Late versus Very Late Tracheostomy Timing for Prolonged Intubated ICU Patients: Implications for Prognosis and Mechanical Ventilator Weaning

Abstract

Objective: To compare late (10–21 days) and very late (>21 days) tracheostomy in adult ICU patients with prolonged intubation in terms of success of mechanical ventilator weaning, ICU and hospital stay, and mortality.

Methods:
Design: Retrospective Cohort Study
Setting: Tertiary Government Training Hospital
Participants: Adult Intensive Care Unit (ICU) patients (≥18 years) from 2016 to 2024 who underwent tracheostomy after ≥10 days of intubation. Patients were divided into late (10-21 days) and very late (>21 days) timing of tracheostomy groups.

Results: A total of 128 patients were included (48 Late, 80 Very Late). No significant differences were found in mechanical ventilator weaning success, ICU discharge rate, 30-day mortality, or overall mortality between groups. Time to weaning, ICU stay, and time to mortality were longer in the very late group but was not statistically significant. Post-tracheostomy hospital stay was significantly longer in the very late group (M = 25.8 ± 26.1 vs. 37.6 ± 40.7 days, t(125.4) = −2.00, p = .048). Subgroup analyses of pulmonary and neurologic patients showed similar results. Ventilator-associated pneumonia was a common pre-operative comorbidity and was the leading cause of mortality. Older age and prior cerebrovascular disease were associated with decreased odds of weaning success and survival respectively.

Conclusion: The results of our study may challenge the assumption that further delays in tracheostomy timing lead to worse outcomes. Tracheostomy done earlier within 10-21 days of intubation leads to shorter post-operative hospital stay, but was not accompanied by improved odds of ventilator weaning, ICU discharge, or survival. Timing of tracheostomy may not be the primary determinant of prognosis in these patients as much as the confounding co-morbidities, especially ventilator-associated pneumonia.