title: Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial.
abstract: BACKGROUND
  Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources.
  
  
  OBJECTIVE
  To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days.
  
  
  METHODS
  Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater.
  
  
  METHODS
  Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy).
  
  
  METHODS
  The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive.
  
  
  RESULTS
  Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15).
  
  
  CONCLUSIONS
  Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00262431.
authors.affiliation: Anestesia e Rianimazione 1, Ospedale S. Giovanni Battista, Università di Torino, Turin, Italy.
authors.forename: Pier Paolo
authors.initials: PP
authors.lastname: Terragni
authors.forename: Massimo
authors.initials: M
authors.lastname: Antonelli
authors.forename: Roberto
authors.initials: R
authors.lastname: Fumagalli
authors.forename: Chiara
authors.initials: C
authors.lastname: Faggiano
authors.forename: Maurizio
authors.initials: M
authors.lastname: Berardino
authors.forename: Franco Bobbio
authors.initials: FB
authors.lastname: Pallavicini
authors.forename: Antonio
authors.initials: A
authors.lastname: Miletto
authors.forename: Salvatore
authors.initials: S
authors.lastname: Mangione
authors.forename: Angelo U
authors.initials: AU
authors.lastname: Sinardi
authors.forename: Mauro
authors.initials: M
authors.lastname: Pastorelli
authors.forename: Nicoletta
authors.initials: N
authors.lastname: Vivaldi
authors.forename: Alberto
authors.initials: A
authors.lastname: Pasetto
authors.forename: Giorgio
authors.initials: G
authors.lastname: Della Rocca
authors.forename: Rosario
authors.initials: R
authors.lastname: Urbino
authors.forename: Claudia
authors.initials: C
authors.lastname: Filippini
authors.forename: Eva
authors.initials: E
authors.lastname: Pagano
authors.forename: Andrea
authors.initials: A
authors.lastname: Evangelista
authors.forename: Gianni
authors.initials: G
authors.lastname: Ciccone
authors.forename: Luciana
authors.initials: L
authors.lastname: Mascia
authors.forename: V Marco
authors.initials: VM
authors.lastname: Ranieri
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007558:Italy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D053717:Pneumonia, Ventilator-Associated / Q000517:prevention & control*; D012121:Respiration, Artificial / Q000009:adverse effects*; D013997:Time Factors; D014140:Tracheotomy