Systematic Review/Meta-analysis
Otolaryngology–
Laryngotracheal Stenosis in Early vs Late
Tracheostomy: A Systematic Review
Steven D. Curry, MD, MPH1, and Paul J. Rowan, PhD, MPH2
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. For critically ill patients undergoing long-term
mechanical ventilation, to determine whether early conver-
sion from endotracheal intubation to tracheostomy reduces
the incidence of laryngotracheal stenosis.
Data Sources. MEDLINE, Embase, the Cochrane Central
Register of Controlled Trials, and the Cumulative Index to
Nursing and Allied Health Literature.
Review Methods. A systematic review in accordance with the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines and an assessment of
bias were performed. Included studies reported outcomes
of patients who were converted from endotracheal intuba-
tion to tracheostomy, compared early vs late tracheostomy,
and reported the incidence of laryngotracheal stenosis and
details of postoperative surveillance. Data were also col-
lected for intensive care setting, method of tracheostomy,
and timing of tracheostomy.
Results. Seven articles met inclusion criteria: 2 randomized
trials, 2 quasi-randomized trials, 1 prospective cohort, and 2
retrospective cohorts. A total of 966 patients were included
in this analysis (496 in the early tracheostomy group and
470 in the late tracheostomy group). The mean incidence of
laryngotracheal stenosis was 8.9% (range, 0%-20.8%), with a
mean incidence of 8.1% in early tracheostomy groups and
10.9% in late tracheostomy groups. In studies with the least
risk of bias, there were no differences in the incidence of
laryngotracheal stenosis in patients who underwent early vs
late tracheostomy.
Conclusion. In critically ill patients undergoing long-term
mechanical ventilation, early conversion to tracheostomy
within 7 days of intubation does not significantly decrease
the risk of laryngotracheal stenosis compared to later con-
version as defined by the included studies.
Keywords
tracheostomy, laryngotracheal stenosis, mechanical ventila-
tion, critical care, systematic review
Received May 2, 2019; accepted October 31, 2019.
Head and Neck Surgery
2020, Vol. 162(2) 160–167
Ó American Academy of
Otolaryngology–Head and Neck
Surgery Foundation 2019
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599819889690
http://otojournal.org
T
racheostomy is a common procedure performed in
2% to 11% of patients requiring mechanical ventila-
tion in the intensive care unit (ICU) and one of the
most commonly performed procedures in critically ill
patients.1-4 Long-term mechanical ventilation is the most
common indication for tracheostomy in ICU patients. The
performance of tracheostomy has multiple reported advan-
tages over continued endotracheal intubation, including
improved patient comfort, decreased airway resistance,
easier and safer tracheal suction, improved patient commu-
nication, and improved oral feeding.3,5,6
Numerous randomized controlled trials (RCTs), systematic
reviews, and meta-analyses have examined the timing of tra-
cheostomy and have shown benefits of early tracheostomy in
ICU patients requiring long-term mechanical ventilation.
Reported advantages of early tracheostomy include improved
mortality rates, decreased incidence of ventilator-associated
pneumonia, decreased length of ICU stay, shorter duration of
mechanical ventilation, and decreased median hospital cost.5
Although the literature favors early tracheostomy for these
outcomes, less is known concerning how laryngotracheal ste-
nosis (LTS) should be factored into the clinical decision-
making process for these patients. This outcome was excluded
in trials such as the TracMan randomized trial.7
Over time, endotracheal tubes cause pressure injury and
necrosis at the posterior glottis and cuff site. Acute injury to
the epithelium has been observed within hours of intuba-
tion8,9 and can lead to severe commissural and tracheal scar-
ring. Earlier performance of elective tracheostomy, and thus
removal of the endotracheal tube, may reduce the complica-
tions caused by the endotracheal tube.10,11 Published litera-
ture on the incidence of LTS and the utility of early
tracheostomy to decrease this complication is conflicting,
with reported rates of the incidence of LTS in patients
undergoing long-term intubation ranging from zero patients
developing laryngeal scarring or stenosis during follow-up
1
Department of Otolaryngology–Head and Neck Surgery, University of
Nebraska Medical Center, Omaha, Nebraska, USA
2
Division of Management, Policy, and Community Health, University of
Texas School of Public Health, Houston, Texas, USA
Corresponding Author:
Steven D. Curry, MD, MPH, Department of Otolaryngology–Head and
Neck Surgery, University of Nebraska Medical Center, 981225 Nebraska
Medical Center, Omaha, NE 68198-1225, USA
Email: steven.curry@unmc.edu
Curry and Rowan
in 1 study12 to rates of nearly 20%.13 Furthermore, the con-
clusions the authors have drawn in these studies about the
risk reduction in patients who underwent early vs late tra-
cheostomy vary from observing no significant difference14
to finding a dose-dependent decrease in the incidence and
severity of complications with early tracheostomy.15
Performance of tracheostomy, whether an operative or
percutaneous technique is used, introduces the patients to
additional risks. These include both acute complications
such as bleeding, infection, subcutaneous emphysema, pneu-
mothorax, and chronic complications such as stenosis at the
tracheostomy stoma and the cuff site.16,17 These potential
complications of undergoing tracheostomy must be balanced
against the risks of continued intubation. The goal of this
systematic review was to investigate whether early tra-
cheostomy reduces the risk of LTS in adults requiring long-
term mechanical ventilation.
Methods
Data Sources and Search Strategy
A systematic search of MEDLINE, Embase, the Cochrane
Central Register of Controlled Trials, and the Cumulative Index
to Nursing and Allied Health Literature (CINAHL) was per-
formed. Electronic searches were performed using the keywords
and phrases ‘‘early tracheostomy,’’ ‘‘early tracheotomy,’’ ‘‘tra-
cheostomy timing,’’ ‘‘tracheotomy timing,’’ and ‘‘tracheal ste-
nosis.’’ The reference lists of included articles were examined
for additional articles meeting inclusion criteria. Institutional
review board approval was not required since this analysis of
data was obtained from published literature.
Study Selection
The titles and abstracts of all articles found using the search
strategy were screened for relevance, and the full texts of
remaining articles were reviewed. Studies were included if
they met the following inclusion criteria: published through
March 2018, written in the English language, assessed criti-
cally ill patients treated in the ICU, compared outcomes
between patients who were converted from endotracheal
intubation to either early or late tracheostomy (as defined
by each study’s protocol), and reported outcomes on the
incidence of LTS. Two authors independently evaluated
potential articles. Agreement was reached by consensus of
the authors. Included study designs were randomized con-
trolled trials and cohort trials; reviews, editorials, and case
reports were excluded.
Data Extraction and Quality Assessment
Data from included studies were extracted onto a spreadsheet.
Extracted data for each article included article title, authors’
names, study design, year of publication, number of enrolled
patients, ICU setting, patient selection and randomization
method, tracheostomy timing, tracheostomy method, length
of follow-up, surveillance method, and laryngotracheal com-
plications observed, including stenosis. Any disagreement
regarding the data was resolved by discussion.
161
Figure 1. Flowchart of study selection. ET, early tracheostomy
group; LT, late tracheostomy group; LTS, laryngotracheal stenosis.
The assessment of the risk of bias in included studies was
conducted in accordance with the Cochrane Collaboration’s
tool for assessing the risk of bias.18 Risk specifically relating
to the outcomes relevant to the present analysis was appraised
in the following domains: random sequence generation, alloca-
tion concealment, blinding of participants and personnel, blind-
ing of outcome assessment, incomplete outcome data, selective
reporting, and other potential sources of bias. Results were
summarized as ‘‘low risk of bias,’’ ‘‘unclear risk of bias,’’ or
‘‘high risk of bias’’ and plotted using RevMan 5.3.19
Data Synthesis and Analysis
Extracted data from included articles were summarized in
the included tables. Pooled effects were calculated using a
random-effects model (DerSimonian-Laird method), and a
forest plot was constructed. Analyses were performed in R
version 3.3.3 (R Foundation for Statistical Computing,
Vienna, Austria). Results were reported in accordance with
the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) protocol.20
Results
The search strategy yielded a total of 2373 citations,
including 1368 unduplicated articles. Seven studies, with a
total of 1076 patients, were identified that met inclusion
criteria. These included 4 randomized or quasi-randomized
trials (501 patients) and 3 cohort trials (577 patients),
including 1 prospective and 2 retrospective cohorts. The
median number of patients per study was 152 (range, 74-
225). The literature search selection process is shown in
Figure 1. The included articles examined various critical
care settings, including medical,13-15 surgical,13,15 coronary
care,15 and trauma ICUs.21-24 Characteristics of these stud-
ies are listed in Table 1.
162
Table 1. Characteristics of Included Studies.a
Author Year Study Design Method ICU Setting Surveillance and Follow-up

Rumbak et al14 2004 RCT PDT Medical ICUs Physical examination, fiberoptic bronchoscopy, and linear radiographic
tomography at in-hospital examination and at 10 weeks
postintubation
Sugerman et al22 1997 RCT Both Trauma ICUs Laryngoscopy at the time of endotracheal tube or trach removal and
again 3 to 5 months after discharge in all symptomatic patients and in
patients who had a Lindholm grade II injury or worse
Dunham and LaMonica21 1984 Quasi-randomized trial Surgical Shock trauma ICU Laryngoscopy at 30-day intervals in patients intubated .30 days and
again at extubation. Patients who developed postextubation
respiratory distress were examined by laryngoscopy. Fifty percent
were evaluated at 4 to 6 months after extubation and the others
were interviewed 12 months after extubation.
Stauffer et al13 1981 Quasi-randomized trial Both Medical and surgical ICUs Autopsy in 63 of 86 patients who died. Survivors were examined at
approximately 1 month (range, 2-11 weeks) and again between 3 and
6 months (range, 12-20 weeks) after extubation or decannulation
with history and physical examination, anteroposterior linear air
tomograms of the larynx and trachea, and maximal serial inspiratory-
expiratory flow-volume curves.
Whited15 1984 Prospective cohort Unspecified Medical and surgical ICUs, Mirror or fiberoptic laryngoscopy-tracheoscopy within 24 hours of
coronary care unit extubation, weekly/biweekly until discharge, and a final examination at
3 to 6 months after extubation. If there were patient-reported or
clinical problems observed, other studies (eg, radiographic, PFTs)
were conducted.
Romero et al23 2009 Retrospective cohort Both Trauma (spinal cord injury) No information given
Ganuza et al24 2011 Retrospective cohort Both Trauma (spinal cord injury) A systematic screening method that included clinical signs (stridor and
dyspnea), functional respiratory tests (FEV, FVC, FEV/FVC), and
bronchoscopy
Abbreviations: FEV, forced expiratory volume; FVC, forced vital capacity; ICU, intensive care unit; PDT, percutaneous dilational tracheostomy; PFT, pulmonary function test; RCT, randomized controlled trial.
a
In the Method column, both indicates that either PDT or surgical tracheostomy was performed.
Curry and Rowan 163

Table 2. Timing of Tracheostomy and Cases of Laryngotracheal Stenosis.

Group Size and Incidence of Events

Group Classification, d ET (n = 496) LT (n = 470)

Study Sample Size (N = 1078) ET LT No. No. (%) of Events No. No. (%) of Events

Randomized and quasi-randomized studies

Rumbak et al14 120 1-2 14-16 60 15a (25.0) 60 10a (16.7)
Sugerman et al22 155 3-5 10-14 127 0 (0) 28 0 (0)
Dunham and LaMonica21 74 3-4 14 34 9b (—) 40 — (—)
Stauffer et al13 150 2 21 53 11c (20.8) 97 6c (6.2)
Cohort studies
Whited15 200 2-5 11-24 50 1 (2.0) 50 6 (12.0)
Romero et al23 152 1-7 8 71 1 (1.4) 81 13 (16.0)
Ganuza et al24 225 1-7 8 101 3 (3.0) 114 16 (14.0)
Abbreviations: ET, early tracheostomy group; LT, late tracheostomy group; —, data not available.
a
Includes patients with at least 21% stenosis at 10-week follow-up.
b
Data for ET and LT were reported together, rather than as separate groups.
c
Includes data for survivors at follow-up and 1 patient in the late tracheostomy group who died and was found to have stomal stenosis at autopsy.

The definitions of early vs late tracheostomy varied

across studies but comprised 2 nonoverlapping categories
among the included studies. Early tracheostomy in the
included studies included procedures performed from 1 to 7
days after intubation. The late tracheostomy groups included
patients who underwent tracheostomies from day 8 after
intubation up to day 24 after intubation. While this created
a convenient demarcation between 2 groups, the division
into ‘‘early’’ and ‘‘late’’ tracheostomy is inherently arbi-
trary, heterogenous, and nonbinary. Patients were allocated
into either early or late tracheostomy groups using protocols
that included randomization14,22 and quasi-randomization
based on the patient’s hospital ID number,13,21 or else the
decision to perform and the timing of tracheostomy was
made by the treating physician.15,23,24 One study15 included
a middle period at 6 to 10 days of intubation between early
and late tracheostomy. Patients in this middle group were
excluded from the present analysis. The timing of conver-
sion to tracheostomy and incidence of LTS in the included
studies are listed in Table 2. The treatment effect of early
tracheostomy varied widely between studies (Figure 2).
The included articles were each assessed for their risk of
bias in the following domains: random sequence generation,
allocation concealment, blinding of participants and person-
nel, blinding of outcome assessment, incomplete outcome
data, selective outcome reporting, and other potential
sources of bias.18 Results are shown in Table 3 and sum-
marized in Figure 3.
Patients underwent either operative or percutaneous tra-
cheostomy by study protocol or per the treating physician’s
choice. Both techniques were used in 4 studies.13,22-24 The
others used exclusively surgical tracheostomies21 or percuta-
neous dilational tracheostomies,14 or the method was unspe-
cified.15 Because of the nature of the intervention, patients
and treating physicians were not blinded to the timing of
tracheostomy performance.
Figure 2. Forest plot. CI, confidence interval; ET, early tracheost-
omy group; LT, late tracheostomy group; OR, odds ratio.
Study methodology was associated with finding signifi-
cant differences between treatment groups. Three of the ran-
domized or quasi-randomized trials found no difference in
the incidence of LTS between the early and late tracheost-
omy groups, and none of the 4 randomized or quasi-
randomized trials found a significant benefit to early tra-
cheostomy. All 3 of the cohort studies reported significantly
higher incidences of LTS in the late tracheostomy groups
compared to early tracheostomy groups.
Methods of surveillance for LTS varied by study but usu-
ally involved both an in-hospital examination and a subse-
quent laryngoscopy after more than 2 months following
extubation or decannulation. Surveillance methods also
included radiologic evaluation,14,15 patient interviews, and
autopsies in patients who died during the study period.13 In
1 study, no information was given regarding the methods
for surveillance of laryngotracheal pathology.23 In another
study of patients at the same hospital, however, the authors
retrospectively analyzed data of prospectively collected data
in patients who had been systematically screened using
methods that included clinical signs, functional respiratory
164 Otolaryngology–Head and Neck Surgery 162(2)

Table 3. Risk of Bias.

Random Blinding of Blinding of Incomplete Other
Sequence Allocation Participants Outcome Outcome Selective Potential
Generation Concealment and Personnel Assessment Data Outcome Sources
Study (Selection Bias) (Selection Bias) (Performance Bias) (Detection Bias) (Attrition Bias) Reporting of Bias

Rumbak et al14 Unclear Low Low Low High Low Unclear

Sugerman et al22 Low Low Low Low High Low High
Dunham and LaMonica21 High High Low Low High High High
Stauffer et al13 High High Low Low High Low High
Whited15 High High Low Low High Low High
Romero et al23 High High Low Low High Low High
Ganuza et al24 High High Low Low Low Low Low

Figure 3. Summary of risk of bias.

function tests, and bronchoscopy.24 No information is given
about whether the data collectors were blinded to the
patients’ group allocation.
Loss to follow-up, patient mortality, and incomplete out-
come reporting decreased the number of enrolled patients
available for outcome assessment and increased the risk of
bias in the included studies. Nearly half of the patients in
Rumbak et al14 died. In this study, there were more deaths
in the delayed tracheostomy group (n = 37, 61.7%) com-
pared to the early tracheostomy group (n = 19, 31.6%), pro-
ducing a differential loss to follow-up. No information was
reported regarding evaluation of LTS in these patients.
Autopsies were performed on 63 of 86 (73.3%) patients
who died in Stauffer et al13 to evaluate for laryngeal and
tracheal injuries both grossly and microscopically. Multiple
centers that enrolled patients in Sugerman et al22 did not
submit data forms for analysis to the lead investigators, and
many of the patients with head injuries were transferred to
rehabilitation hospitals and were not examined with postex-
tubation laryngoscopy.
Discussion
While endotracheal intubation provides a route for ventila-
tory assistance in critically ill patients, its use must be
balanced against the risks of both short- and long-term
complications compared to those of the alternative methods
for providing respiratory support. LTS is a known complica-
tion of endotracheal intubation caused by pressure from the
endotracheal tube and the inflated cuff. LTS has previously
been found to be associated with the duration of intubation,
the size of the endotracheal tube, high cuff pressure, trau-
matic intubation, and reintubation. Comorbid disease pro-
cesses such as diabetes mellitus and airway infection are
also associated with an increased risk of acquired LTS.25,26
Iatrogenic causes of LTS are associated with higher rates of
tracheostomy dependence compared to traumatic or idio-
pathic causes.27 Performance of early tracheostomy purports
to reduce the sequelae of mechanical ventilation via an
endotracheal tube, but there is controversy regarding the
optimal timing of this procedure.
In the present analysis, our goal was to determine added
risk of LTS in patients undergoing tracheostomy following
longer periods of endotracheal intubation. This would allow
LTS to be better factored into the clinical decision-making
and informed consent processes. In studies with the lowest
risk of selection bias due to their properly randomized
designs, there was no significant difference in the incidence
of LTS between early and late tracheostomy groups. One of
the quasi-randomized studies found a higher rate of LTS in
the early tracheostomy group among those who survived to
Curry and Rowan
follow-up, but there was no significant association between
the duration of endotracheal intubation or tracheotomy and
the overall amount of laryngotracheal injury found at
autopsy in patients who died during the study.13
In all 3 of the cohort studies, there was a moderate differ-
ence favoring a decreased incidence of LTS in patients
undergoing early tracheostomy. The cohort studies are at
greater risk of bias, especially confounding by indication. It
is not clear, however, to what degree the results were
affected by this bias, and differences may reflect an actual
phenomenon. If the duration of endotracheal intubation
were a consistent cause of LTS in the time frames studied,
it would be expected to be reflected in the outcomes of the
randomized trials. Furthermore, in the cohort studies, the
patients in the late tracheostomy groups were not always
converted to tracheostomy by day 14 of intubation, extend-
ing the time frame for late tracheostomy beyond what was
accepted in the randomized trials and allowing for a greater
risk of time-dependent effects of endotracheal intubation.
Treatment protocols that leave the decision about when a
patient undergoes tracheostomy up to the treating physician
may further bias outcome comparisons because physicians
may be less likely to recommend surgery when patients are
less ill and there is greater hope that the patients will able to
extubate soon, or physicians may delay the conversion to
tracheostomy in patients who are deemed not good candi-
dates for surgery or who are not expected to survive long
enough to benefit from the procedure. This may explain, in
part, the consistent negative impact associated with late tra-
cheostomy in the cohort studies. In the 2 studies on spinal
cord trauma patients, patients in the late tracheostomy
groups had higher Acute Physiology and Chronic Health
Evaluation II scores, longer total time of mechanical venti-
lation, and longer total ICU days compared to the early tra-
cheostomy group.23,24 In another study,15 patients were
rarely converted to tracheostomy before problems were
observed or suspected. While these problems could have
occurred due to the duration of endotracheal intubation
itself causing pathology, these decisions select for patients
at higher risk of LTS. Given these clinical differences in the
patients who were selected for the late tracheostomy groups
in these studies, it is possible that their higher acuity
accounts, at least in part, for the increase in LTS reported in
these cohorts.
A systematic review and meta-analysis of 17 RCTs
found no difference in major periprocedural and long-term
complications between percutaneous dilatational tracheost-
omy and operative tracheostomy in critically ill patients.28
In the 2 studies included here that specified that only 1 tra-
cheostomy method was used, whether percutaneous14 or sur-
gical,21 there was no significant difference in complications.
One notable finding among the different ICU settings of
the included studies was the markedly increased incidence
of major laryngotracheal pathology in patients with rigid
posture due to head injury compared to patients without
head injury or head injury with nonrigid posture (8/24
patients [33%] vs 3/50 [6%]).21 Dunham and LaMonica21
165
attributed this to repeated Valsalva maneuvers and tonic
activity of the strap muscles during acute and chronic mus-
cular rigidity. When patients with rigid posture vs those
without were stratified between early and late tracheostomy,
no significant difference in the incidence of LTS was found.
This suggests that patients with rigid posture due to head
injury have an increased risk of injury that may occur
within the first few days of intubation. While it may be
easier to predict the need for long-term ventilatory support
in severely neurologically compromised patients, early tra-
cheostomy in these patients is not associated with better out-
comes. Early tracheostomy is associated with a decrease in
the total days of mechanical ventilation in patients with
severe head trauma but also with an increased risk of hospi-
tal death.29-31 Taken together, these results do not show a
clear benefit to early tracheostomy in patients with severe
head trauma.
While the true incidence of LTS is not clear, in a large,
retrospective study of 1130 consecutive tracheostomies,32
there were 21 cases of tracheal stenosis (1.9% incidence).
Among the studies included in this review, the mean inci-
dence of stenosis was much higher at 8.9% (range, 0%-
20.8%). This increased incidence may reflect the greater
risk of LTS in patients who undergo tracheostomy after a
longer period of endotracheal intubation compared to
patients for whom tracheostomy was performed for other
reasons, including extensive maxillofacial trauma, upper
airway obstruction, or as an adjunct to head and neck sur-
gery. An increase in LTS, however, is also likely to be
observed in a study with a defined protocol for surveillance
of all the patients who undergo tracheostomy compared to a
retrospective review of tracheostomies, which would likely
miss stenosis in asymptomatic or mildly symptomatic
patients. The surveillance of all patients who undergo tra-
cheostomy in these studies suggests a meaningful risk of
LTS even when tracheostomy is performed within 1 week
of intubation.
Altogether, relatively few studies addressed the incidence
of LTS in early vs late tracheostomy, and their methods were
quite varied. The 7 included studies varied in their methods
of patient selection, group allocation, ICU setting, and sur-
veillance of laryngotracheal pathology. There was no one
definition of ‘‘early’’ and ‘‘late’’ tracheostomy, limiting the
comparability of results of some of these studies, although in
the included studies, all patients in the early tracheostomy
groups were scheduled to undergo tracheostomy within 7
days after the initiation of endotracheal intubation, and all
patients in the late tracheostomy groups were assigned to
undergo tracheostomy no earlier than day 8 of intubation.
The heterogeneity of inclusion criteria, patient demographics,
treatment techniques, and timing of tracheostomy prevent
true meta-analysis of the included studies.
Based on the evidence available, there is a notable risk
of LTS in patients undergoing long-term mechanical venti-
lation who are converted from endotracheal intubation to
tracheostomy within 7 days of intubation. Although the
included studies evaluated various end points in their late
166
tracheostomy groups, there does not appear to be a signifi-
cant decrease in the incidence of LTS in the early tracheost-
omy groups. While it is preferable to not subject patients to
additional procedures such as tracheostomy, previous stud-
ies have found that physicians have a limited ability to
predict which patients will require extended ventilatory sup-
port,7 and common clinical scales have poor predictive
value in identifying which patients will be able to undergo
early extubation.33 Thus, clinical decision making should
rely on other factors to determine when is the best time to
perform a tracheostomy in an intubated patient. Future
investigation should examine ways to decrease the risk of
laryngotracheal injury that can occur within the first few
days of intubation and improve posttracheostomy screening
to identify early cases of LTS, which are associated with
better treatment outcomes compared to those that undergo
later treatment.34
This analysis is limited due to the small number of avail-
able studies meeting the inclusion criteria. Using the aver-
age incidence of LTS in the late tracheostomy groups as a
baseline estimate (namely, 10.9%), designing a study with a
= 0.05 and power = 0.8 would require a sample size of 826
individuals (with 413 in each group) to find a significant
difference, if the proposed study anticipates half the inci-
dence of LTS in the intervention group.
Conclusion
Endotracheal intubation and conversion to tracheostomy
within 1 week carries a noteworthy risk of LTS. In studies
with the least risk of selection bias due to their properly ran-
domized design, there were no differences in the risk of
LTS in patients who were intubated for long-term mechani-
cal ventilation and underwent early tracheostomy compared
to patients who underwent late tracheostomy. The timing of
tracheostomy should be individualized, and early tracheost-
omy, as defined by the studies in this review, does not sig-
nificantly decrease the risk of LTS.
Author Contributions
Steven D. Curry, conception of the project, design of the study,
acquisition of data, analysis and interpretation of the data, drafting
and revising the manuscript, final approval of the manuscript,
agreement of accountability for the work; Paul J. Rowan, study
design, acquisition of data, analysis and interpretation of data,
drafting and revising of the manuscript, final approval of the
manuscript, agreement to be accountable for the work.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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