Indication and Timing

Tracheostomy is performed in patients requiring prolonged mechanical ventilation aiming at avoiding the potential detrimental effect of a sustained translaryngeal intubation (e.g. laryngeal oedema, mucosal ulcerations). Potential benefits of tracheostomy in critically ill patients are improved comfort and reduced need for sedation, easier clearance of secretions and oral hygiene, and a possible faster weaning from mechanical ventilation. Controversy exists over optimal timing (early, tracheostomy placement compared with later time points) in patients with respiratory failure. Among the published randomised controlled trials, two large studies did not report a significant advantage of an early tracheostomy compared to a late procedure for the primary outcomes of incidence of ventilator-associated pneumonia and all-cause of mortality at 30 days from randomisation. In non-head injured blunt trauma patients with prolonged respiratory failure, tracheostomy placement after 7–10 days seems appropriate. This timing would avoid the potential procedural complications of an unnecessary procedure in patients with a possible shorter period of mechanical ventilation. Further investigations are needed for giving proper indication and timing of tracheostomy in selected populations (e.g. traumatic and non-traumatic neurologic injuries).