CARING FOR THE CRITICALLY ILL PATIENT Effect of Early vs Late Tracheostomy Placement on Survival in Patients Receiving Mechanical Ventilation

A TRACHEOSTOMY IS COMmonly performed when clinicians predict a patient will need prolonged mechanical ventilation. The use of this procedure has increased, especially following the introduction of a practical bedside percutaneous tracheostomy technique in 1985, such that up to onethird of patients requiring prolonged mechanical ventilation now receive a tracheostomy. The perceived advantages of a tracheostomy over prolonged translaryngeal endotracheal intubation include improved patient comfort and reduced sedative drug use, faster weaning from mechanical ventilation, a reduced incidence of nosocomial pneumonia, and shorter hospitalization. These beneficial effects might be maximized if tracheostomies were performed early in a patient’s illness. The United Kingdom has a very limited intensive care provision, with about one-seventh of the intensive care beds per 10 000 population provided in the United States and a third of those provided in France. As a result, patients treated in UK intensive care units (ICUs) tend to be more severely ill, with more than two-thirds mechanically ventilated on admission compared with less than one-fifth of other countries such as the United States. The low provision of, and hence increased pressure on, intensive care beds in the United For editorial comment see p 2163. Author Affiliations are listed at the end of this article. Corresponding Author: Duncan Young, DM, Adult Intensive Care Unit, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, England (duncan.young @nda.ox.ac.uk). Caring for the Critically Ill Patient Section Editor: Derek C. Angus, MD, MPH, Contributing Editor, JAMA ([email protected]). Importance Tracheostomy is a widely used intervention in adult critical care units. There is little evidence to guide clinicians regarding the optimal timing for this procedure.