Trouillet et al randomized patients requiring mechanical ventilation 4 days after cardiac surgery to either immediate perc-trach, or delayed percutaneous tracheostomy at 15 days. There were no differences in ventilator-free days at 60 days, nor in survival at 28, 60, or 90 days, nor in rates of VAP; however, the early-trach group had a lower need for sedation, less delirium, and fewer unplanned extubations. Only 27% of patients in the late group actually got a tracheostomy, echoing earlier studies suggesting many early tracheostomies are unnecessary. (n=216) Ann Intern Med 2011;154:373-383.