Back to the future: Timing of tracheostomy
Myron Yaster MD and Justin L. Lockman MD MSEd
There are very few constants in medicine other than change – whatever you think is right today will turn out to be wrong in 10-20 years. And if you live long enough, you will see many of those things turn out to be right again in another 10-20 years.
Almost 50 years ago, the late, great Dr. Jack Downes and his colleagues at Children’s Hospital of Philadelphia had the radical idea that children, infants, and neonates with chronic respiratory failure could benefit from early tracheostomy and chronic, prolonged, controlled mechanical ventilation. People told Jack that he was crazy, and that he was ruining people’s lives; he persisted, constantly keeping best interest of the child in mind. Interestingly, tracheostomy had been very common even as a first line management tool in respiratory failure in the 1960s, but was largely abandoned with the advent of safe oral/nasal cuffed and uncuffed endotracheal tubes. Perhaps because of my (MY) experience as a CHOP PICU fellow in the 1970s, I always wondered why tracheostomy was abandoned, particularly when the disadvantages of prolonged oral or nasal endotracheal tube were so obvious. Just think about all of the problems with sedation, delirium, and chemical dependence in the ICUs that could be virtually eliminated simply by performing tracheostomies EARLY. Today’s PAAD is based on a large cohort of pediatric patients with respiratory failure. Using the Pediatric Health Information System (PHIS) database, Mehrotra et al.1 looked at clinical outcomes based on early (< 14 days), late (15-60 days), and extended (> 60 days) mechanical ventilation at the time of tracheostomy. Cutting to the chase, the earlier the tracheostomy the better the outcome proving once again that what goes around comes around. Myron Yaster MD
Original article
Mehrotra P, Thomas C, Gerber LM, Maresh A, Nellis M. Timing of Tracheostomy in Critically Ill Infants and Children With Respiratory Failure: A Pediatric Health Information System Study. Pediatr Crit Care Med. 2023 Feb 1;24(2):e66-e75. PMID: 3650824
Tracheostomy is one of the oldest surgical procedures in medicine; ancient Egyptian, Hindu, and Greek texts/artifacts are thought to depict versions of the procedure. The modern technique, still in use, was first described in 1909 by Dr. Chevalier Jackson. And as long as the procedure has been performed, it seems, there has been controversy about when, and in whom, it should be performed. “The primary objective of this study by Mehrota et al.1 was to describe the timing of tracheostomy placement and associated demographic and clinical characteristics in a large pediatric critical care cohort. The secondary objective was to compare the clinical outcomes based on timing of tracheostomy. We hypothesized that pediatric patients who underwent tracheostomy within 14 days of MV [mechanical ventilation] had improved clinical outcomes during their hospitalization compared with those who underwent tracheostomy later”. This “large (10,295 patients) retrospective observational cohort study used the Pediatric Health Information System (PHIS) database. Overall, 52% (5,310/10,295) were children, 32% (3,247/10,295) were infants, and 17% (1,738/10,295) were neonates. In this cohort, the majority of patients were male (57%, 5,881/10,295). Importantly, ninety-five percent of patients (9,823/10,295) had complex chronic disease; their population largely excludes previously healthy but acutely injured patients (such as severe traumatic brain injury victims). The most common overall diagnostic category for all patients was respiratory/otolaryngology (45%, 4,654/10,295), and the least common was hematology/oncology (5%, 471/10,295).”1 The authors defined early, late and extended time to tracheostomy as early (< 14 days), late (15-60 days), and extended (> 60 days) of mechanical ventilation at the time of tracheostomy.
Patients who underwent early tracheostomy (ET) and late tracheostomy (LT) were admitted most commonly for a respiratory/otolaryngology-based principal diagnosis (ET—57%, 2,284/4,006; LT—43%, 1,776/4,159), whereas those who underwent extended tracheostomy (ExT) were admitted most commonly for a cardiovascular (30%, 635/2,130) or other (35%, 740/2,130) diagnosis.
What did they find? “Among the 10,295 pediatric patients who underwent tracheostomy, those within the ET subgroup had the best clinical outcomes”.1 Mortality, hospital acquired infections, hospital and ICU length of stay, and hospital costs were all significantly lower in the early tracheostomy cohort. The authors unfortunately do not mention outcomes for sedation, critical illness neuropathy/myopathy, delirium, or chemical dependency, but we suspect that all would also be improved based on the outcomes they did measure. Anyone who has ever been in a PICU knows that, despite great efforts (and progress) towards progressive mobility by the Picu Up! group,2, 3 prolonged sedation +/- paralysis remain an enormous problem there.
The results are similar to a previous review and meta-analysis by Alkhatip et al., who called for a larger study to confirm their findings.4 The early tracheostomy group in that study was defined as undergoing the procedure within 14 days of mechanical ventilation.
Further, we were disappointed by the lack of study of even earlier tracheostomy. We believe that, as in adults, tracheostomy should be considered within 7 days or less of mechanical ventilation in certain patients such as those with the aforementioned severe traumatic brain injury. Because early tracheostomy is almost never performed in such children, this study cannot comment on its success. However, we know that in adults with severe TBI, early trach leads to early rehab, less delirium/sedation, and shorter ICU lengths of stay – and (most importantly) better neurologic outcomes. Just think of U.S. Representative Gabby Giffords, who was shot in the head in 2011, had an early trach, and was in rehab in about 2 weeks. She was back voting on the floor of Congress within 8 months of the shooting. How many of you have cared for children who are still in the ICU months after a trauma?
Similarly, although neonates do have higher complication rates (pneumonia, sepsis, and death) after tracheostomy placement5, we suspect there are some neonates who would benefit from MUCH earlier tracheostomy than is common practice in most NICUs and PICUs.
Why then the hesitancy to early tracheostomy? Long term complications, not really looked at in this study include prolonged cannulation and ventilator dependence, stenosis, erosion, and tracheitis.6 Further, the care taker burden of taking care of children with a tracheostomy cannot be understated.1 Perhaps most importantly, and not sufficiently addressed by this study, is the emotional obstacle among providers surrounding tracheostomy in children. Sometimes we find ourselves proving that children will “fail extubation” multiple times before we feel ready to discuss tracheostomy with parents. Is that really the best thing for the children involved?
As current (JL) and former (MY) PICU attendings, we think the benefits of early tracheostomy far outweigh the negatives, and we’re thrilled that this study adds to that literature. Perhaps it’s time we consider this as a new standard in appropriate patients, instead of as a last resort. What do you think? Send your comments to Myron and I will post in a reader response.
References
1. Mehrotra P, Thomas C, Gerber LM, Maresh A, Nellis M. Timing of Tracheostomy in Critically Ill Infants and Children With Respiratory Failure: A Pediatric Health Information System Study. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Feb 1 2023;24(2):e66-e75. doi:10.1097/pcc.0000000000003120
2. Patel RV, Redivo J, Nelliot A, et al. Early Mobilization in a PICU: A Qualitative Sustainability Analysis of PICU Up! Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Apr 1 2021;22(4):e233-e242. doi:10.1097/pcc.0000000000002619
3. Walker T, Kudchadkar SR. Early Mobility in the Pediatric Intensive Care Unit: Can We Move On? The Journal of pediatrics. Dec 2018;203:10-12. doi:10.1016/j.jpeds.2018.08.058
4. Abdelaal Ahmed Mahmoud MAA, Younis M, Jamshidi N, et al. Timing of Tracheostomy in Pediatric Patients: A Systematic Review and Meta-Analysis. Critical care medicine. Feb 2020;48(2):233-240. doi:10.1097/ccm.0000000000004114
5. Mahida JB, Asti L, Boss EF, et al. Tracheostomy Placement in Children Younger Than 2 Years: 30-Day Outcomes Using the National Surgical Quality Improvement Program Pediatric. JAMA Otolaryngol Head Neck Surg. Mar 2016;142(3):241-6. doi:10.1001/jamaoto.2015.3302
6. Epstein SK. Late complications of tracheostomy. Respiratory care. Apr 2005;50(4):542-9.