ABSTRACT Background The optimal airway management strategy for critically ill patients requiring prolonged mechanical ventilation is debated. Tracheostomy is often performed to mitigate complications of prolonged endotracheal intubation (ETT), but its comparative impact on outcomes remains unclear due to confounding by indication. Aim To compare the baseline characteristics and unadjusted clinical outcomes between mechanically ventilated ICU patients managed with an ETT and those who underwent tracheostomy. Study Design A prospective observational cohort study was conducted over 1 year (January to December 2024) in the General, Trauma and Medical Intensive Care Units of a tertiary university hospital in Cairo, Egypt. Baseline severity was assessed using APACHE II scores. Primary outcomes were VAP incidence and in‐hospital mortality. Only unadjusted analyses were performed due to significant baseline confounding. Results Mechanically ventilated adult patients were grouped based on their airway status into an Endotracheal Tube (ETT) group ( n = 89) and a Tracheostomy group ( n = 57). Patients in the tracheostomy group had significantly higher baseline illness severity (mean APACHE II: 26.4 ± 5.7 vs. 23.2 ± 5.9; p = 0.001) and a different clinical profile, with a higher prevalence of neurological diagnoses (63.2% vs. 9.0%, p < 0.001). The unadjusted incidence of VAP was higher in the tracheostomy group (80.7% vs. 57.3%; p = 0.004). Mortality was also higher (52.6% vs. 46.1%), but this difference was not statistically significant ( p = 0.455). The tracheostomy group had longer durations of mechanical ventilation and ICU stays. Conclusions In this observational study, patients selected for tracheostomy were sicker at baseline and had poorer unadjusted outcomes than those managed with ETTs. The findings highlight profound confounding by indication, where tracheostomy is performed on patients with a poorer prognosis. The results underscore that valid comparisons of airway strategies require randomised controlled trials or meticulously adjusted observational studies to account for baseline differences. The high‐performance predictive model can serve as a sustainability indicator for quality improvement initiatives, allowing ICUs to track the long‐term effectiveness of airway management's protocols. Relevance to Clinical Practice This study challenges the perception that tracheostomy universally improves outcomes in mechanically ventilated ICU patients. Clinicians should carefully weigh the timing and indication for tracheostomy, recognising that it may not reduce—and could potentially increase—infection risk and mortality, particularly in high‐severity patients. Rigorous infection control measures and daily assessment for tracheostomy weaning or decannulation are essential.
Mahran et al. (Sun,) studied this question.