered questions concerning this procedure. These questions include the following: (1) Which patients with acute respiratory failure should have a tracheostomy? (2) When during the course of mechanical ventilation should a tracheostomy be performed? (3) What are the benefits in terms of patient outcomes associated with tracheostomy?9 10
In this issue of CHEST (see page 220), Engoran and colleagues describe their experience with tracheostomy for patients requiring long-term respiratory support. Over 3 years, these investigators retrospectively identified 429 patients who underwent tracheostomy during the course of mechanical ventilation. This represented 8.3% of all patients requiring mechanical ventilation at their institution. The overall mortality rate of patients receiving a tracheostomy was 22.1%. Among patients with a tracheostomy, the nonsurvivors were statistically more likely to be older, have a nonsurgical admission, have the new onset of renal dysfunction, lack placement of a surgically inserted feeding tube, and have a lower nadir hemoglobin level compared to survivors. Interestingly, the statistically lower use of surgically inserted feeding tubes among nonsurviving patients suggests that these individuals differed in some way from the survivors. Nonsurviving patients likely had a greater severity of illness potentially preventing the surgical placement of feeding devices. Although severity-of-illness data in the form of an APACHE (acute physiology and chronic health evaluation) score is not provided, this possibility is supported by differences in the baseline laboratory data, age, and comorbidities shown in Table 1 between survivors and nonsurvivors. Another intriguing possibility is that surgically placed feeding tubes were avoided in the nonsurvivors because of health-care provider suspicions or biases favoring a lower likelihood of hospital survival in these patients. In a previous study11 of patients requiring prolonged mechanical ventilation, individuals receiving a tracheostomy had a statistically lower mortality rate compared to patients not receiving a tracheostomy, despite having a similar severity of illness at the time of admission to the ICU. These studies support the hypothesis that medical care among similar types of patients in the intensive care setting may differ based on clinician assessments of prognosis.12
Engoren et al also demonstrated that among the 334 hospital survivors, 118 patients (35.3%) were discharged completely ventilator dependent, 25 patients (7.5%) were discharged partially ventilator dependent, and 191 patients (57.2%) were discharged completely liberated from mechanical ventilation. However, patients who were completely liberated from mechanical ventilation had significantly longer hospital stays and greater hospital costs compared to patients discharged receiving mechanical ventilation. Finally, these investigators showed that overall survival for patients receiving a tracheostomy was poor with 36% of patients dead at 1 year and 42% dead 2 years after discharge. Among patients completing the Short Form-36 questionnaire, good emotional health was reported, but patients remained with major physical limitations related to their underlying illnesses and comorbidities. Therefore, extensive medical resources are required to achieve this quality of life in a limited number of patients with acute respiratory failure receiving a tracheostomy.
Are the data from this new publication helpful in clarifying any of the fundamental questions regarding tracheostomy for patients with acute respiratory failure outlined above? Engoren et al suggest that specific subgroups of patients may benefit from tracheostomy. One obvious group includes those individuals who are likely to survive their hospitalization. Identifying these survivors early-on in their hospitalizations is problematic. Younger patients without renal dysfunction and without a medical admitting diagnosis would appear to have better odds of surviving compared to patients not meeting these criteria. However, other studies1 13 have found that many medical patients do survive and potentially benefit from tracheostomy. The 1-year survival results associated with treatment in long-term weaning facilities are also similar to those reported by Engoren et al and include a broad mix of patients.14 Therefore, clinicians are left in a situation where they must use good clinical judgment in evaluating an individual patient’s likelihood of survival and benefit from a tracheostomy.
A question related to who should have a tracheostomy is when should it be performed. Engoren et al demonstrated that their patients generally received tracheostomy approximately 2 weeks after hospital admission for acute respiratory failure. However, the range of timing to tracheostomy was quite broad in their population. These investigators did not assess whether patients receiving earlier tracheostomy had improved outcomes or shorter lengths of stay compared to patients receiving tracheostomy later in their hospitalization. Other studies15 16 17 have shown that early tracheostomy can be associated with shorter durations of mechanical ventilation and hospitalization. Total medical-care costs also appear to be related to the timing of tracheostomy, especially if this results in shorter hospital lengths of stay.17 However, one must be careful to account for the shifting of medical-care costs that may occur as a result of patients receiving a tracheostomy and being transferred to long-term care facilities.18
The final question is what patient-related outcomes are beneficially influenced by tracheostomy. Consensus opinion suggests that patient comfort is improved with the use of tracheostomy compared to prolonged translaryngeal intubation, but this has not been well investigated.10 Decreasing airway resistance and the work of breathing with tracheostomy should improve the likelihood of successful liberation from mechanical ventilation and reduce the duration of its application.5 10 However, the quality of existing studies (lack of adequate controls, blinding, and utilization of protocols for the uniform management of mechanical ventilation and weaning) limit any conclusions on this issue from the available studies. Therefore, the fundamental questions concerning the optimal utilization of tracheostomy for patients with acute respiratory failure remain unanswered. Observational studies1 11 such as the one reported by Engoren et al provide important insights regarding current medical practices in acute respiratory failure. However, these studies should also serve as justification and motivation for the performance of larger prospective trials aimed at providing more definitive answers for the important clinical questions surrounding tracheostomy for acute respiratory failure.
References
This article has been cited by other articles:
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  C. D. Epstein and J. R. Peerless Weaning Readiness and Fluid Balance in Older Critically Ill Surgical Patients Am. J. Crit. Care., January 1, 2006; 15(1): 54 - 64. [Abstract] [Full Text] [PDF]
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