title: Early versus late percutaneous dilational tracheostomy in critically ill patients anticipated requiring prolonged mechanical ventilation.
abstract: BACKGROUND
  Tracheostomy should be considered to replace endotracheal intubation in patients requiring prolonged mechanical ventilation (MV). However, the optimal timing for tracheostomy is still a topic of debate. The present study aimed to investigate whether early percutaneous dilational tracheostomy (PDT) can reduce duration of MV, and to further verify whether early PDT can reduce sedative use, shorten intensive care unit (ICU) stay, decrease the incidence of ventilator associated pneumonia (VAP), and increase successful weaning and ICU discharge rate.
  
  
  METHODS
  A prospective, randomized controlled trial was carried out in a surgical ICU from July 2008 to June 2011 in adult patients anticipated requiring prolonged MV via endotracheal intubation. Patients meeting the inclusion criteria were randomly assigned to the early PDT group or the late PDT group on day 3 of MV. The patients in the early PDT group were tracheostomized with PDT on day 3 of MV. The patients in the late PDT group were tracheostomized with PDT on day 15 of MV if they still needed MV. The primary endpoint was ventilator-free days at day 28 after randomization. The secondary endpoints were sedation-free days, ICU-free days, successful weaning and ICU discharge rate, and incidence of VAP at day 28 after randomization. The cumulative 60-day incidence of death after randomization was also analyzed.
  
  
  RESULTS
  Total 119 patients were randomized to either the early PDT group (n = 58) or the late PDT group (n = 61). The ventilator-free days was significantly increased in the early PDT group than in the late PDT group ((9.57 ± 5.64) vs. (7.38 ± 6.17) days, P < 0.05). The sedation-free days and ICU-free days were also significantly increased in the early PDT group than in the late PDT group (20.84 ± 2.35 vs. 17.05 ± 2.30 days, P < 0.05; and 8.0 (interquartile range (IQR): 5.0 - 12.0) vs. 3.0 (IQR: 0 - 12.0) days, P < 0.001 respectively). The successful weaning and ICU discharge rate was significantly higher in early PDT group than in late PDT group (74.1% vs. 55.7%, P < 0.05; and 67.2% vs. 47.5%, P < 0.05 respectively). VAP was observed in 17 patients (29.3%) in early PDT group and in 30 patients (49.2%) in late PDT group (P < 0.05). There was no significant difference between the two groups in the cumulative 60-day incidence of death after randomization (P = 0.949).
  
  
  CONCLUSIONS
  The early PDT resulted in more ventilator-free, sedation-free, and ICU-free days, higher successful weaning and ICU discharge rate, and lower incidence of VAP, but did not change the cumulative 60-day incidence of death in the patients' anticipated requiring prolonged mechanical ventilation.
authors.affiliation: Department of Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China.
authors.forename: Yue
authors.initials: Y
authors.lastname: Zheng
authors.forename: Feng
authors.initials: F
authors.lastname: Sui
authors.forename: Xiu-Kai
authors.initials: XK
authors.lastname: Chen
authors.forename: Gui-Chen
authors.initials: GC
authors.lastname: Zhang
authors.forename: Xiao-Wen
authors.initials: XW
authors.lastname: Wang
authors.forename: Song
authors.initials: S
authors.lastname: Zhao
authors.forename: Yang
authors.initials: Y
authors.lastname: Song
authors.forename: Wei
authors.initials: W
authors.lastname: Liu
authors.forename: Xin
authors.initials: X
authors.lastname: Xin
authors.forename: Wen-Xiong
authors.initials: WX
authors.lastname: Li
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial; D013997:Time Factors; D014139:Tracheostomy / Q000379:methods*