• Graeme J Duke, John L Moran, John D Santamaria, and Owen Roodenburg.
• Department of Intensive Care Medicine, Eastern Health, Box Hill, Australia; Monash University, Clayton, Australia. Electronic address: graeme.duke@easternhealth.org.au.
• J Crit Care. 2021 Feb 1; 61: 144-151.

RationaleThe endotracheal tube (ETT) is the most common route for invasive mechanical ventilation (MV) yet controversy attends its long-term safety.ObjectiveAssess the safety of ETT compared with tracheostomy tube (TT) for MV support in the intensive care unit (ICU).MethodsRetrospective analysis of five year national dataset of 128,977 adults (age > 15-years) admitted for MV therapy with tracheostomy tube (TT; n = 4772) or without (ETT; n = 124,204), excluding those with neurological diagnoses or likely to require a surgical airway (n = 27,466), in 93 public health service ICUs across Australia, between July 2013-June 2018.MeasurementsHospital survival (including liberation from MV) for ETT Group compared with TT Group using a probit regression model adjusted for confounding using fixed, endogenous and non-random treatment assignment covariates, and their interactions; analysed and plotted as marginal effects by duration of MV.ResultsMedian duration of MV was 2 (IQR =1-4) days, predominantly via ETT (124,205; 96.3%), and 21,620 (16.7%) died. Temporal trend for ETT increased (OR = 1.06 per year, 95%CI =1.03-1.10) compared to TT, even for prolonged (>3 weeks) MV (38.1%). Higher risk-adjusted mortality was associated with longer duration of MV and after 9 days of MV with retention of ETT compared with TT - average (mortality) treatment effect 12.6% (95%CI =10.7-14.5). The latter was not significant after 30 days of MV.ConclusionsThe safety of ETT compared with TT beyond short-term MV (≤9-days) is uncertain and requires prospective evaluation with additional data.Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

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