Practice management guidelines for timing of tracheostomy: The EAST practice management guidelines work group

STATEMENT OF THE PROBLEM The ideal time for performing a tracheostomy has not been clearly established. Periods ranging from 3 days to 3 weeks have 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 2,862 cases in the literature, Zeitouni and Kost1 reported 0% mortality in their series and 0.3% mortality in the other series since 1973. The risks of prolonged endotracheal intubation—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 a 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 multiple injury 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 by converting 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 intensive care unit length of stay (ICU LOS)? 4. Does “early” tracheostomy influence the rate of ventilatorassociated pneumonia?