氣切早晚在60-90天清算時對outcome看來差不多

此為法國study，心外手術後病人，此篇一出也許提倡早切者會稍受挫。若可apply to ARDS病人，則治療2星期仍是可接受的，不需太早promote急切

然則臨床判斷仍要緊

Early Tracheotomy vs. Prolonged Intubation and Late Tracheotomy

Outcomes were similar with both approaches in patients requiring mechanical ventilation.

Proponents of early tracheotomy (during days 3–6 of mechanical ventilation) say it lessens morbidity and mortality relative to prolonged intubation and late tracheotomy (at approximately 2 weeks), but evidence is unclear. In this single-center trial from France, 216 patients who underwent cardiac surgery and were expected to require prolonged mechanical ventilation were randomized to early tracheotomy or prolonged intubation and late tracheotomy (if mechanical ventilation was necessary beyond 15 days). All patients were managed with strict sedation and weaning protocols.

At 60 days, no difference was noted in ventilator-free days between groups. In addition, no significant differences were observed in mortality at 60 or 90 days, frequency of ventilator-associated pneumonia, or length of hospitalization. However, early tracheotomy patients spent less time under heavy sedation, were transferred from bed to chair earlier, and had more "comfortable" days.

Comment: In this randomized trial, early tracheotomy provided no significant benefit in hard outcomes over prolonged intubation and late tracheotomy. Given that the trial was slightly underpowered, and given that some "soft outcomes" favored early tracheotomy, these results will not end the debate. However, as noted in an accompanying editorial, enthusiasm for early tracheotomy should be tempered unless future studies show benefit.

— Jamaluddin Moloo, MD, MPH

Published in Journal Watch General Medicine April 12, 2011

Citation(s):

Trouillet J-L et al. Early percutaneous tracheotomy versus prolonged intubation of mechanically ventilated patients after cardiac surgery: A randomized trial. Ann Intern Med 2011 Mar 15; 154:373. (http://www.annals.org/content/154/6/373.long)

Patel SB and Kress JP. Early tracheotomy after cardiac surgery: Not ready for prime time. Ann Intern Med 2011 Mar 15; 154:434. (http://www.annals.org/content/154/6/434.full)

Context
It is not clear whether early tracheotomy improves the
outcome of patients who are expected to require prolonged
mechanical ventilation.
Contribution
In this randomized trial of patients who still required
mechanical ventilation 4 days after cardiac surgery, immediate
tracheotomy did not decrease mortality or length of
intensive care unit or hospital stay or increase the number
of days off the ventilator compared with waiting 2 weeks
to consider tracheotomy. Early tracheotomy did, however,
reduce the use of sedatives, ease nursing care, and improve
patient comfort.
早切不會少死人，不會少住ICU，不會少用ventilator，VAP不會少....
早切可以少用鎮靜劑，好care，病人舒適度增加
Caution
Patients in the control group were free of mechanical
ventilation sooner than anticipated, possibly limiting the
ability to detect a benefit from early tracheotomy.
Implication
More study is required to determine whether routine early
tracheotomy is beneficial.
https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B278nGJMQBk7NTcyNjc3ZmYtOTgwMi00NTYwLWJjNzMtNmUxNjEzYmM0Y2U2&hl=zh_TW

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