Boudreaux et al.1 are to be commended for their publication in this month’s ASAIO regarding the utility of early tracheostomy in 150 patients placed on venovenous (VV) extracorporeal membrane oxygenation (ECMO) for respiratory failure. Thirty-five of the patients received a tracheostomy. There was no difference in survival between patients receiving a tracheostomy and those who did not (53.1% vs. 57.5%). In patients with a tracheostomy, they found significantly shorter intensive care unit (ICU) (25 vs. 36 days; p = 0.04) and hospital (33 vs. 47 days; p = 0.017) length of stay when it was performed within 7 days of ECMO cannulation. However, tracheostomy patients had longer lengths of mechanical ventilation (25.5 vs. 8 days; p < 0.01), length of intravenous (IV) sedation (17 vs. 7 days), ICU (31.5 vs. 21 days; p = 0.01) and hospital (39 vs. 30; p = 0.04), and total length of ECMO support (14 vs. 5 days) compared to patients that did not require tracheostomy despite pre-cannulation Respiratory ECMO Survival Prediction (RESP) scores.2

These results mirror previous findings by the University of Maryland group.3 They found early tracheostomy placement (<7 days) in patients placed on VV ECMO for acute respiratory distress syndrome (ARDS) to be associated with reduced time on ECMO. No change in ICU or length of stay were seen. However, no patients in this study were managed without tracheostomy.

Similarly, Nukiwa et al.4 performed a retrospective study of 98 patients admitted to a single ICU in Japan who had undergone ECMO and tracheostomy. The majority of patients had been placed on venoarterial ECMO for cardiogenic shock. Tracheostomy timing was divided into quartiles (≤15 days, 16–19 days, 20–26 days, >26 days). Ventilator and ECMO days and ICU and hospital mortality were higher in the fourth quartile. However, this group contained more COVID-19 patients, and many of the patients captured in the first quartile (≤15 days prior to tracheostomy) would have met the definition of late tracheostomy in other trials. Additionally, during the same time frame 192 patients at this hospital were placed on ECMO and managed without tracheostomy. No data is available for that cohort.

The timing of tracheostomy in critically ill patients remains controversial. Oral endotracheal intubation is an uncomfortable therapy for a patient usually requiring deep sedation and interfering with mobilization, oral care, and communication. Occasionally, more disastrous complications arise such as tube dislodgement or airway injury. Proponents of early tracheostomy expound its potential to alleviate many of these issues, potentially leading to early ventilator weaning, reduced ventilator-acquired pneumonia (VAP) rates, earlier ICU and hospital discharge, and reduced mortality.

However, when examining real world data, the benefits of early tracheostomy are less clear. Single center retrospective studies and meta-analysis have shown mixed results regarding reductions in mortality, cost, and complications.5,6

Any retrospective study, particularly those regarding treatment decisions in critically ill patients is sure to contain significant bias. To address this, Terragni et al.7 conducted a randomized clinical trial on 600 medical ICU (MICU) patients across 12 ICUs in Italy. Four hundred nineteen remained intubated after 48 hours, deemed eligible for tracheostomy, and were randomized to tracheostomy at either 6–8 or 13–15 days. There was no significant difference in VAP, length of stay, or mortality. Notably, only 69% of patients in the early group and 57% of patients in the late group required tracheostomy. Shortly, thereafter, Young et al.8 published the results of the TracMan trial, the largest study randomized trial comparing early to late tracheostomy to date. Nine hundred nine patients at 72 centers in the United Kingdom expected to require greater than 7 days of ventilation were randomized to tracheostomy within 4 days of ICU admission or after 10 days of ventilation if still needed. Once again, there was no difference in the mortality or ICU stay. Additionally, only 44.9% of patients in the late tracheostomy group required a tracheostomy, highlighting the difficulty identifying which patients will require tracheostomy early in their ICU course.

Considering these results, the benefit of early tracheostomy for MICU patients is questionable. Certain groups of patients may still benefit though including stroke, head trauma, and burns.9 Is it possible that ECMO patients fall into such a category? The answer may depend on a few questions. First, is tracheostomy in ECMO patients safe? Multiple studies have shown small increases in bleeding but no procedural mortality or need for surgical reintervention.10,11 Boudreaux et al.1 found similar results.

Second, are there ECMO cohorts that would benefit from tracheostomy for airway protection but not require ventilator support? Patients requiring venoarterial support for cardiogenic shock may fall into this group. Multiple retrospective studies have shown awake extubated VA ECMO to be associated with reduced risk of VAP and mortality.12,13 Occasionally, these patients are unable to be extubated due to intolerance of a sedation wean. In this circumstance, proceeding with tracheostomy expeditiously may improve mobilization, assist with patient comfort, and provide some of the benefits of extubation.

For patients with pure respiratory failure, the use of awake ECMO has been well documented in pre-lung transplant14 and chronic obstructive pulmonary disease (COPD) patients.15 It’s utility in ARDS patients is less clear, but multiple case series suggest favorable outcomes.16–18 Additional theoretical benefits in ARDS patients include prevention of diaphragmatic fatigue and reduction in ventilator-induced lung injury.19 It is conceivable that early tracheostomy could assist with transition to awake ECMO strategies in patients who are unable to be extubated due to issues with sedation, oxygenation, or hemodynamics. However, most patients in the previous series were able to be extubated. Like the TracMan trial, difficulty remains in identifying who will require a tracheostomy early in their course.

What should the clinician take from all of this? First, awake, extubated ECMO is a reasonable goal for most patients, including those with ARDS. Second, for those not tolerating extubation, performance of a tracheostomy is safe with a mild increase in bleeding risk. Third, for those unable to be extubated, there may be some benefit regarding length of stay and recovery in performing tracheostomy relatively early for patients unlikely to be weaned from ECMO within 7–10 days. Unfortunately, beyond clinical judgment, there is little data available to assist with anticipating who these patients will be and that remains an area ripe for study.

1. Boudreaux JC, Urban M, Thompson SL, Castleberry AW, Moulton MJ, Siddique A: Does tracheostomy improve outcomes in those receiving venovenous extracorporeal membrane oxygenation? ASAIO J 69:e240-e247, 2023. 2. Schmidt M, Bailey M, Sheldrake J, et al.: Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med 189: 1374–1382, 2014. 3. DiChiacchio L, Boulos FM, Brigante F, et al.: Early tracheostomy after initiation of venovenous extracorporeal membrane oxygenation is associated with decreased duration of extracorporeal membrane oxygenation support. Perfusion 35: 509–514, 2020. 4. Nukiwa R, Uchiyama A, Tanaka A, et al.: Timing of tracheostomy and patient outcomes in critically ill patients requiring extracorporeal membrane oxygenation: A single-center retrospective observational study. J Intensive Care 10: 56, 2022. 5. Meng L, Wang C, Li J, Zhang J: Early vs late tracheostomy in critically ill patients: A systematic review and meta-analysis. Clin Respir J 10: 684–692, 2016. 6. Griffiths J, Barber VS, Morgan L, Young JD: Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ (Clin Res Ed) 330: 1243, 2005. 7. Terragni PP, Antonelli M, Fumagalli R, et al.: Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: A randomized controlled trial. J Am Med Assoc 303: 1483–1489, 2010. 8. Young D, Harrison DA, Cuthbertson BH, Rowan K, et al.; TracMan Collaborators: Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: The TracMan randomized trial. J Am Med Assoc 309: 2121–2129, 2013. 9. Freeman BD, Morris PE: Tracheostomy practice in adults with acute respiratory failure. Crit Care Med 40: 2890–2896, 2012. 10. Dimopoulos S, Joyce H, Camporota L, et al.: Safety of percutaneous dilatational tracheostomy during veno-venous extracorporeal membrane oxygenation support in adults with severe respiratory failure. Crit Care Med 47: e81–e88, 2019. 11. Matsuyoshi T, Shimizu K, Kaneko H, et al.: Optimal timing of tracheostomy in patients on veno-venous extracorporeal membrane oxygenation for coronavirus 2019: A case series. Acute Med Surg 8: e662, 2021. 12. Bataillard A, Hebrard A, Gaide-Chevronnay L, et al.: Extubation in patients undergoing extracorporeal life support. Int J Artif Organs 40: 696–700, 2017. 13. Behouche A, Gaide-Chevronnay L, Piot J, et al.: Early extubation in extracorporeal life support patients: A propensity score-matched study [published online ahead of print April 2, 2023]. Artif Organs doi:10.1111/aor.14532. 14. Biscotti M, Gannon WD, Agerstrand C, et al.: Awake extracorporeal membrane oxygenation as bridge to lung transplantation: A 9-year experience. Ann Thorac Surg 104: 412–419, 2017. 15. Pisani L, Polastri M, Pacilli AMG, Nava S: Extracorporeal lung support for hypercapnic ventilatory failure. Respir Care 63: 1174–1179, 2018. 16. Yeo HJ, Cho WH, Kim D: Awake extracorporeal membrane oxygenation in patients with severe postoperative acute respiratory distress syndrome. J Thorac Dis 8: 37–42, 2016. 17. Gurnani PK, Michalak LA, Tabachnick D, Kotwas M, Tatooles AJ: Outcomes of extubated COVID and non-COVID patients receiving awake venovenous extracorporeal membrane oxygenation. ASAIO J 68: 478–485, 2022. 18. Xia J, Gu S, Li M, et al.: Spontaneous breathing in patients with severe acute respiratory distress syndrome receiving prolonged extracorporeal membrane oxygenation. BMC Pulm Med 19: 237, 2019. 19. Langer T, Santini A, Bottino N, et al.: “Awake” extracorporeal membrane oxygenation (ECMO): Pathophysiology, technical considerations, and clinical pioneering. Crit Care 20: 150, 2016.