title: The ventilator liberation process: update on technique, timing, and termination of tracheostomy.
abstract: Tracheostomy is one of the most commonly performed procedures in the ICU. Despite the frequency of the procedure, there remains controversy regarding selection of patients who should undergo tracheostomy, the optimal technique, timing of placement and decannulation, as well as impact  on outcome associated with the procedure. A growing body of literature demonstrates that percutaneous tracheostomy performed in the ICU is a safe procedure, even in high risk patients. Advances in techniques, together with adjuncts to improve visualization, seem promising and likely to further  improve the safety of the technique. Although there was initial enthusiasm in support of early tracheostomy to improve patient outcomes, repeated studies have been unable to produce robust benefits. The question of optimal timing and location of decannulation has not been answered, but there  is some reassurance that in aggregate, across a variety of ICUs, patients do not appear to be harmed by transfer to ward with tracheostomy. Future research into techniques, timing, and termination of tracheostomy is warranted.
authors.affiliation: Surgical Intensive Care Unit, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Bittner
authors.forename: Ulrich H
authors.initials: UH
authors.lastname: Schmidt
mesh_terms: D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects; D018579:Patient Selection; D013997:Time Factors; D014139:Tracheostomy / Q000009:adverse effects / Q000379:methods*; D015300:Ventilator Weaning