Outcome for tracheostomized patients who requiring prolonged stay in intensive care unit.

Sir,

The association between tracheostomy and outcomes reported in the studies of tracheostomized patients remains unclear.[12] There is no proven benefit of the procedure itself or related care and it might be that, after several days of mechanical ventilation (MV), intensive care unit (ICU) physicians adequately select candidates for tracheostomy, based on the highest probability of MV weaning failure associated with a reasonable probability of ICU survival.[3]

The objectives of this study was to evaluate the effect of tracheostomy on ICU and in-hospital mortality for patients requiring prolonged (>14 days) stay in ICU.

We retrospectively reviewed data collected prospectively on patients admitted to the ICU from January 2004 to December 2010, with prolonged stay (>14 days). We analyzed outcomes of tracheostomized and non-tracheostomized patients using univariable and multivariable logistic-regression analyses.

Of the 707 patients requiring prolonged ICU stay, 448 were tracheostomized. The results of the predictive model of survival in ICU show the performing a tracheostomy define survival (odds ratio 2.445, 95% confidence interval 1.520-3.918, P = 0.000). However, these patients will have a better outcome at discharge from the hospital when a tracheotomy was not performed (odds ratio 0.331, 95% confidence interval 0.139-0.768, P = 0.011). Kaplan–Meier estimates of the cumulative probability of survival as a function of the number of days after ICU admission differed significantly between the two groups, with better outcome for tracheostomized patients [Figure 1].

Figure 1

Kaplan–Meier survival curves depending on the application or not of tracheostomy

We might have missed, in the present study, factors associated with the decision to perform a tracheostomy that might alter ICU and hospital outcomes as prolonged MV duration because of weaning failure, need for reintubation, nosocomial pneumonia, or aspiration.[45] Anyway, our results may not be applicable to patients receiving MV in other centers with different case-mixes and different MV weaning strategies. Furthermore, we did not record decisions to withhold or withdraw life-sustaining treatments either in our unit or after discharge from it. Such decisions might have affected the results. These data might be the focus of future studies.

In conclusion, tracheostomy performed in our ICU for long-term stay patients was associated with lower ICU mortality, but higher in-hospital rates. Whether the tracheostomy really affects the outcomes of these long-term MV patients will remain speculative until the large-scale and adequately powered randomized, controlled trials.