In reference to late tracheotomy is associated with higher morbidity and mortality in mechanically ventilated patients.

I am writing to you in reference to an article titled “Late Tracheotomy Is Associated With Higher Morbidity and Mortality in Mechanically Ventilated Patients” by Patel et al., which was published in your esteemed journal. The study was planned and executed and is very thought provoking. However, I beg to differ with the authors’ conclusion and would like to highlight my argument through your esteemed journal. The cases requiring prolonged mechanical ventilation are varied and differ widely in their etiology. The patients requiring mechanical ventilation for more than 14 days are likely to be in a more serious condition and are prone to higher mortality. In such a situation, the conclusion that patients in whom tracheotomy is delayed have higher mortality may be biased and incorrect. Another point of concern is that tracheotomy is itself associated with a risk of mortality and other serious complications, therefore doing an early tracheotomy may expose the patient to these risks. In many trials and meta-analysis of randomized control trials on the same topic, the authors concluded that the timing of the tracheotomy did not significantly alter clinical outcomes in critically ill patients. The difference between the so-called “early” and “delayed” tracheotomy is very arbitrary and still a matter of debate. Therefore, a consensus needs to be arrived at before conducting a trial of this nature. In our institute, elective tracheotomy is done within 2 to 3 days of when we anticipate prolonged ventilation, as in severe head injury patients. The decision to do elective tracheotomy in other patients is decided on a case-by-case basis, and all decisions are made in conjunction with the concerned doctors, patient, patient relatives, and critical care team. I would like to conclude by agreeing with Pelosi and Severgnini that a definite time frame for tracheotomy cannot be fixed for all patients requiring prolonged mechanical ventilation, and the decision to do so should be individualized on a case-by-case basis.