Original

Intensive Care Medicine

, Volume 34, Issue 10, pp 1779-1787

Early tracheotomy versus prolonged endotracheal intubation in unselected severely ill ICU patients

  • François BlotAffiliated withIntensive Care Unit, Institut Gustave Roussy Email author 
  • , Thomas SimilowskiAffiliated withDepartment of Respiratory Medicine and Intensive Care, Groupe Hospitalier Pitié-Salpêtrière, AP-HP
  • , Jean-Louis TrouilletAffiliated withIntensive Care Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP
  • , Patrick ChardonAffiliated withMedical-surgical ICU, Hôpital Lapeyronie
  • , Jean-Michel KorachAffiliated withMedical-surgical ICU, Centre Hospitalier
  • , Marie-Alyette CostaAffiliated withNephrology ICU, Hôpital Tenon, AP-HP
  • , Didier JournoisAffiliated withUniversité Descartes, Intensive Care Unit, Hôpital Européen Georges Pompidou, AP-HP
  • , Guillaume ThiéryAffiliated withMedical ICU, Hôpital Saint Louis, AP-HP
  • , Muriel FartoukhAffiliated withPneumology ICU, Hôpital Tenon, AP-HP
    • , Isabelle PipienAffiliated withIntensive Care Unit, Institut Gustave RoussyMedical-surgical ICU, Centre Hospitalier des Quatre Villes
    • , Nicolas BruderAffiliated withIntensive Care Unit, Institut Gustave RoussyMedical-surgical ICU, Hôpital Timone
    • , David OrlikowskiAffiliated withIntensive Care Unit, Institut Gustave RoussyMedical ICU, Hôpital Raymond Poincaré, AP-HP
    • , Frédéric TankereAffiliated withIntensive Care Unit, Institut Gustave RoussyDepartment of Otorhinolaryngology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP
    • , Isabelle Durand-ZaleskiAffiliated withIntensive Care Unit, Institut Gustave RoussyDepartment of Public Health, Hôpital Henri Mondor, AP-HP
    • , Christian AuboyerAffiliated withIntensive Care Unit, Institut Gustave RoussyMedical-surgical ICU, Hôpital Nord
    • , Gérard NitenbergAffiliated withIntensive Care Unit, Institut Gustave Roussy
    • , Laurent HolzapfelAffiliated withIntensive Care Unit, Institut Gustave RoussyMedical-surgical ICU, Centre Hospitalier
    • , Alain TenaillonAffiliated withIntensive Care Unit, Institut Gustave RoussyMedical-surgical ICU, Centre Hospitalier Sud Francilien
    • , Jean ChastreAffiliated withIntensive Care Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP
    • , Agnès LaplancheAffiliated withIntensive Care Unit, Institut Gustave RoussyBiostatistics Unit, Institut Gustave Roussy

Rent the article at a discount

Rent now

* Final gross prices may vary according to local VAT.

Get Access

Abstract

Objective

Although several advantages are attributed to tracheotomy in ICU patients requiring mechanical ventilation (MV), true benefits and the optimal timing of tracheotomy remain controversial. In this study, we compared early tracheotomy (ET) with prolonged intubation (PI) in severely ill patients requiring prolonged MV.

Design

Prospective, randomized study.

Setting

Twenty-five medical and surgical ICUs in France.

Patients

Patients expected to require MV > 7 days.

Measurements and results

Patients were randomised to either (open or percutaneous) ET within 4 days or PI. The primary end-point was 28-day mortality. Secondary end-points were: the incidence of ICU-acquired pneumonia, number of d1-d28 ventilator-free days, time spent in the ICU, 60-day mortality, number of septic episodes, amount of sedation, comfort and laryngeal and tracheal complications. A sample size of 470 patients was considered necessary to obtain a reduction from 45 to 32% in 28-day mortality. After 30 months, 123 patients had been included (ET = 61, PI = 62) in 25 centres and the study was prematurely closed. All group characteristics were similar upon admission to ICU. No difference was found between the two groups for any of the primary or secondary end-points. Greater comfort was the sole benefit afforded by tracheotomy after subjective self-assessment by patients.

Conclusions

The trial did not demonstrate any major benefit of tracheotomy in a general population of ICU patients, as suggested in a previous meta-analysis, but was underpowered to draw any firm conclusions. The potential advantage of ET may be restricted to selected groups of patients.

Keywords

Tracheotomy Tracheostomy Mechanical ventilation Intensive care unit Critical care ICU-acquired pneumonia Hospital mortality Randomised controlled trial