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

François Blot, Thomas Similowski, Jean-Louis Trouillet, Patrick Chardon, Jean-Michel Korach, Marie-Alyette Costa, Didier Journois, Guillaume Thiéry, Muriel Fartoukh, Isabelle Pipien, Nicolas Bruder, David Orlikowski, Frédéric Tankere, Isabelle Durand-Zaleski, Christian Auboyer, Gérard Nitenberg, Laurent Holzapfel, Alain Tenaillon, Jean Chastre, Agnès Laplanche
Intensive Care Medicine 2008, 34 (10): 1779-87

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.

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