In response to late tracheotomy is associated with higher morbidity and mortality in mechanically ventilated patients

We sincerely appreciate our colleague’s interest in our paper titled “Late Tracheotomy Is Associated With Higher Morbidity and Mortality in Mechanically Ventilated Patients” and the related commentary. We also kindly thank the editors of The Laryngoscope for the opportunity to respond. Although we certainly agree with several of the points made in the letter and have endorsed them in our own articles, we must correct the perception that we are recommending a fixed time for tracheotomy for all patients requiring prolonged mechanical ventilation. On the contrary, as we stated in our conclusions, we are advocating for development of evidence-based guidelines around tracheotomy decision making that incorporate patient factors, provider factors, and institutional factors that currently influence treatment decision making, and to that end we are advocating for multi-institutional efforts to prospectively document these factors and study them to enable the question of timing to be properly answered. As we also described, we agree that meta-analyses of some randomized controlled trials have shown that timing did not alter outcomes, but have pointed out that the protocols used in these studies may not represent all current practices, as evidenced by the variation in practices between the institutions in our multi-institutional study. We also pointed out that some other well-designed studies have suggested timing can have an impact. We also agree that there is variability and debate about the definition of “early” versus “late” tracheotomy, as noted in our discussion, and appreciate that Dr. Bakshi too feels a consensus should be reached. This further supports our recommendation for multi-institutional and multidisciplinary efforts to continue to study this subject systematically. We appreciate Dr. Bakshi’s description of his own standardized practice of performing elective tracheotomy within 2 or 3 days when prolonged ventilation is anticipated or for severely head-injured patients, as well as his reference to the multi-institutional retrospective study of critically ill patients by Pelosi and Severgnini, which suggests that patients with neurological illnesses had higher rates of tracheotomy. This study supports our assertion that practices vary between institutions, and that there may be merit in systematically studying factors that influence treatment decision making regarding tracheotomy. We again sincerely appreciate the opportunity to discuss decision making around tracheotomy and remain optimistic that continued study can further improve patient outcomes.