Original Research

Journal of Intensive Care Medicine

1-10
Patient-Centred Outcomes Following © The Author(s) 2023

Tracheostomy in Critical Care Article reuse guidelines:

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DOI: 10.1177/08850666231160669
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A. Mc Mahon, MB Bch BAO, FCAI, FJFICMI ,

S. Griffin, MB Bch BAO, Emma Gorman, MSc, BSc,
Aoife Lennon, MSc, BSc, Stephen Kielthy, MSc, ANP, Andrea Flannery, MSc, ANP,
Bindu Sam Cherian, MSc, ANP, Minu Josy, BSc, and B. Marsh, FFARCSI, FJFICMI,
FCICM (ANZ)

Abstract
Introduction: Around 20% of intensive care unit (ICU) patients undergo tracheostomy insertion and expect high-quality care
concentrating on patient-centered outcomes including communication, oral intake, and mobilization. The majority of data has
focused on timing, mortality, and resource utilization, with a paucity of information on quality of life following tracheostomy.
Methods: Single center retrospective study including all patients requiring tracheostomy from 2017 to 2019. Information col-
lected on demographics, severity of illness, ICU and hospital length of stay (LOS), ICU and hospital mortality, discharge dispo-
sition, sedation, time to vocalization, swallow and mobilization. Outcomes were compared for early versus late tracheostomy
(early = <day 10) and age category (≤ 65 vs ≥ 66 years).
Results: In total, 304 patients were included and 71% male, median age 59, APACHE II score 17. Median ICU and hospital LOS
16 and 56 days, respectively. ICU and hospital mortality 9.9% and 22.4%. Median time to tracheostomy 8 days, 8.55% open.
Following tracheostomy, median days of sedation was 0, time to noninvasive ventilation (NIV) 1 day (94% of patients achieving
this), ventilator-free breathing (VFB) 5 days (72%), speaking valve 7 days (60%), dynamic sitting 5 days (64%), and swallow assess-
ment 16 days (73%). Early tracheostomy was associated with shorter ICU LOS (13 vs 26 days, P < .0001), reduced sedation (6 vs
12 days, P < .0001), faster transition to level 2 care (6 vs 10 days, P < .003), NIV (1 vs 2 days, P < .003), and VFB (4 vs 7 days, P <
.005). Older patients received less sedation, had higher APACHE II scores and mortality (36.1%) and 18.5% were discharged
home. Median time to VFB was 6 days (63.9%), speaking valve 7 days (64.7%), swallow assessment 20.5 days (66.7%), and dynamic
sitting 5 days (62.2%).
Conclusion: Patient-centered outcomes are a worthy goal to consider when selecting patients for tracheostomy in addition to
mortality or timing alone, including in older patients.

Keywords
tracheostomy, critical care, outcomes, patient centered, communication, oral intake, mobilization

Introduction relate to communication, mobility, and swallow, de-escalation

Around 10% to 20% of intensive care unit (ICU) patients will
undergo tracheostomy insertion. Patients with a tracheostomy
often have a long duration of ICU stay and high mortality.1
For the majority, survivors, these patients expect high-quality
care focused on patient-centered outcomes including communi-
cation, swallow, and mobilization. There has been little research
performed on quality of life of patients post-tracheostomy and
recommendations have been made that future studies should
do so.2 Although studies have shown no mortality benefit
from early tracheostomy,3 others suggest a reduction in resource
utilization including reduced ICU length of stay (LOS).4 We
have already demonstrated that introduction of a multidisciplin-
ary tracheostomy team (MTT) has reduced time to decannula-
tion.5 We now want to ascertain if our tracheostomy patients
are achieving the goals that are important to them—those that
to lower dependency units allowing progression of rehabilitation
and social mixing. Obtaining this information will help better
delineate the benefits associated with tracheostomy use to aid
in the decision-making process surrounding tracheostomy inser-
tion and timing and identify areas for improvement in the care of
patients who undergo a tracheostomy in the future.
Department of Critical Care Medicine, Mater Misericordiae University
Hospital, Dublin, Ireland
Received April 17, 2022. Accepted August 5, 2022.
Corresponding Author:
Aisling Mc Mahon, MB Bch BAO, FCAI, FJFICMI, Department of Critical Care
Medicine, Mater Misericordiae University Hospital, Eccles St, Dublin 7, Ireland.
Email: aislingmcmahon@mater.ie
2 Journal of Intensive Care Medicine 0(0)

Methods agitation was preventing weaning. From a ventilation perspective,

we used time post-tracheostomy to noninvasive ventilation (NIV)
This is a longitudinal retrospective observational study con-
and ventilator-free breathing (VFB), defined as the first 24 h
ducted in the Mater Misericordiae University Hospital
period free from positive pressure (either invasive mechanical ven-
(MMUH), Dublin. MMUH is a university-affiliated adult qua-
tilation or NIV), as markers of weaning progress. In our unit
ternary referral center with an 18-bedded mixed medical and
patients are transitioned to NIV once gas exchange is stable on rel-
surgical ICU, with 1200 admissions per year. MMUH incorpo-
atively minimal settings on the ventilator, for example, an FiO2 of
rates the National Centre for Cardiothoracic Surgery (including
40%, low positive end expiratory pressure (PEEP) and pressure
heart and lung transplantation), pulmonary hypertension, adult
support (PS) less than around 16 cmH2O. The time spent on NIV
extracorporeal membrane oxygenation service and the National
daily is increased gradually according to the patient’s ability to tol-
Centre for Spinal Injuries, as well as all major specialties
erate it until they are established on NIV 24 h a day. To determine
excluding neurosurgery.
whether or not our tracheostomy patients would have been extu-
All consecutive patients requiring tracheostomy insertion
bated soon after tracheostomy and may not have needed to
during their ICU stay from 2017 to 2019 were included in the
undergo an invasive procedure, we used a post-tracheostomy surro-
study. Patients having a permanent tracheostomy prior to ICU
gate for “fit for extubation.” This surrogate consisted of the time to
admission were excluded.
achieve settings we believed would be consistent with extubation,
Data was retrieved from the critical care electronic patient
namely a PS <10, fraction of inspired oxygen (FiO2) <40% with a
record (ICCA, Philips Healthcare), on patient demographics,
good cough and expectorating secretions or cuff deflation. This sur-
ICU admission category, and severity of illness scores. The
rogate affords a decision point of probable extubation, but not nec-
number of tracheostomies performed over the study period
essarily extubation success, where data would suggest a possible
was recorded, including technique (percutaneous vs open)
10-20% extubation failure rate with a prolonged weaning patient
and time to tracheostomy insertion. Outcomes documented
cohort.6 When assessing mobilization post-tracheostomy, we
included ICU and hospital LOS, time to transition to level 2
used the Chelsea Critical Care Physical Assessment Tool (CPAx)
care (high dependency), ICU and hospital mortality and dis-
to assess physical morbidity. We chose this outcome measure as
charge location. Patient-centered outcomes detailed included
it is calculated on a daily basis from day 5 of admission on our
use of sedation, time to liberation from ventilation, time to res-
ICU patients. It is also ICU specific, validated by specialist physio-
toration of speech, time to swallow assessment and time to
therapists and has good internal and inter-rater reliability.7 The spe-
mobilization. Information gathered during a patient’s ICU
cific parameters we chose, days post-tracheostomy to a dynamic
stay was retrieved from the critical care electronic patient
sitting score of 2 (moderate assistance required), sitting to the
record. For outcomes post-ICU discharge, this was gathered
edge of the bed score of 3 (minimal assistance) and sit to stand
from our post-tracheostomy MTT audit and recorded patient
score of 3 (minimal assistance), were chosen following discussion
hospital disposition. Details of swallow assessment timing
with our physiotherapy colleagues on what represented meaningful
and results were obtained from our MTT records. The overall
progression outcomes for our patients.
ICU mortality for the time period included was retrieved from
The influence of tracheostomy insertion timing, dividing the
intensive care national audit and research center Irish
group into early versus late tracheostomy (<10 days vs ≥10
National ICU Audit quality reports.
days), was analyzed. This was to investigate any effect of
In terms of patient-centered outcomes, when looking at use
timing of insertion on outcomes and resource utilization.
of sedation, we looked not only at days of sedation (total and post-
Outcomes were also analyzed according to age being divided
tracheostomy insertion), but also the Richmond Agitation-Sedation
into younger (age 65 years or less) and older (age 66 years
Scale (RASS) score of our patients 1 day prior to tracheostomy and
and older) subgroups.
the time to RASS 0 post-tracheostomy to ascertain if deep sedation/
Normally distributed data were compared with Student’s
Table 1. Baseline Characteristics, LOS, and Mortality for Patients t-test. Categorical data were compared using Fisher’s exact
with Tracheostomy. test. Data that was not normally distributed was compared
Total using the Mann-Whitney U test. A two-tailed P value of
<0.05 for each test was used for statistical significance. Data
Male 217 (71.4%) was analyzed in Microsoft excel and Prism 9 (GraphPad LLC).
Age, mean (SD) 59 (16)
APACHE II, median (IQR) 17 (13-21)
ICU LOS, median (IQR) 16 (11-26) Results
Hospital LOS, median (IQR) 56 (37-89)
ICU mortality (%) 9.9 In total, 304 patients required tracheostomy insertion from 2017
Hospital mortality (%) 22.4 to 2019. The demographic data, severity of illness scores, LOS,
ICU mortality all admissions (%) 11.3 and mortality of our tracheostomy patients can be seen in
Hospital mortality all admissions (%) 17.6 Table 1. The median ICU LOS was 16 days with a median hos-
Abbreviations: APACHE, acute physiology and chronic health evaluation; ICU,
pital LOS of 56 days. Of note the ICU mortality of our trache-
intensive care unit; IQR, interquartile range; LOS, length of stay; SD, standard ostomy patients was 9.9% in comparison with 11.3% for our
deviation. total ICU population over the same time period. Information
Mc Mahon et al 3

on ICU admission category can be seen in Table 2. The majority 7 days). There was no significant difference in other outcomes
of admissions were medical (69%), with the largest proportion between the early and late tracheostomy groups.
of these presenting with a respiratory illness. In keeping with Evaluation of outcomes based on age category can be seen in
the hospital being the National Centre for Cardiothoracic Table 5. Mean age of older patients was 74 years versus 49 for
Surgery, the preponderance of surgical admissions were cardio- the younger group. Patients who were older (≥66) had a higher
thoracic in origin. Acute Physiology and Chronic Health Evaluation (APACHE) II
In terms of the procedure itself, the median time to tracheos- score (19 vs 15) and a higher hospital mortality (36.1% vs
tomy was 8 days (Table 3 and Figure 1). The majority were per- 14.1%). They had a shorter total duration of sedation in compari-
formed percutaneously in the ICU with a median stay in the son to younger patients (6 vs 8 days). Swallow assessment
ICU of 7 days following insertion. occurred later in the older subgroup (20.5 vs 15 days). Although
Data on patient-centered outcomes following tracheostomy the return to mobility was numerically longer in the older patients,
can also be seen in Table 3. Sedation was promptly discontin- this was not statistically significant. Two-thirds of older patients
ued post-tracheostomy (Figure 2), with patients being lightly achieved VFB, placement of a SpV, swallow assessment, and
sedated prior to the procedure (median RASS −1) and achiev- dynamic sittings. And 50% of older patients passed their
ing a state of alert and calm a median of 2 days following tra- swallow assessment versus 58.5% of younger patients.
cheostomy. The majority (94.4%) of patients were rapidly Discharge disposition of patients who underwent tracheos-
transitioned to NIV and progressed to VFB by a median of 5 tomy can be seen in Table 6. About 40.9% of survivors
days (72%). This is in comparison to a median of 7 days to (31.6% of the total population) were discharged home from
the extubation surrogate. And 60% of patients had a speaking hospital. A further 30.6% were transferred to another acute
valve (SpV) placed at 1 week. There was data available for
279 patients regarding swallow assessment. This occurred at a
median of 16 days from tracheostomy with 73% of patients Table 3. Procedure Type and Patient-Centered Outcomes for
having an assessment performed. Reasons for not undergoing Patients Undergoing Tracheostomy in the Intensive Care Unit.
swallow assessment included death and transfer prior to assess-
Tracheostomy Patients
ment. In terms of mobilization, as expected the first target
achieved was dynamic sitting (median 5 days). The proportion N 304
of patients reaching each incremental target declined so that Open (%) 26 (8.55)
only 19% accomplished a CPAx sit to stand score of 3 prior Days to tracheostomy 8
Days to level 2 care 7
to discharge to critical care.
post-tracheostomy
Analysis of tracheostomy timing on outcomes can be seen in Sedation
Table 4. There was no difference in demographics, severity of Total days of sedation 7
illness, or mortality between the groups. There was a shorter Days of sedation 0
ICU LOS in the early tracheostomy group (median 13 vs 26 post-tracheostomy
days) and a faster transition to level 2 care (6 vs 10 days). RASS 1 day prior to −1
There was a more rapid cessation of sedation in the early tracheostomy
Days to RASS 0 2
group (median total days of sedation 6 vs 12) and earlier
post-tracheostomy
weaning to NIV (median 1 vs 2 days) and VFB (median 4 vs Ventilation (post-tracheostomy)
Days to NIV 1 (94.4%)
Days to VFB 5 (72%)
Table 2. Admission Categories for Patients Undergoing Days to extubation 7 (63%)
Tracheostomy Insertion During Intensive Care Stay. surrogate
Speech (post-tracheostomy)
Admission Category Total (%) Days to SpV 7 (60%)
Mobility (post-tracheostomy)
Medical 209 (69) Days to dynamic sitting 2 5 (64%)
Cardiac 33 (11) Days to CPAx sit to edge 3 10 (26%)
Respiratory 113 (37) Days to CPAx sit to stand 3 13.5 (19%)
Neurological 39 (13) Swallow (post-tracheostomy)
Gastrointestinal 4 (1) Days to swallow 16 (73%)
Renal 7 (2) assessment
Endocrine 2 (1) Swallow assessment N = 279 Pass 154 (55%) Fail 49 (18%)
Psychiatric 3 (1) outcome (%) Dead 45 (16%) TF NPO 24 (9%) N/A 7
Other 8 (3) (2%)
Surgical 95 (31)
Cardiac 45 (15) Values presented as medians. Percentages represent the proportion of patients
Thoracic 22 (7) attaining each variable. Abbreviations: CPAx, Chelsea Critical Care Physical
Gastrointestinal 7 (2) Assessment Tool; N/A, not applicable; NIV, noninvasive ventilation; RASS,
Orthopedic 21 (7) Richmond Agitation-Sedation Scale; SpV, speaking valve; TF NPO transferred nil
per oral; VFB, ventilator-free breathing.
4 Journal of Intensive Care Medicine 0(0)

Figure 1. Timing of tracheostomy insertion following ICU admission in the total population. Abbreviation: ICU, intensive care unit.

Figure 2. Proportion of patients discontinuing sedation on each day following tracheostomy insertion.

hospital, 11.9% to a rehabilitation hospital and 10.2% to
another facility including nursing home (8.9%), hospice
(0.4%) or no fixed abode (0.9%). When stratified by age,
those in the oldest category (≥66) had the lowest proportion
of patients being discharged home from hospital (18.5%;
Figure 3). Over one-third of tracheostomies (38.5%) were per-
formed in this age group (Figure 4).
Discussion
We have looked at outcomes for our tracheostomy patients in a
university-affiliated teaching hospital over a 3-year period from
2017 to 2019. Around 10% of our patients require tracheostomy
insertion (around 100 patients per year in a unit with 1200
admissions annually), in keeping with previously published
data.1,8,9 The majority of these are performed percutaneously,
as is the trend internationally.3 In our own center, we have doc-
umented that the proportion of percutaneous tracheostomies has
increased over time in comparison with the open technique
from 80% to 85% in 2009 to 91% in our current study.5
Considering timing of tracheostomy, the procedure was per-
formed at a median of 8 days from ICU admission, consistent
with previous data from our own center.5
The median LOS in ICU was 16 days in our tracheostomy
population, and 56 days for hospital LOS. This is similar to
Mc Mahon et al 5

Table 4. Comparison of Patient Characteristics and Outcomes for Table 6. Discharge Disposition for Hospital Survivors Stratified by
Early and Late Tracheostomy. Age (Younger ≤ 44, Older 45-65, Oldest ≥ 66 Years.

Early Late P Value Survivors Younger Older Oldest

N 188 116 N 235 53 106 76

Male 72.3% 69.8% .70 Home 96 (40.9%) 19 (35.8%) 55 (51.9%) 22 (28.9%)
Age, mean 60 56.5 .06 Other acute 72 (30.6%) 16 (30.1%) 28 (26.4%) 28 (36.8%)
APACHE II 17 16 .61 Hospital
ICU mortality 7.98% 12.93% .17 Rehabilitation 28 (11.9%) 8 (15.1%) 10 (9.4%) 10 (13.2%)
Hospital mortality 19.24% 28.45% .07 Other 24 (10.2%) 5 (9.4%) 7 (6.6%) 12 (15.8%)
ICU LOS 13 26 <.0001 Unknown 15 (6.4%) 5 (9.4%) 6 (5.6%) 4 (5.3%)
Hospital LOS 55 64 .06
Days sedation total 6 12 <.0001 Abbreviation: Other—nursing home, hospice, no fixed abode.
Days sedation post-tracheostomy 0 1 .06
Days to outcome post-tracheostomy
Level 2 care 6 10 .003
the expected values expressed in the UK Guidance for
NIV 1 2 .003
VFB 4 7 .005 Tracheostomy Care,1 but notably longer, particularly for hospi-
Extubation surrogate 7 7 .44 tal LOS, than those in secondary analysis of the LUNG-SAFE
SpV 7 7.5 .44 study (11 and 24 days for ICU and hospital LOS, respectively)
Swallow 15 17 .48 and in Mehta’s paper for the 2012 data (26-day hospital
Dynamic sitting 5 6 .06 LOS).9,10 A potential explanation for this could be the differing
Sit to edge 10 12 .43 patient cohorts included in the studies.9 It may also be a reflec-
Sit to stand 12 14 .41
tion of ICU capacity, with Ireland having the lowest rate of ICU
Variables presented as median unless otherwise stated. Abbreviations: beds per head of population, at 5 per 100,000, in the latest report
APACHE, Acute Physiology and Chronic Health Evaluation; ICU, intensive care available from the Organisation for Economic Cooperation and
unit; LOS, length of stay; NIV, noninvasive ventilation; SpV, speaking valve; VFB,
Development (OECD) on ICU capacity, meaning an unwell
ventilator-free breathing.
patient cohort, with a median APACHE II score of 17, requiring
prolonged ventilation are admitted to our unit.11 This underlines
that a tracheostomy is not performed lightly in our center.
Despite a relatively long ICU LOS, once tracheostomy was per-
formed, patients were discharged to a level 2 area at a median of
7 days. This is in keeping with previous results from our center
Table 5. Comparison of Patient Characteristics and Outcomes by
and emphasizes the MTT in enhancing and progressing patient
Age (Younger ≤ 65, Older ≥ 66 Years).
care.5
Younger Older P value The ICU mortality was 9.9% in our patient population.
Although we could not statistically compare them, this is
N 185 119
Male 72.4% 69.8% .70
slightly lower than the mortality for our ICU patient group as
APACHE II 15 19 <.0001 a whole (11.3%). The converse is true when it comes to hospital
ICU mortality 8.1% 12.6% .24 mortality, with our tracheostomy population having worse out-
Hospital mortality 14.1% 36.1% <.0001 comes than the ICU patients as a whole (22.5% vs 17.6%). Our
ICU LOS 17 15 .07 ICU and hospital mortality are noticeably lower than those in
Hospital LOS 55 61 .40 the study by Young et al.3 For our patients, an a priori decision
Days to tracheostomy 8 7 .06 is made that the patient has either an uncertain prognosis or is
Days sedation total 8 6 <.0001
Days sedation post-tracheostomy 1 0 .03
more likely to survive. Our lower mortality may signify
Days to outcome post-tracheostomy improvements in care, as there has been a downward trend in
Level 2 care 8 7 .35 hospital mortality over time in our patients, looking at previ-
NIV 1(94%) 1(94%) .03 ously reported figures from our own center.5 The increase in
VFB 5(77.3%) 6(63.9%) .69 mortality seen at hospital discharge is in keeping with that
Extubation surrogate 7(69.2%) 7.5(53.8%) .65 found in the LUNG-SAFE secondary analysis.9 In this article,
SpV 7(62.7%) 7(64.7%) .87 they suggested that although tracheostomy improves short-term
Swallow 15(76.6%) 20.5(66.7%) .05
Dynamic sitting 6(78.3%) 5(62.2%) .17
survival, it has no impact on long-term outcomes. In fact,
Sit to edge 10(30.3%) 14(38.7%) .18 although there was a reduction in hospital mortality in
Sit to stand 13(22.1%) 17(12.6%) .13 Mehta’s study, this may signify only a change in location of
death to long-term care facilities.10 We would argue that a hos-
Variables presented as median unless otherwise stated, percentage of reaching
pital mortality of 22.5% for ICU patients with tracheostomy is
each goal in brackets. Abbreviations: APACHE, Acute Physiology and Chronic
Health Evaluation; ICU, intensive care unit; LOS, length of stay; NIV, noninvasive consistent with the 90-day mortalities of recent sepsis
ventilation; SpV, speaking valve; VFB, ventilator-free breathing. studies.12,13
6 Journal of Intensive Care Medicine 0(0)

Figure 3. Hospital discharge disposition for patients with tracheostomy stratified by age. Oldest ≥66, older 45 to 65, younger ≤44 years.
Abbreviation: Other—other acute hospital, rehabilitation, nursing home, hospice, no fixed abode.

Figure 4. Age of patients at the time of tracheostomy insertion.

The Young et al’s paper and other studies are often mis- index for appropriateness of the procedure. Outcomes that
quoted as reasons not to perform a tracheostomy, either are important to the patient should be considered during
early or late, contending that neither has an impact on mortal- the decision-making process and the significance of the
ity. However, we contend that mortality should not be the potential return to vocalization, swallow, and increased
Mc Mahon et al
mobility following tracheostomy should not be under-
appreciated. The value to the patient is premised on appropriate
patient selection, with a particular focus on the patient with
longer term ventilation needs and a predicted prolonged ICU
stay, associated myopathy, deconditioning and prolonged reha-
bilitation requirements.
We feel that the ability to rapidly wean sedation following
tracheostomy is an important patient-centered outcome, as it
reflects the ability of the patient to interact with their environ-
ment, caregivers, and family and to take an active role in
their care and rehabilitation. A reduction in use of sedation
with tracheostomy has been noted in previous randomized-
control trials and meta-analysis.3,14 In our own population we
were able to stop sedation on the day of tracheostomy for a
large proportion of our patients. Including a measure of the
depth of sedation enabled us to ensure that our patients were
calm and alert following discontinuation. Deep sedation is asso-
ciated with an increased risk of death, delirium, and delayed
extubation in mechanically ventilated patients.15 Exposure to
psychoactive drugs, with benzodiazepines being of particular
concern, has been identified as a modifiable delirium risk
factor.16 There is also concern that prolonged sedation could
contribute to long-term cognitive impairment, particularly exec-
utive function.17 Given that tracheostomy-facilitated discontin-
uation of sedation in our patients, this could potentially reduce
the incidence of delirium and long-term cognitive impairment
and have a positive effect on mortality.
The ability to transition from invasive ventilation to NIV is a
patient-centered outcome from our perspective for a number of
reasons. The first and foremost is that once patients are weaned
from ventilation, they are free from the apparatus required for
its delivery. This leaves them free to mobilize and interact
with their surroundings and take a more active role in their reha-
bilitation. The second is that of resource utilization. Patients can
be discharged to a high dependency level of care once estab-
lished on NIV via a tracheostomy and may be discharged to a
ward with follow up by our MTT once VFB is accomplished.
This is in keeping with previous trials in ICU trauma patients
and recent meta-analysis.4,18 There is a conflicting evidence
in the literature as to whether tracheostomy reduces days of
mechanical ventilation.3,4,14,18 In our own population, once tra-
cheostomy was performed 94% of our patients were transi-
tioned to NIV at a median of 1-day postinsertion, with VFB
by day 5 in 72%. In comparison, it took a median of 7 days
to reach our extubation surrogate and only 63% of patients
reached this target suggesting that tracheostomy insertion
potentially reduced days on mechanical ventilation with the
patient-centered benefits of this as described above. It also
implies that we are correctly identifying a group of patients
who require prolonged ventilation in which to perform trache-
ostomy, many of whom have ongoing high ventilatory require-
ments or excess secretions and a poor cough as a component of
their critical illness. It should be taken into consideration that
our extubation surrogate does not equate to extubation
success. An extubation failure rate of 10% to 20% in the pro-
longed weaning cohort is to be expected.6
7
Restoration of vocalization represents one aspect of high-
quality care for tracheostomy patients and is a key patient-
centered outcome. According to the latest guidance document
from the UK Faculty of Intensive Care Medicine on tracheos-
tomy care, vocalization should be a daily goal of care and
speech and language therapy (SLT) assessment should occur
at the point when sedation is held, and ventilation being
weaned.1 It is well known that loss of the ability to communi-
cate causes fear, anxiety, and powerlessness in tracheostomy
patients.1,19 It can also contribute to depression and post-
traumatic stress disorder.20 Attempts at nonverbal communica-
tion can be frustrating and cumbersome for patients as they may
not have the strength, energy, or co-ordination it takes to com-
plete such tasks. This makes restoration of vocal communica-
tion a crucial goal of tracheostomy care. This is most often
achieved with use of an SpV, which in addition to restoration
of speech, has a number of other advantages including
improved laryngeal sensation and function, improved smell
and taste, and creation of a level of continuous positive pres-
sure. In our patients, the median time to placement of an SpV
was 7 days and this occurred in 60% of the population. In a
paper looking at early targeted intervention for vocalization,
return to phonation occurred at a median of 7 days in compar-
ison to 18 days for those in the control group.20 Our figures are
reassuring when comparing to this trial. However, they mea-
sured return to phonation as the ability to count from 1 to 10
whereas we have used first placement of an SpV as a surrogate
for speech. In a recent trial analyzing the impact of implement-
ing quality improvement initiatives from the Global
Tracheostomy initiative in 20 sites, time to first use of an
SpV decreased from 14 to 7 days with implementation of stan-
dardized multidisciplinary care, educational initiatives, patient
and family involvement, and tracking patient data.21 Our insti-
tution has had an MTT in place since 2009, with weekly full
team ward rounds, daily advanced nurse practitioner rounds
and standardized equipment, protocols and guidelines for care
of tracheostomy patients. We have previously shown that estab-
lishment of the MTT lead to a reduction in time to decannula-
tion.5 The MTT and early involvement of SLT with our ICU
patients likely accounts for the short time to placement of an
SpV. Our data give us a benchmark for further improvement,
along with recording time to first SLT referral and consideration
of 40% of the patients who did not meet this target. A propor-
tion of this may be down to documentation but looking into
other clinical, systems, or process reasons for this would help
improve outcomes.
Return to oral intake is a significant goal for patients. It is
well known that dysphagia is a common occurrence in trache-
ostomy patients. While this was initially thought to be due to
the presence of a tracheostomy tube altering swallowing biome-
chanics, it is more likely that dysphagia is part of the underlying
condition leading to tracheostomy insertion.22 As with speech,
there can be significant patient fear and anxiety surrounding
swallow and diet with a tracheostomy in place. Return to oral
intake is recommended as a daily goal of care for tracheostomy
patients.1 It has been highlighted that recognition of dysphagia
8 Journal of Intensive Care Medicine 0(0)
needs to improve, with earlier referral to SLT an essential com-
ponent in management, including use of functional endoscopic
evaluation of swallow (FEES).1,23 The median time to swallow
assessment in our population was 16 days, with 55% of those
followed resuming oral intake following assessment. This is
with an MTT in place and regular use of FEES in our center.
In comparison, a retrospective review of tracheostomy patients
in a tertiary referral center found a median of 10.5 days to
resumption of oral intake, with 82% of patients commencing
diet with a tracheostomy in situ. A small proportion of these
resumed intake prior to cuff deflation.22 The quality improve-
ment initiative referred to above also found a significant reduc-
tion in time to first oral intake (decrease from a median of 26 to
9 days), with introduction of their initiatives.21 In comparison to
these papers, there is a significant delay to swallow assessment
with a smaller proportion of patients resuming oral intake. At
the time of our data collection, there was a 0.5 whole time
equivalent SLT covering both ICU and ear nose and throat
(ENT) tracheostomy patients and providing services to the out-
patient department. This likely contributed to the delay in time
to swallow assessment. In a paper by Sutt et al they found a
return to swallow on average 7.4 days earlier with a tracheos-
tomy versus endotracheal tube but commented that this was
in a well-resourced department with several full-time allied
health professionals.24 Recent guidelines from the Faculty of
Intensive Care Medicine and Intensive Care Society in the
United Kingdom recommend 0.1 SLT staff per ICU bed.25
Our data underlines the necessity of such a valuable resource.
Resources in our own unit have improved in recent times
with an increase in the number of SLTs dedicated to the ICU.
Along with this, education and awareness of the importance
of early referral to SLT and speech and swallow assessment
has increased, and it would be interesting to compare our
current data to that which we have here.
Mobility has been recognized as an important patient-
centered outcome following tracheostomy.2 Functional disabil-
ity is well described following critical illness. A study by
Herridge et al26 found that all patients reported weakness 1
week following ICU discharge, with 60% being unable to
walk without assistance. The worst outcomes were seen in
older patients with longer ICU LOS. This was the subgroup
most likely to undergo tracheostomy. And 77% of these patients
could not walk unassisted 1 week after ICU stay and had a
1-year mortality of 40%.22 In our patients insertion of a
tracheostomy-facilitated discontinuation of sedation enabling
patients to actively participate in rehabilitation. As a result,
the majority of patients with tracheostomy were able to sit
with assistance 2 days earlier than when the extubation surro-
gate was achieved. A recent paper looking at patient-centered
outcomes with earlier tracheostomy found that 88% of patients
could perform out of bed exercises by ICU discharge. They also
found that this occurred 6.2 days earlier with early tracheos-
tomy.24 Although there was no statistically significant differ-
ence in time to mobilization between our early and late
tracheostomy groups, we measured these variables from trache-
ostomy insertion, this then suggests that with earlier
tracheostomy patients are able to mobilize sooner. Insertion
of a tracheostomy therefore accelerated patient rehabilitation
and improved outcomes important to patients.
The ability to return home is highly valued by patients and
their families. Reassuringly, the majority of our tracheostomy
patients were discharged home (40.9%). Nearly one-third of
patients were transferred to another acute hospital reflecting
the fact that our hospital is a quaternary referral center and
only 8.9% were discharged to a nursing home. This indicates
that we are selecting a patient population with a positive trajec-
tory. The discharge location diverges with Mehta’s paper in
which the discharge disposition of 71.9% of patients was long-
term care in the recent period, with only 13.1% being dis-
charged home.10 This may reflect the differing structure of
the healthcare system in the United State, with greater availabil-
ity of long-term care facilities that can care for tracheostomy
patients, shifting the burden of care for these patients.10
Similar to Herridge’s data, it was our oldest patients (≥66)
who were least likely to be discharged home (28.9%).26 This
information can help inform discussion about selection of
patients for tracheostomy in the future considering it from a
patient-centered perspective.
As noted by Herridge et al in their paper, the oldest trache-
ostomy patients had the worst outcomes in terms of mortality
and discharge home.26 This is backed up by recent evidence
from the CoVIP investigators who reported a 50.4% mortality
in patients with COVID-19 over 70 years of age with a trache-
ostomy.27 Another recent paper has found that, not only are
mortality rates high in elderly tracheostomized patients, but
that survivors had profound physical morbidity with a signifi-
cant impact on their functional independence with greatly
reduced ability to eat, speak, and ambulate.28 The hospital mor-
tality in our older patients (36.1%), although high, was lower
than both these studies. In comparison to the COVID 19
disease in Very Elderly Intensive Care Patients (CoVIP)
study, whose cohort also had an average age of 74 years, mor-
tality was measured at 3 months rather than hospital discharge
and included only patients with COVID-19.27 In the paper by
Lee et al, the average age was 81 years, perhaps explaining
the higher mortality rate than our own. More importantly, in
contrast to the paper by Lee et al, around two-thirds of our
older patients reached VFB, had an SpV placed, swallow
assessment performed (with 50% pass rate) and achieved
dynamic sitting.28 The older subgroup also received less days
of sedation than the younger population allowing them to inter-
act with their surroundings, caregivers, and family earlier. This
reduction in sedation may also contribute to reduced rates of
delirium and long-term cognitive impairment as mentioned
above. This reinforces our viewpoint that mortality is not the
only or most valuable point to be considering when making
the decision to perform a tracheostomy. The significance to
older patients of being able to communicate, eat, and interact
with their loved ones should not be underestimated. Again,
this is premised on appropriate patient selection, focusing on
those who we feel are more likely survive and to require pro-
longed ventilation.
Mc Mahon et al
When analyzing our population by time to tracheostomy,
there were a number of significant differences between our
early and late groups. We found that early tracheostomy was
associated with a shorter ICU LOS, transition to level 2 care,
reduced duration of sedation and less days of mechanical ven-
tilation. Although there are a number of studies that have not
found any association with early tracheostomy and reduced
LOS or ventilation,3,14 there are a number of recent publications
that support our findings.4,18 A lower incidence of ventilator-
associated pneumonia was also found in these papers.4,18 We
did not find a mortality difference with early tracheostomy in
our group, similar to the majority of previously published
data, including a Cochrane systematic review whose findings
were only suggestive at best that early tracheostomy was asso-
ciated with reduced mortality.29 We did not find a statistically
significant difference in patient-centered outcomes with early
tracheostomy. This is in contrast with the paper by Sutt et al
which found that patients had return of voice, oral intake, and
mobilization on average 1 week earlier with early tracheos-
tomy.24 This paper looked at time from endotracheal tube inser-
tion to patient centric outcome, with tracheostomy insertion
being an intermediate event. Multistate modeling was used to
account for the varying time to tracheostomy insertion, rather
than an arbitrary cut-off to define an early or late event which
they felt would create bias.24 This is in comparison to our
own which used day 10 as the cut-off point for early tracheos-
tomy and measured timing of patient-centered outcomes from
the day of tracheostomy insertion. The variation in methods
of statistical analysis may account for why no difference was
found in our groups. We agree with the Sutt paper that
patient centric outcomes are an important goal when consider-
ing tracheostomy insertion.
The limitations of our study are that it is retrospective in
nature and performed in a single center with a heterogenous
case mix. We have used a number of broad measures of ICU
outcome including LOS and mortality and surrogates such as
placement of an SpV to measure our patient-centered outcomes.
We did not include a control group of ventilated ICU patients
who did not receive tracheostomy, instead using a surrogate
measure for extubation. Finally, we followed patients only to
hospital discharge and disposition at this time and did not
look at long-term outcome.
Conclusion
Patient-centered outcomes are a worthy goal to consider when
selecting patients for tracheostomy. Mortality, which has been
improving over time, is not the only, or most appropriate
metric on which to base the decision and selecting patients
with a positive or uncertain prognostic trajectory is more impor-
tant than timing of tracheostomy alone. In our single center ret-
rospective study, tracheostomy facilitated rapid weaning of
sedation, ventilation, and progression to a high dependency
level of care. Around two-thirds of patients with a tracheostomy
achieved meaningful patient-centered outcomes in terms of
communication, oral intake, and mobilization and a
9
considerable number were discharged home. Although our
oldest subgroup of patients had the highest mortality and
were least likely to be discharged home, two-thirds of them
also reached noteworthy patient-centered outcomes. This
knowledge will help inform discussions on how best to use a
scarce resource in patients who may go on to have a protracted
stay in the ICU. It will also ensure we are considering outcomes
important to patients when making these decisions surrounding
their care and identify areas for future research in patients with
tracheostomies in critical care.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
A. Mc Mahon, MB Bch BAO, FCAI, FJFICMI https://orcid.org/
0000-0003-3914-2850
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