10.14639/0392-100X-suppl.1-42-2022-08
Patients affected by severe acute respiratory distress syndrome due to severe acute res- piratory syndrome coronavirus 2 (SARS-CoV-2) infection have a high likelihood of need- ing prolonged intubation. As observed worldwide during the Coronavirus Disease 2019 (COVID-19) pandemic, the need for tracheotomy in patients with prolonged respiratory failure has dramatically increased. Tracheotomy in these patients offers several advantages over prolonged translaryngeal intubation: improved patient comfort may allow a reduction in intravenous administration of analgesics, sedatives and muscle relaxant drugs, enhance mobility with particular regard to respiratory muscles, and patients may achieve autonomy earlier. However, there is still debate about the optimal timing and surgical technique of tracheotomy. Similarly, debate is still open regarding the relative merits of open surgical tracheotomy (ST) versus percutaneous dilatational techniques (PDT). In general, PDT is commonly used in elective tracheotomy in adult patients in intensive care units; ST may be preferred depending upon the practitioner’s experience and patient’s characteristics. Cor- rect timing of tracheotomy should be individualised and the indication for tracheotomy should balance the problems related to prolonged intubation and the risk of early or late complications related to the surgical procedure.
text/xml
1827-675X
2112
en
Angelo Ghidini
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
mechanical ventilation
The role of tracheotomy in patients with moderate to severe impairment of the lower airways
Text.Serial.Journal
https://www.actaitalica.it/
42
Annual congress report
2022-04-26
2022-04-06
2022-04-28
2022-04-28
S73-S78
1
Angelo Ghidini
2022/04/26
10.14639/0392-100X-suppl.1-42-2022-08
S73
Otorhinolaryngology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
1827-675X
mechanical ventilation
S78
The role of tracheotomy in patients with moderate to severe impairment of the lower airways
https://www.actaitalica.it/article/download/2112/776
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42(SUPPL.1):S73-S78; doi: 10.14639/0392-100X-suppl.1-42-2022-08




The role of tracheotomy in patients with moderate
to severe impairment of the lower airways
Il ruolo della tracheotomia nei pazienti affetti da disfunzione moderata
o severa delle vie aeree inferiori
Cecilia Botti1, Marcella Menichetti2, Caterina Marchese2, Carmine Pernice2, Davide Giordano2,
Daniele Perano2, Paolo Russo3, Angelo Ghidini2
1
 Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Reggio Emilia, Italy;
2
 Otorhinolaryngology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy; 3 Department of Otorhinolaryngology Head
and neck surgery, University Hospital of Modena, Modena, Italy


SUMMARY
Patients affected by severe acute respiratory distress syndrome due to severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have a high likelihood of
needing prolonged intubation. As observed worldwide during the Coronavirus Disease 2019
(COVID-19) pandemic, the need for tracheotomy in patients with prolonged respiratory
failure has dramatically increased. Tracheotomy in these patients offers several advantages
over prolonged translaryngeal intubation: improved patient comfort may allow a reduction
in intravenous administration of analgesics, sedatives and muscle relaxant drugs, enhance
mobility with particular regard to respiratory muscles, and patients may achieve autonomy
earlier. However, there is still debate about the optimal timing and surgical technique of
tracheotomy. Similarly, debate is still open regarding the relative merits of open surgical
tracheotomy (ST) versus percutaneous dilatational techniques (PDT). In general, PDT is
commonly used in elective tracheotomy in adult patients in intensive care units; ST may
be preferred depending upon the practitioner’s experience and patient’s characteristics.
Correct timing of tracheotomy should be individualised and the indication for tracheotomy
should balance the problems related to prolonged intubation and the risk of early or late
complications related to the surgical procedure.
KEY WORDS: tracheotomy, intensive care, respiratory insufficiency, respiratory failure,
mechanical ventilation                                                                        Received: January 20, 2022
                                                                                              Accepted: February 7, 2022

RIASSUNTO                                                                                     Correspondence
Durante la pandemia di COVID-19 la necessità di eseguire una tracheotomia nei pazienti        Cecilia Botti
con insufficienza respiratoria prolungata è drammaticamente aumentata, poiché i pa-           Otolaryngology Unit, Department of Surgery,
zienti contagiati dal virus SARS-CoV-2 manifestano una sindrome da distress respirato-        Azienda USL-IRCCS di Reggio Emilia
rio acuto grave che spesso necessita di un’intubazione prolungata. La tracheotomia offre      viale Risorgimento 80, 42123 Reggio Emilia, Italy
diversi vantaggi rispetto all’intubazione translaringea prolungata: un migliore comfort       E-mail: botceci@gmail.com
del paziente può infatti consentire una riduzione della somministrazione di analgesici e
sedativi, può migliorare la mobilità con particolare riguardo ai muscoli respiratori e i        How to cite this article: Botti C, Menichetti
pazienti possono raggiungere un’autonomia più precocemente. Tuttavia in letteratura è           M, Marchese C, et al. The role of tracheotomy
ancora aperto un dibattito su quale sia, nell’esecuzione della tracheotomia, la tempistica      in patients with moderate to severe impairment
ottimale e la tecnica chirurgica più appropriate, così come se sia più indicate la tecnica      of the lower airways. Acta Otorhinolaryngol
a cielo aperto (ST) rispetto alla dilatazione percutanea (PDT). In generale, in terapia         Ital 2022;42(SUPPL.1):S73-S78. https://doi.
intensiva, la PDT in elezione è più comunemente usata; la ST può essere preferita a             org/10.14639/0392-100X-suppl.1-42-2022-08
seconda dell’esperienza del medico e delle caratteristiche del paziente. La tempistica
di esecuzione deve essere individualizzata sulle condizioni del paziente e l’indicazione      © Società Italiana di Otorinolaringoiatria
                                                                                              e Chirurgia Cervico-Facciale
deve considerare i problemi legati all’intubazione prolungata e il rischio di complicanze
legate alla procedura chirurgica.
                                                                                                             OPEN ACCESS
PAROLE CHIAVE: tracheotomia, terapia intensiva, insufficienza respiratoria, ventilazione      This is an open access article distributed in accordance with
meccanica                                                                                     the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                              Commercial-NoDerivatives 4.0 International) license. The
                                                                                              article can be used by giving appropriate credit and mentio-
                                                                                              ning the license, but only for non-commercial purposes and
                                                                                              only in the original version. For further information: https://
                                                                                              creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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Introduction                                                     muscular conditions, poor cardiorespiratory reserve, bulbar
                                                                 dysfunction, or brain injury. Tracheotomy may also be re-
A tracheotomy is usually performed for one of the                quired in patients with severe lung diseases who need pro-
following reasons: to bypass an obstructed upper airway,         longed respiratory support (such as in case of bronchopul-
to clear secretions from the airway, or to deliver oxygen        monary dysplasia), in chronic pulmonary disease to reduce
to the lungs more easily and more safely in patients who         anatomic dead space, in severe sleep apnoea not treatable
require prolonged mechanical ventilation 1. The most             with continuous positive airway pressure devices or other
frequent indication for tracheotomy is to assist mechanical      less invasive surgery, or for chest wall injuries. The lower
ventilation, followed by head and neck surgery and upper         airways can also be indirectly affected by other conditions,
airway obstruction. In addition, the need for tracheotomy        such as neuromuscular diseases paralysing or weakening
in patients with prolonged respiratory failure has recently      chest muscles and diaphragm, anaphylaxis, aspiration re-
increased due to the COVID-19 pandemic. Patients affected        lated to pharyngolaryngeal motor or sensory impairment,
by severe acute respiratory distress syndrome due to SARS-       fractures of cervical vertebrae with spinal cord injury, long-
CoV-2 infection have a high likelihood of needing prolonged      term coma and disorders of respiratory central control such
intubation and may require tracheotomy 2. It is important to     as congenital central hypoventilation or central apnoea.
recognise the complications of tracheotomy, and measures
should be taken to prevent them. Optimal timing and
surgical technique for tracheotomy are still being debated,      Potential advantages of tracheotomy versus
and well-designed studies to establish clear guidelines          translaryngeal intubation
regarding the timing of tracheotomy are not available 1.         Most of the aforementioned diseases require intensive
On the other hand, early tracheotomy may decrease the            care. Tracheotomy in the critically ill patient offers several
need for sedation and length of stay in intensive care units.    advantages over prolonged translaryngeal intubation 1,3.
However, it does not decrease rates of ventilator-associated     First of all, improved patient comfort may allow a reduction
pneumonia or mortality 3. Similarly, debate is still open        in intravenous administration of analgesics, sedatives and
regarding the relative benefits of open surgical tracheotomy     muscle relaxant drugs, thus enhancing mobility and speech
(ST) versus percutaneous dilatational techniques (PDT) 2,4.      so that patients may achieve autonomy earlier 6. As the
There are also continuing developments in materials like         patient recovers, a fenestrated tracheotomy tube should be
the preferential use of more flexible tracheotomy tubes 5.       inserted to allow phonation. Clearance of airway secretions,
Tubes with removable inner cannula greatly reduce the risk       oral hygiene and enteral nutrition are facilitated. When
of tube obstruction by encrusted secretion. As opposed to        respiratory mechanics improve, weaning is facilitated. In
the abovementioned debates, tracheotomy currently has            the meantime, the risk of unscheduled accidental extubation
an established role in the management of lower airway            decreases, since tracheotomy allows a gradual transition
impairment and intensive care. It is usually performed in        between different weaning modes avoiding attempts to
critically ill patients affected by moderate to severe lower     extubate followed by reintubation. It should be noted that
airway impairment to provide airway care or ease weaning         patients with COVID-19-related acute respiratory distress
from assisted ventilation 5. The aim of this narrative review    syndrome often require prolonged intubation. In addition,
is to describe the role of tracheotomy in patients affected by   early extubating attempts frequently require a reintubation
lower airways impairment.                                        procedure. Reintubations should be considered a difficult
                                                                 procedure in severe COVID-19 patients for several reasons
Indications for tracheotomy in lower airway                      (i.e., no respiratory reserve, need for strict infection
                                                                 control, urgency, bulky personal protective equipment,
impairment
                                                                 psychological pressure). Tracheotomy offers several
Tracheotomy is usually performed in patients affected by         advantages that allow easier attempts of weaning from
lower airway impairment to remove secretions from the air-       ventilator. Therefore, the procedure is frequently required
way, to deliver oxygen to the lungs more easily and more         not only to avoid complications related to prolonged
safely in patients who require prolonged mechanical ven-         intubation, but also to facilitate weaning process 8,9. The
tilation and to ease weaning from prolonged mechanical           anatomic dead space contained in the upper airway and the
ventilation 1. The lower airways can be impaired directly or     intrathoracic conducting airways is approximately 150 mL
indirectly by several diseases. Factors indicating the need      in an adult. This is clearly more than the volume in the
for tracheotomy in critically ill patients include: prolonged    tracheotomy tube, which is around 5 ml, plus connecting
weaning from assisted ventilation, acute or chronic neuro-       pieces. However, the difference in internal volume of



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standard endotracheal tubes and tracheotomy tubes of same         to create a false tract. Orotracheal intubation could be
sizes is less than 20 ml, and it seems unlikely that such         needed when correct replacement is not obtained.
small volume differences could significantly affect lung        Late complications (> 7 days) 11,12:
mechanics in vivo. Anatomical dead space is reduced with        • Dysphagia. Factors that contribute to swallowing
both tracheotomy and translaryngeal intubation. A more            impairment are decreased laryngeal elevation, decreased
plausible reason to facilitate weaning would be reduced           laryngeal sensibility and oesophageal compression from
work of breathing because of a decrease in flow resistance        the tube cuff.
due to the reduction in the tube length. This difference        • Tracheal stenosis. Tracheal stenosis occurs in
increases with increasing inspiratory flows. Intrinsic            approximately 1-2% and usually results from tracheal
positive end-expiratory pressure is also slightly reduced         ischaemia, caused by forced angulation of the tube or
after tracheotomy 7. Tracheotomy may allow earlier                hyperinflation of the cuff. It is recommended to monitor
discharge from intensive care to lower intensity units. The       the cuff pressure (< 20 mm Hg) 1. Stenosis could also
risk of laryngeal and tracheal ulceration decreases, as the       be caused by tracheal ring fractures or posterior tracheal
respiratory tube is taken out from the first digestive tract,     wall injuries occurring during surgical manoeuvers.
eliminating the up and down movements and frictions             • Tracheomalacia. It can develop because of ischaemia
related to deglutition. Endotracheal intubation can result        and necrosis of tracheal cartilage. Causes are the same
in severe injury of the upper airways (tracheal stenosis,         seen for stenosis.
subglottic stenosis, arytenoid anchyloses) which can be         • Tracheo-innominate artery fistula. The tube can erode
largely prevented by early tracheotomy 10.                        into the artery if tracheotomy is too low or innominate
                                                                  artery is high riding. This severe and potentially deadly
Potential disadvantages of the tracheotomy                        complication usually occurs at 7 to 14 days after the
                                                                  tracheotomy. Sentinel bleeding may be present and
Tracheotomy is a surgical act procedure associated with           should be carefully investigated.
early and late complications 1.                                 • Tracheo-oesophageal fistula. Due to pressure and erosion
Early complications (< 7 days) 1:                                 against the posterior tracheal wall by the tracheotomy
• Haemorrhage. The cuff of the tracheotomy tube should            cuff or angled tube. This condition can otherwise cause
   be inflated immediately. Minor haemorrhage can be              further complications such as ab ingestis pneumonia
   controlled by packing. Major bleeding may require              which, if not promptly treated, can induce major lower
   reoperation.                                                   airways complications such as pulmonary fibrosis.
• Wound infection. This complication often requires local       • Persistent stoma. Epithelialisation between the skin and
   antibiotics. In case of necrotising tracheal infection,        the tracheal mucosa can occur when the tube has been
   conversion to orotracheal intubation, debridement of           left in position for a prolonged period. Surgical closure
   necrotic tissues and systemic antibiotics may be needed.       can be proposed.
• Subcutaneous emphysema and pneumothorax. These                • Granuloma formation.
   complications can be caused by positive pressure
   ventilation. Subcutaneous emphysema can be also
   caused by coughing against a tightly sutured or packed
                                                                Timing of tracheotomy
   wound. It can be prevented by removing the suture and        Timing of tracheotomy is controversial and strongly
   packing around the tube. The emphysema will resolve          influenced by the indications for the procedure 1. In most
   spontaneously within a few days. A chest radiograph          institutions, tracheotomies are performed within 2 weeks
   should be obtained to rule out a pneumomediastinum.          of prolonged mechanical ventilation. Median timing is 11
• Tracheotomy tube obstruction. The tube can be obstructed      days 13,14. The decision about the most appropriate time
   by mucus, secretions, blood clots, or angulation of the      to perform tracheotomy in patients undergoing invasive
   tube against the tracheal wall. Failure to re-establish      mechanical ventilation should balance the problems related
   adequate ventilation by suctioning through the tube          to prolonged intubation and tracheotomy. Firstly, the risk of
   requires immediate replacement of the inner cannula or       laryngeal injury with the prolonged use of an endotracheal
   the entire tube.                                             tube. Secondly, the possibility that surgical complications
• Early tube displacement or false passage. The tube can        occur during or following tracheotomy. Previous
   displace into surrounding soft tissues. Early displacement   studies 15,16 showed that very early (< 48 hours) tracheotomy
   of the tube can create an airway emergency. Replacement      significantly reduced the duration of mechanical ventilation,
   of the tube should be attempted immediately, caring not      mortality, pneumonia and length of stay in the intensive



                                                                                                                             S75
C. Botti et al.




care unit compared to late (14-16 days) tracheotomy.           available comparing PDT and ST in this subset of patients.
However, data regarding ventilator-associated pneumonia        Ideal selection of patients for PDT is not well defined 3.
and mortality are conflicting 3,17. As yet, there are not      The following criteria for PDT are well accepted: palpable
enough well-designed studies to establish clear guidelines     cricoid cartilage at least 3 cm above the sternum with
regarding the timing of tracheotomy. The decision to           head extension, history of uncomplicated translaryngeal
perform a tracheotomy should be individualised and             endotracheal intubation, positive end-expiratory pressure
take into consideration factors other than time: improved      of less than 10 cm H2O. Contraindications to PDT include
patient comfort as well as enhanced nursing care. Early        neck masses, uncorrectable coagulopathy, high positive
tracheotomy at 7 days of mechanical ventilation could be       end-expiratory pressure (> 20 cm H2O), need for emergent
appropriate for patients in whom weaning and extubation        airway, or paediatric use 28,29. Bronchoscopy and ultrasound
are not likely before day 14.                                  use decrease procedural complications in PDT.
In patients needing prolonged invasive mechanical              In case of patients with severe COVID-19, airborne
ventilation for severe COVID-19, tracheotomy may               spread of viral particles and limited time of apnoea
be needed. In this particular case, viral load and risk        must be considered in the choice of the safest technique.
of viral transmission must be taken into consideration         PDT could result in longer apnea and longer exposure
when deciding the timing of tracheotomy. The American          to generated aerosol 30. In our experience 4, a similar
Academy of Otolaryngology – Head and Neck Surgery              incidence of postoperative complication rates was reported
issued a position statement on March 27, 2020 (revised
                                                               in PDT and ST in patients with severe COVID-19. The
22 April 2021) 18, recommending that tracheotomy be
                                                               incidence of overall complications was higher than the
performed no earlier than 2 weeks after intubation.
                                                               general population, but in line with the literature dealing
Recommendations of the ENT UK and British
                                                               with critically ill patients 31. However, authors recommend
Laryngological Association 19 suggest waiting a minimum
                                                               considering either ST or PDT in COVID-19 patients at
of 14 days of intubation to allow prognostic information to
                                                               the discretion of the medical staff involved, according
become clear and for viral load to potentially decrease 20.
Similar recommendations have been issued by others 21. In      to the personal experience of the operators performing
contrast, other authors proposed shorter timings if patients   the procedure. Adjunctive safeguards are required when
are far from reaching weaning targets 22. Up to now, timing    dealing with COVID-19. Since tracheotomy is considered
of elective tracheotomy in the intensive care unit for         a highly aerosol-generating procedure, the highest level
intubated patients with severe COVID-19 is still unclear.      of personal protective equipment and precise surgical
                                                               planning are required 32-35.
Percutaneous dilatational tracheotomy
versus open surgical approach                                  Removal of tracheal cannula
                                                               In tracheotomised patients, weaning can be obtained
Tracheotomy can be performed with either a percutaneous
or open surgical approach. Usually, the choice of the          through non-invasive ventilation applied via a nasal or full-
technique depends on the preference of practitioners and       face mask with the tracheotomy tube capped off and its
patient-related factors. Even if the debate is still open,     cuff deflated 36. After weaning from mechanical ventilation,
several studies showed that when elective tracheotomy is       removal of the tracheal cannula can be considered if patients
indicated in critically ill adult patients, the technique of   are clinically stable, have adequate swallowing, are able
PDT 21 offers important advantages over ST (level 1B) 1,24-    to expectorate and do not have psychiatric disorders 37. A
26
   . Less wound infection is observed in PDT, probably         deflated-cuff tracheotomy occlusion procedure should be
due to minimisation of local tissue trauma and a tighter fit   performed before removing the tracheal cannula. After
between the cannula and surrounding tissues. There is no       deflation of the tracheotomy cuff, the opening of the tube
difference in bleeding in PDT versus ST. The occurrence        should be occluded and the patient observed for signs of
of long-term complications is not affected by the choice       respiratory distress. In case of problems, one promptly
of technique 26,27. The decision whether to perform PDT        returns the patient to breathing through the tracheotomy
or ST in obese or short neck patients should depend upon       tube and perform an endoscopic examination to rule out
the experience of the practitioner and the possibility to      possible airway obstructions. In case of copious respiratory
identify anatomical landmarks. Obesity is considered a         tract secretions or expectoration impairment, the tube can
risk factor for increased complications for many surgical      be downsized1. After tracheal tube removal, the wound
procedures including tracheotomy. However, no data are         spontaneously heals in 10 days in most cases.



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Conclusions                                                                           complication rates, relative risks and benefits. Auris Nasus Larynx
                                                                                      2021;48:511-517. https://doi.org/10.1016/j.anl.2020.10.014
Tracheotomy is increasingly needed to manage patients                            5
                                                                                      Barry BN, Bodenham AR. The role of tracheostomy in ICU.
with prolonged respiratory failure. PDT is commonly used                              Anaesth Intens Care 2004:5:375-378. https://doi.org/10.1383/
in elective tracheotomy in adult patients in intensive care                           anes.5.11.375.53408
units, but ST may be preferred depending upon the experi-
                                                                                 6
                                                                                      Nieszkowska A, Combes A, Luyt CE, et al. Impact of tracheotomy on
                                                                                      sedative administration, sedation level, and comfort of mechanically
ence of the practitioner and patient’s characteristics. Cor-                          ventilated intensive care unit patients. Crit Care Med 2005;33:2527-
rect timing of tracheotomy should be individualised. The                              2533. https://doi.org/10.1097/01.ccm.0000186898.58709.aa
indication to tracheotomy in intensive care should balance                       7
                                                                                      Davis K, Campbell RS, Johannigman JA, et al. Changes in respiratory
the problems related to prolonged intubation and the risk                             mechanics after tracheostomy. Arch Surg 1999;134:59-62. https://doi.
                                                                                      org/10.1001/archsurg.134.1.59
of early or late complications related to the surgical pro-
                                                                                 8
                                                                                      Meng L, Qiu H, Wan L, et al. Intubation and ventilation amid the COV-
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Conflict of interest statement                                                   9
                                                                                      Botti C, Lusetti F, Peroni S, et al. The role of tracheotomy and timing
The authors declare no conflict of interest.                                          of weaning and decannulation in patients affected by severe COV-
                                                                                      ID-19. Ear Nose Throat J 2021;100(Suppl 2):116S-119S. https://doi.
                                                                                      org/10.1177/0145561320965196
Funding
                                                                                 10
                                                                                      Loh KS, Irish JC. Traumatic complications of intubations and other
This research did not receive any specific grant from fund-                           airway management procedures. Anesthesiol Clin North America
ing agencies in the public, commercial, or not-for-profit                             2002;20:953-969. https://doi.org/10.1016/s0889-8537(02)00022-6
sectors.                                                                         11
                                                                                      Norwood S, Vallina VL, Short K, et al. Incidence of tra-
                                                                                      cheal stenosis and other late complications after percutane-
Authors’ contributions                                                                ous tracheostomy. Ann Surg 2000;232:233-241. https://doi.
                                                                                      org/10.1097/00000658-200008000-00014
CB, PR and AG: substantial contributions to the conception                       12
                                                                                      Epstein SK. Late complications of tracheostomy. Respir Care
and design of the work; drafting the work and revising it                             2005;50:542-549.
critically for important intellectual content; final approval                    13
                                                                                      Kluge S, Baumann HJ, Maier C, et al. Tracheostomy in the intensive
of the version to be published; agreement to be accountable                           care unit: a nationwide survey. Anesth Analg 2008;107:1639-1643.
for all aspects of the work in ensuring that questions related                        https://doi.org/10.1213/ane.0b013e318188b818
to the accuracy or integrity of any part of the work are ap-                     14
                                                                                      Veenith T, Ganeshamoorthy S, Standley T, et al. Intensive care unit
propriately investigated and resolved.                                                tracheostomy: a snapshot of UK practice. Int Arch Med 2008;1:21.
                                                                                      https://doi.org/10.1186/1755-7682-1-21
MM, CM, CP, DG and DP: substantial contributions to the                          15
                                                                                      Griffiths J, Barber VS, Morgan L, et al. Systematic review and meta-
acquisition, analysis, or interpretation of data for the work;                        analysis of studies of the timing of tracheostomy in adult patients
final approval of the version to be published; agreement to                           undergoing artificial ventilation. BMJ 2005;330:1243. https://doi.
be accountable for all aspects of the work in ensuring that                           org/10.1136/bmj.38467.485671
questions related to the accuracy or integrity of any part of                    16
                                                                                      Rumbak MJ, Newton M, Truncale T, et al. A prospective, randomized,
the work are appropriately investigated and resolved.                                 study comparing early percutaneous dilatational tracheotomy to pro-
                                                                                      longed translaryngeal intubation (delayed tracheotomy) in critically
                                                                                      ill medical patients. Crit Care Med 2004;32:1689-1694. https://doi.
Ethical consideration                                                                 org/10.1097/01.ccm.0000134835.05161.b6
Institutional Ethics Committee approval is not required for                      17
                                                                                      Dunham CM, Ransom KJ. Assessment of early tracheostomy in
this review article.                                                                  trauma patients: a systematic review and meta-analysis. Am Surg
                                                                                      2006;72:276-281. https://doi.org/10.1177/000313480607200316
                                                                                 18
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