Early tracheostomy or prolonged translaryngeal intubation in the ICU: a long running story.

Since the beginning of intensive care in the 1950s until today, tracheostomy has been in permanent play. Successive epochs may be differentiated through several periods.1 The first period started in August 1952, when Bjorn Ibsen, facing a huge polio epidemic so deadly that about 80% of the patients were dying in Copenhagen from the respiratory form, he performed tracheostomies and delivered continuous intermittent positive-pressure ventilation with a hand balloon, for as long as necessary, from days to months. The same procedure was used until the epidemic ended in December, and the results were stupendous, lowering the mortality rate to 20%.2 That was the “birth certificate” of ICUs, which rapidly spread throughout Europe and the United States.3 Mechanical ventilation took charge in neurologic diseases, post-surgical complications, severe infectious diseases, and respiratory failures due to lung diseases, almost exclusively via tracheostomy. The second period occurred in the 1970s, when the routine performance of tracheostomy diminished, in comparison to intubation. Tube improvement and awareness of risks associated with tracheostomy increased the preference for translaryngeal intubation.4 Although that did not mean the end of tracheotomy, its selection rests as an option for the medical team. The third period started in the mid-1980s, and was highlighted by the refinement of the tracheotomy technique, using percutaneous approaches that are currently completely accepted in the ICU community, rather than the open surgical procedure, explaining a renewed interest in tracheostomy.5 Today both approaches are available for artificial airways in the ICU, and they are prolonged translaryngeal intubation or early tracheostomy, which could be used exclusively. Conversely, it is tempting to draw conclusions on the advantages of each medical procedure with the clear objective to gain important clinical benefits. The advantages of intubation are easy and rapid initial placement, low cost, and avoidance of acute and late surgical complications. The advantages of tracheostomy are reduced orolaryngeal damage, less risk of sinusitis and need for sedation, better oral hygiene, more patient comfort, communication capacity almost unaltered, swallowing, glottis competence, safety of reinsertion, and easier weaning from mechanical ventilation. From a theoretical point of view it is reasonable to propose the following: for the short duration, mechanical ventilation by intubation is used exclusively until extubation, but in case of prolonged mechanical ventilation, tracheostomy becomes preferable. So, 3 questions require answers. What time span should be considered a short duration for intubation? Is it possible to anticipate the putative mechanical ventilation duration for individuals? What medical evidence do we have on hand?