Early tracheostomy in acute lung injury: who could benefit?

Introduction

Early tracheostomy has been associated with improved outcome in patients with high likelihood of death or ventilator dependency. While a significant number of patients with acute lung injury (ALI) require prolonged mechanical ventilation and could potentially benefit from early tracheostomy, lack of an accurate prediction limits its utilization in this group of patients.

Methods

From the database of the second international study of mechanical ventilation we selected patients with ALI who were alive and invasively ventilated on the third day post intubation. From a broad range of risk factors prospectively collected during the first 3 days of mechanical ventilation, univariate and multivariate logistic regression identified variables associated with increased risk of death or ventilator dependency.

Results

From 372 patients meeting inclusion criteria, 281 reached a composite outcome of either death or ventilator dependency of more than 2 weeks. One hundred and ninety-nine (53%) died in the ICU, 104 (28%) were ventilated >14 days and 76 (20%) underwent tracheostomy, median 12 (IQR 8–18) days after the intubation. A score based on age and day 3 values of oxygenation index, VE 40 (minute ventilation needed to bring PaCO₂ to 40 mmHg) and shock predicted death or ventilator dependency better (area under receiver operating characteristic curve [AUC] 0.71) than SAPS II (AUC 0.51) or day 3 SOFA (AUC 0.54) scores.

Conclusion

If confirmed in an independent sample, this score may be a useful tool to identify patients with ALI who might benefit from early tracheostomy.