Consensus conference on artificial airways in patients receiving mechanical ventilation

Liberation of neurosurgical patients from mechanical ventilation and tracheostomy in neurocritical care

Neurosurgical patients commonly require mechanical ventilation and monitoring in a neurocritical care unit. There are only few studies that specifically address the process of liberation from mechanical ventilation in this population. Patients who remain ventilator or artificial airway dependent receive a tracheostomy. The appropriate timing for the procedure is not well defined and may be different among an inhomogeneous population of critically ill patients. In this article, we review the general principles of liberation and the current literature as it pertains to neurosurgical patients with primary brain injury. The criteria for "readiness of extubation" include a combination of neurologic assessment, hemodynamic, and respiratory parameters. Future studies are required to better assess indicators for extubation readiness, evaluate the predictors of extubation failure in brain-injured patients, and define the most appropriate timing for a tracheostomy.

The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The objective of this study was to systematically review and quantitatively synthesize all randomized controlled trials (RCTs), comparing important outcomes in ventilated critically ill patients who received an early or late tracheotomy.

METHODS

A systematic literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, the Cochrane Central Register of Controlled Trials, the National Research Register, the National Health Service Trusts Clinical Trials Register, and the Medical Research Council UK database was conducted using specific search terms. Eligible studies were RCTs that compared early tracheotomy (ET) with either late tracheotomy or prolonged endotracheal intubation in critically ill adult patients.

RESULTS

Seven trials with 1,044 patients were analyzed. ET did not significantly reduce short-term mortality (relative risk [RR], 0.86; 95% CI, 0.65-1.13), long-term mortality (RR, 0.84; 95% CI, 0.68-1.04), or incidence of ventilator-associated pneumonia (RR, 0.94; 95% CI, 0.77-1.15) in critically ill patients. The timing of the tracheotomy was not associated with a markedly reduced duration of mechanical ventilation (MV) (weighted mean difference [WMD], -3.90 days; 95% CI, -9.71-1.91) or sedation (WMD, -7.09 days; 95% CI, -14.64-0.45), shorter stay in ICU (WMD, -6.93 days; 95% CI, -16.50-2.63) or hospital (WMD, 1.45 days; 95% CI, -5.31-8.22), or more complications (RR, 0.94; 95% CI, 0.66-1.34).

CONCLUSIONS

The present meta-analysis suggested that the timing of the tracheotomy did not significantly alter important clinical outcomes in critically ill patients. The duration of MV and sedation, as well as the long-term outcomes of ET in mechanically ventilated patients, should be evaluated in rigorously designed and adequately powered RCTs in the future.

Percutaneous tracheostomy in critically ill patients: 24 months experience at a tertiary care hospital in United Arab Emirates

OBJECTIVE:

We assessed the safety and complications related to percutaneous tracheostomy (PCT) without bronchoscopic guidance in our intensive care unit (ICU).

METHODS:

The prospective data over a period of 24 months were collected for patients who underwent PCT. Major, minor and long-term complications were recorded. The parameters recorded were: age, gender, Glasgow Coma Scale (GCS) score on the day of tracheostomy, acute physiology and chronic health evaluation II (APACHE) score, and predicted mortality based on score on admission and on the day of procedure, number of days on ventilator before and after the procedure, total number of days in the hospital before the final outcome, number of successful decannulations and mortality. The patients were stratified in two groups of survivors and nonsurvivors.

RESULTS:

A total of 117 patients underwent PCT. Overall mean GCS and APACHE-II scores before PCT were 7 ± 3 and 16 ± 5, respectively. The only significant difference was APACHE-II score and the predicted mortality based on APACHE-II score on the day of PCT, which was higher amongst the nonsurvivors (P = 0.008 and P = 0.006). All 57 (49%) survivors were successfully decannulated with mean post tracheostomy days of 24 ± 15. The major complication observed was three episodes of major bleeding. Only six patients had an episode of desaturation during the procedure and there were three episode of accidental puncturing of endotracheal (ET) tube pressure cuff. During subsequent follow-up in hospital, six patients developed stomal cellulitis.

CONCLUSIONS:

PCT without bronchoscopic guidance can be performed safely by carefully selecting patients and having an experienced team High APACHE score on the day of procedure may lead to poor outcome.

Should tracheostomy practice in the setting of trauma be standardized?

PURPOSE OF REVIEW

Trauma is a common predisposing condition in patients developing acute respiratory failure. Selection criteria for tracheostomy use in trauma remain poorly defined. The purpose of this review is to discuss contemporary knowledge regarding the benefits and risks of tracheostomy and to highlight potential strategies to standardize practice.

RECENT FINDINGS

A number of studies have examined the effects of tracheostomy timing on clinically important end points. In general, these studies have produced conflicting findings, and are difficult to apply clinically. As a result, tracheostomy practice varies considerably. An approach to standardizing tracheostomy practice is presented, whereby decision for tracheostomy is based, in part, on a patient's clinical trajectory. The attractiveness of such an approach is that it attempts to match use of tracheostomy to patients with a need for continued ventilatory support.

SUMMARY

Variation in clinical practice is costly. To the extent that variation in tracheostomy practice reflects suboptimal use of this procedure, greater understanding of tracheostomy utility has the potential to enhance the quality of care and more effectively target resources.

Respiratory muscle weakness in peripheral neuropathies

Common peripheral neuropathies do not usually cause diaphragmatic weakness and subsequent respiratory compromise. However, respiratory involvement is relatively common in Guillain-Barré syndrome (GBS). Experience in GBS has led to a standardized approach to manage respiratory problems in peripheral neuropathies. Diaphragmatic weakness is not common in chronic inflammatory demyelinating polyneuropathy and extremely rare in multifocal motor neuropathy. The linkage has been described between certain subtypes of Charcot-Marie-Tooth (CMT) disease such as CMT2C and CMT4B1 and diaphragmatic weakness. A correlation usually has not been found between electrophysiologic findings and clinical respiratory signs or spirometric abnormalities in peripheral neuropathies except in amplitudes of evoked phrenic nerve responses. Careful and frequent assessment of respiratory function by a qualified team of healthcare professionals and physicians is essential. Criteria established for mechanical ventilation in GBS cases may be applied to other peripheral neuropathies with respiratory compromise as necessary.

Early versus late tracheostomy in patients with acute severe brain injury

OBJECTIVE

To compare the effects of early tracheostomy and of late tracheostomy in patients with acute severe brain injury.

METHODS

A retrospective study involving 28 patients admitted to the ICU of the Federal University of Juiz de Fora University Hospital in Juiz de Fora, Brazil, diagnosed with acute severe brain injury and presenting with a Glasgow coma scale (GCS) score < 8 within the first 48 h of hospitalization. The patients were divided into two groups: early tracheostomy (ET), performed within the first 8 days after admission; and late tracheostomy (LT), performed after postadmission day 8. At admission, we collected demographic data and determined the following scores: Acute Physiology and Chronic Health Evaluation (APACHE) II, GCS and Sequential Organ Failure Assessment (SOFA).

RESULTS

There were no significant differences between the groups (ET vs. LT) regarding the demographic data or the scores: APACHE II (26 +/- 6 vs. 28 +/- 8; p = 0.37), SOFA (6.3 +/- 2.7 vs. 7.2 +/- 3.0; p = 0.43) and GCS (5.4 +/- 1.7 vs. 5.5 +/- 1.7; p = 0.87). The 28-day mortality rate was lower in the ET group (9% vs. 47%; p = 0.04). Nosocomial pneumonia occurring within the first 7 days was less common in the ET group, although the difference was not significant (0% vs. 23%; p = 0.13). There were no differences regarding the occurrence of late pneumonia or in the duration of mechanical ventilation between the groups.

CONCLUSIONS

On the basis of these findings, early tracheostomy should be considered in patients with acute severe brain injury.

Experience with 224 percutaneous dilatational tracheostomies at an adult intensive care unit in Bahrain: a descriptive study

Tracheostomy is one of the most commonly performed procedures in critically ill patients. Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). We have described and compared our experience with 224 PDTs that we performed in the last four and a half years. We have also compared PDT performed with and without bronchoscopic guidance at our setting and PDT verses surgical tracheostomy.

Early postoperative alterations of ventilation parameters after tracheostomy in major burn injuries

Purpose: In patients with major burn injuries mechanical ventilation is often required for longer periods. Tracheostomy (TS) plays an integral role in airway management. We investigated the effect of TS on ventilation parameters within 8 hours after TS.

Materials: A retrospective analysis of severely burned patients admitted to the burn unit of a German University Hospital was performed. Ventilation parameters 8 hours before and after TS were registered.

Results: A retrospective analysis of 20 patients which received surgical TS was performed. Mean age was 52±19 years. Mean abbreviated burned severity index (ABSI) was 8.3±2.2. A mechanical ventilation was required for 14.3±4.8 days. TS was performed on day 7±4. Inspiratory oxygen concentration (FiO₂) (p<0.001), peak inspiratory pressure (p<0.001), positive end-expiratory pressure (p=0.003) and pulmonary resistance (p<0.001) were reduced significantly after TS. The arterial partial pressure of oxygen/FiO₂-ratio increased significantly after TS (p<0.001).

Conclusions: We demonstrate that TS reduces invasiveness of ventilation in severely burned patients and by this can optimize lung protective ventilation strategy.

[Dilatation tracheotomy update : indications, limitations and management of complications]

Percutaneous dilatational tracheotomy is a standard procedure today for transient airway management in intensive care units. When correctly indicated and applied, preferably following interdisciplinary case discussion with the otolaryngologist, PDT seems to be as safe as classical surgical tracheotomy. The latter is the alternative when PDT is contraindicated. There is currently a trend towards one-step PDT procedures. In addition to the permanent necessity for an alternative airway, there is a series of clearly defined contraindications to PDT. In such cases, only surgical tracheotomy is viable. In contrast to surgical tracheotomy, PDT presents more challenges to the physicians and nursing staff in order to avoid specific complications such as re-cannulation into a via falsa followed by acute dyspnea. The otolaryngologist is an important partner in the management of PDT-related complications due to his discipline-specific experience. Further prospective trials, especially concerning long-term complications, are needed to answer the question of whether PDT or surgical tracheotomy is the best method in situations with overlapping indications.

Early tracheostomy in intensive care unit: a retrospective study of 506 cases of video-guided Ciaglia Blue Rhino tracheostomies

BACKGROUND

Percutaneous dilatational tracheostomy (PDT) is a common procedure in critically ill patients, but the correct timing is still controversial. This study was designed to establish whether an early timing in video-guided Ciaglia Blue Rhino PDT affects the duration of mechanical ventilation (MV) and the length of stay (LOS) in intensive care unit (ICU). Secondary clinical outcomes were the overall hospitalization duration and the mortality rate.

METHODS

A retrospective, single-center study of 2,210 patients admitted to the ICU of the Emergency Department of the Careggi Teaching Hospital (Florence, Italy) between 2002 and 2007. Among the 506 patients who underwent PDT, 256 and 250 patients were retrospectively assigned to the early tracheostomy (ET) or late tracheostomy (LT) group according to whether the procedure was performed before (ET) or after (LT) 3 days of MV (median time of procedure execution).

RESULTS

The two groups of patients showed comparable demographic and clinical characteristics. The video-guided PDT procedures were performed without major complications in all cases. The average timing of tracheostomy in the ET group was 1.9 +/- 0.9 days, whereas in LT group resulted 6.8 +/- 3.8 days (mean +/- SD). Total hospital LOS and mortality rate were not different between the two groups. However, the duration of MV days and of ICU LOS group were significantly shorter in the ET group (13.3 +/- 9.6 and 16.9 +/- 13.0 days, respectively; p = 0.0001) than in the LT group (16.7 +/- 8.3 days and 20.8 +/- 9.2 days, respectively; p < 0.0001). Stratified analysis by the three major ICU admission diagnosis confirmed that both traumatized and nontraumatized (medical and postsurgical) ET patients had a shorter MV duration and ICU LOS as compared with LT patients.

CONCLUSIONS

Video-guided Ciaglia Blue Rhino PDT is safe and easy to perform in ICU. No difference in overall hospital LOS, incidence of pneumonia, and mortality rate between the ET and LT groups was found. However, in both traumatized and nontraumatized patients, shortened duration of ICU LOS and MV in the ET group (<or=3 days) indicates this procedure as a useful approach for patients and healthcare system.

Airway management in acute tetraplegics: a retrospective study

The objective of this study was to develop an evidence-based airway management protocol for patients with acute tetraplegia. The method consisted of an analysis of the medical records of patients (September 1997-December 2002) with a spinal cord injury and a neurological deficit less than 8 weeks old. Of the 175 patients, 72 (41, 14%) were tracheotomised. This was influenced by the origin of the paralysis, Frankel score, and number of cervical spine operations, accompanying injuries and accompanying illnesses. Tracheotomy did not affect the duration of treatment, duration of ventilation or length of stay in the intensive care unit. The need for a tracheotomy was able to be predicted in 73.31% with neurological level, Frankel score and severity of accompanying injuries. In patients with acute tetraplegia, primary tracheotomy is indicated in sub C1-C3 with Frankel stage A/B, sub C4-C6 with Frankel stage A/B with trauma and accompanying injuries/accompanying illnesses, and in patients with complex cervical spine trauma that requires a combined surgical approach. In other patients, an attempt at extubation should be made.

Early vs late tracheostomy in critical care

This article reviews the current literature and practice of tracheostomy with consideration of timing and the benefits of early tracheostomy, taking account of the results from the recent TracMan study.

Tracheostomy timing in traumatic spinal cord injury

The study conducted is the retrospective study and the main objective is to evaluate the benefits and safety of early versus late tracheostomy in traumatic spinal cord injury (SCI) patients requiring mechanical ventilation. Tracheostomy offers many advantages in critical patients who require prolonged mechanical ventilation. Despite the large amount of patients treated, there is still an open debate about advantages of early versus late tracheostomy. Early tracheostomy following the short orotracheal intubation is probably beneficial in appropriately selected patients. It is a retrospective clinical study and we evaluated clinical records of 152 consecutive trauma patients who required mechanical ventilation and who received tracheostomy. The results show that the early placement (before day 7 of mechanical ventilation) offers clear advantages for shortening of mechanical ventilation, reducing ICU stay and lowering rates of severe orotracheal intubation complication, such as tracheal granulomas and concentric tracheal stenosis. On the other hand, we could not demonstrate that early tracheostomy avoids neither risk of ventilator-associated pneumonia nor the mortality rate. In SCI patients, the early tracheostomy was associated with shorter duration of mechanical ventilation, shorter length of ICU stay and decreased laryngotracheal complications. We conclude by suggesting early tracheostomy in traumatic SCI patients who are likely to require prolonged mechanical ventilation.

Postintubation injuries and open surgical tracheostomy: should we always perform isthmectomy?

OBJECTIVE

To evaluate the influence of the surgical team (general surgery or thoracic surgery) and the surgical technique (with or without isthmectomy) on the incidence of postintubation injuries in the airways of tracheostomized patients.

METHODS

Between January 1st and August 31st, 2007, 164 patients admitted to the adult intensive care unit and tracheally intubated for more than 24 h were studied prospectively at the Sumaré State Hospital, located at the city of Sumare, Brazil. When tracheostomy was necessary, these patients were randomly assigned to thoracic or general surgery teams. All of the patients were submitted to fiberoptic tracheoscopy for decannulation or late evaluation of the airway.

RESULTS

Of the 164 patients in the study, 90 (54.88%) died (due to causes unrelated to the procedure), 67 (40.85%) completed follow-up, and 7 (4.27%) were lost to follow-up. Of the 67 patients who completed follow-up, 32 had undergone tracheostomy (21 by the general surgery team and 11 by the thoracic surgery team), and 22 had been submitted to isthmectomy (11 by the general surgery team and 11 by the thoracic surgery team). There was no difference between the surgical teams in terms of the incidence of stomal complications. However, there was a significant difference when the surgical techniques (with or without isthmectomy) were compared.

CONCLUSIONS

Not performing isthmectomy in parallel with tracheostomy leads the surgeon to open the tracheal stoma more distally than expected. In such cases, there were more stomal complications.

The effect of tracheostomy timing during critical illness on long-term survival

BACKGROUND

Tracheostomy is common in intensive care unit patients, but the appropriate timing is controversial.

OBJECTIVE

To determine whether earlier tracheostomy is associated with greater long-term survival.

DESIGN

Retrospective cohort analysis.

SETTING

Acute care hospitals in Ontario, Canada (n = 114).

PATIENTS

All mechanically ventilated intensive care unit patients who received tracheostomy between April 1, 1992 and March 31, 2004, excluding extreme cases (< 2 or > or = 28 days) and children (< 18 yrs).

MEASUREMENTS

For crude analyses, tracheostomy timing was classified as early (< or = 10 days) vs. late (> 10 days) with mortality measured at multiple follow-up intervals. Proportional hazards analyses considered tracheostomy as a time-dependent variable to adjust for measurable confounders and possible survivor treatment bias. We used stratification, propensity score, and instrumental variable analyses to adjust for patient differences.

RESULTS

A total of 10,927 patients received tracheostomy during the study, of which one-third (n = 3758) received early and two-thirds late (n = 7169). Patients receiving early tracheostomy had lower unadjusted 90-day (34.8% vs. 36.9%; p = 0.032), 1 yr (46.5% vs. 49.8%; p = 0.001), and study mortality (63.9% vs. 67.2%; p < 0.001) than patients receiving late tracheostomy. Multivariable analyses treating tracheostomy as a time-dependent variable showed that each additional delay of 1 day was associated with increased mortality (hazard ratio 1.008, 95% confidence interval 1.004-1.012), equivalent to an increase in 90-day mortality from 36.2% to 37.6% per week of delay (relative risk increase 3.9%; number needed to treat, 71 patients to save one life per week delay).

LIMITATIONS

This analysis provides guidance regarding timing but not patient selection for tracheostomy.

CONCLUSIONS

Physicians performing early tracheostomy should not anticipate a large potential survival benefit. Future research should concentrate on identifying which patients will receive the most benefit.

Safety and complications of percutaneous tracheostomy in a cohort of 800 mixed ICU patients

Percutaneous tracheostomy is used primarily to assist weaning from mechanical ventilation in the intensive care unit. We report our experiences of 800 such procedures performed in the intensive care unit by a collaborative team (critical care and ENT specialists). Most procedures (85.6%) were performed by residents supervised by the intensive care unit staff. Complications occurred in 32 patients (4%). Intraprocedural complications occurred in 17 patients (2.1%), early postprocedural complications in six (0.75%), and late postprocedural complications in nine (1.1%). No deaths were directly related to percutaneous tracheostomy. The incidence of complications was greater in percutaneous tracheostomy performed by the residents during their initial five attempts compared to their later attempts (9.2% vs 2.6%, p < 0.05). The low incidence of complications indicates that bedside percutaneous tracheostomy can be performed safely as a routine procedure in daily care of intensive care unit patients.

Intubating laryngeal mask as a ventilatory device during percutaneous dilatational tracheostomy: a descriptive study

BACKGROUND

We use an intubating laryngeal mask (ILM) in preference to an endotracheal tube (ETT) as the ventilatory device during percutaneous dilatational tracheostomy (PDT) to overcome potential problems such as difficult ventilation, accidental extubation, damage of the ETT or of the bronchoscope, and need for additional assistant to secure the airway. We report our experience with this method.

METHODS

In this prospective observational study, PDT was performed using the ILM in 86 patients. The insertion of the ILM, the quality of ventilation, and the view of the tracheal puncture site were rated as: 'very good', 'good', 'difficult', and 'not possible with ILM'.

RESULTS

The bronchoscope was not damaged during any case, and all PDTs were performed by two physicians, without the need for an additional assistant. PDTs with ILM were successful in 95% of the patients (n=82). The ratings were 'very good' or 'good' in 80% of cases with regards to ventilation, in 90% for identification of relevant structures and tracheal puncture site, and in 85% for the view inside the trachea during PDT. Tracheal re-intubation was required for inadequate ventilation with ILM in four patients.

CONCLUSIONS

The advantages of this procedure were lack of damage to the bronchoscope, the need for two instead of three persons to perform the PDT, and the excellent view inside the trachea. We recommend the ILM as a standard device for ventilation during bronchoscope-guided PDT.

Tracheostomy in the critically ill: indications, timing and techniques

PURPOSE OF REVIEW

Tracheostomy is one of the most common procedures performed in the intensive care unit. Indications, risks, benefits, timing and technique of the procedure, however, remain controversial. The decision of when and how to perform a tracheostomy is often subjective, but must be individualized to the patient. The following review gives an update on recent literature related to tracheostomy in the critically ill.

RECENT FINDINGS

Surprisingly, few data are available on the current practice of tracheostomy in the intensive care unit setting. Very few trials address this issue in a prospective, randomized fashion (randomized controlled trial). Most reports include small numbers representing a heterogeneous population, describing contrary results and precluding any definite conclusions. Evidence seems to suggest that early tracheostomy, however, might be preferable in selected patients.

SUMMARY

Due to increased experience and advanced techniques, percutaneous tracheostomy has become a popular, relatively safe procedure in the intensive care unit. The question of appropriate timing, however, has not been definitely answered with a randomized controlled trial. Instead, a number of retrospective studies and a single prospective study have shed some light on this issue. Most reports favor the performance of tracheostomy within 10 days of respiratory failure.

Early versus Late Tracheostomy in Patients with Severe Traumatic Head Injury

BACKGROUND AND PURPOSE

A majority of patients with severe traumatic brain injury (TBI) need ventilatory support and require endotracheal intubation. There has been substantial debate regarding the timing of tracheostomy. We reviewed our data to determine the impact of early tracheostomy on our resources.

STUDY DESIGN

Retrospective review of a consecutive series of patients with severe TBI treated at a Level II trauma center.

METHOD

All 55 patients admitted to the surgical intensive care unit (ICU) with severe TBI from January, 2002 through September, 2005 were reviewed through the trauma registry. The inclusion criteria were severe TBI with a Glasgow Coma Scale (GCS) score < or = eight points at the time of admission and expected survival for longer than three days. All of these patients required mechanical ventilation and subsequently underwent tracheostomy. According to the timing of tracheostomy, subjects were classified as early group (< or = 7 days; N = 27) or late group (> 7 days; N = 28). The Wilcoxon rank sum test, the log-rank test, and Fisher exact tests were used to compare these groups.

RESULT

The average time of the tracheostomy procedure was 5.5 +/- 1.8 (SD) days in the early group and 11.0 +/- 4.3 days in the late group. There were no significant differences between the groups in terms of age, proportion of female sex, GCS, Injury Severity Score, or need for blood transfusion. However, patients in the early group had a significantly shorter stay in the ICU than patients in the late group (19.0 +/- 7.7 vs. 25.8 +/- 11.8 days; P = 0.008). There was no difference between the groups in ventilator days (15.7 +/- 6.0 vs. 20.0 +/- 16.0 days; p = 0.57). There were no significant differences between the groups regarding overall mortality (15% vs. 4%; p = 0.19), incidence of pneumonia prior to tracheostomy (41% vs. 50%; p = 0.59), median total hospital length of stay (24 days vs. 28 days; p = 0.42), discharged to rehabilitation (74% vs. 82%; p = 0.53), or median total hospital cost (292,329 dollars vs. 332,601 dollars; p = 0.26).

CONCLUSION

Early tracheostomy was beneficial, resulting in a shorter ICU stay.

Repeat percutaneous tracheostomy in the neurocritically ill patient

INTRODUCTION

Percutaneous tracheostomy is a widely used and accepted method for long-term mechanical ventilation and airway protection. Neurocritically ill patients sometimes require repeat tracheostomy, which is traditionally considered a relative contraindication for percutaneous procedure. The aim of this study was to determine the safety of repeat percutaneous tracheostomy in neurocritically ill patients with a history of previous tracheostomy.

METHODS

In the 16-bed academic neurointensive care unit, we prospectively enrolled patients who needed new tracheostomy placement for airway protection or prolonged mechanical ventilation and had previously undergone percutaneous tracheostomy placement. We collected data on indications, procedure, periprocedural complications, and outcome of repeated tracheostomy.

RESULTS

Between January 2001 and October 2005, we enrolled 12 consecutive patients (mean age 35.4 +/- 7.0 years) who underwent repeat percutaneous tracheostomy. Head injury was the most common underlying diagnosis (seven patients, 58%). Tracheostomy tube placement was easy and successful in all patients, and none of the patients needed conversion to surgical tracheostomy. In three patients, ultrasound-guided needle aspiration was used before the procedure to confirm the position of the trachea. No patients died or experienced serious complication related to the procedure. Two patients (17%) had a minor periprocedural bleeding, which was controlled with local compression. Long-term outcome was poor, with only two patients alive and off the ventilator at hospital discharge, both with serious disability.

CONCLUSION

Repeat percutaneous tracheostomy can be performed safely in neurocritically ill patients who have undergone previous tracheostomy.

[Timing of tracheostomy and outcome of patients requiring mechanical ventilation]

OBJECTIVES

To assess the impact of tracheostomy timing on outcome of critically ill patients requiring mechanical ventilation (MV).

STUDY DESIGN

Retrospective clinical study in a twelve beds intensive care unit (ICU).

PATIENTS AND METHODS

From January 2001 to June 2005, patients under MV who received tracheostomy were divided into 2 groups: early tracheostomy group when tracheostomy was performed before or on day 7 and late tracheostomy group when it was performed thereafter. We compared prevalence of nosocomial pneumonia, length of sedation, lengths of MV, length of stay in ICU, weaning from MV and mortality rates between the 2 groups.

RESULTS

During this period of 4 years and half, 112 patients underwent tracheostomy, 62 of whom had early tracheostomy and 50 had late tracheostomy. Early tracheostomy was associated with significant reduction of length of sedation (10+/-3 vs 17+/-5 days, P<0.001), length of MV (21+/-19 vs 29+/-17 days, P=0.02) and length of stay in ICU (33+/-22 vs 42+/-18 days, P=0.042). There were no differences in prevalence of pneumonia (21% for early tracheostomy group vs 31% for late tracheostomy group, P=0, 13), weaning from MV (50 vs 36%, P=0.19), and mortality rates between the 2 groups (38 vs 54%, P=0.15).

CONCLUSION

This study demonstrated that early tracheostomy (< or =7 days), was associated with shorter length of sedation, shorter duration of MV and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival.

Mobilizing the patient in the intensive care unit: the role of early tracheotomy

A large number of studies have evaluated the benefits of early tracheotomy. Heterogeneity in the various studies reviewed in this article is apparent, with early tracheotomy ranging from one to several days, and benefits regarding incidence of pneumonia and mortality are variable. An additional factor likely contributing to the differing results relates to the varied patient populations in the individual studies, which ranged from burn patients to medical ICU patients to trauma patients and head trauma patients. A close look at the studies with the least confounding variables suggests that early tracheotomy has some merit. Most studies suggest that time in the ICU, on mechanical ventilation, and in the hospital is reduced.

EMG and duration of ventilatory support in children with Guillain-Barre syndrome

RATIONALE

Predicting length of stay in the intensive care unit (ICU) in children with Guillain-Barre syndrome may help decision-making at admission.

MATERIALS AND METHODS

Between 1996 and 2003, we attended to 30 children with Guillain-Barre syndrome who required ventilatory support in ICU. We prospectively collected different variables that could potentially predict prolonged length of stay and ventilatory support in ICU.

CONCLUSION

Using Cox proportional hazard analysis we found that lack of electrical excitability was the best predictor.

Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients

We have previously reported cases of severe suprastomal stenosis after tracheostomy. In this observational study we investigated the occurrence of suprastomal stenosis as a late complication. Patients with persistent tracheostomy after intensive care underwent an endoscopic examination of tracheostoma, larynx and trachea. A percutaneous dilational tracheostomy was employed in 105 (71.9%) and surgical tracheostomy in 41 (28.1%) of the cases (n = 146). The incidence of severe suprastomal stenosis (grade II > 50% of the lumen) was 23.8% (25 of 105) after dilational tracheostomy and 7.3% (3 of 41) after surgical tracheostomy (p = 0.033). Age, gender, underlying disease, ventilation time, and swallowing ability were not significantly associated with the tracheal pathology. This study suggests that dilational tracheostomy is associated with an increased risk of severe suprastomal tracheal stenosis compared to the surgical technique.

Predicting the Need for Early Tracheostomy: A Multifactorial Analysis of 992 Intubated Trauma Patients

BACKGROUND

Tracheostomy has few, severe risks, while prolonged endotracheal intubation causes morbidity. The need for tracheostomy was assessed, based on early clinical parameters.

METHODS

Adult trauma patients (January 1994-August 2004), intubated for resuscitation, ventilated >24 hours, were retrospectively evaluated for demographics, physiology, brain, and pulmonary injury. Tracheostomy patients were compared with those without. Chi-square, Mann-Whitney, and multivariate logistic regression were used with statistical significance at p < 0.05.*

RESULTS

Of 992 patients, 430 (43%) underwent tracheostomy at 9.22 +/- 5.7 days. Risk factors were age (45.6* +/- 18.8 vs. 36.7 +/- 15.9, OR: 2.1 (18 years increments), ISS (30.3* +/- 12.5 vs. 22.0 +/- 10.3, OR: 2.1 (12u increments), damage control (DC) [68%*(n = 51) vs. 32%*(n = 51), OR: 3.8], craniotomy [70%*(n = 21) versus 30%(n = 9), OR: 2.6], and intracranial pressure monitor (ICP) [65.4%*(n = 87) vs. 34.6%(n = 46), OR: 2.1]. A 100% tracheostomy rate (n = 30, 3.0%) occurred with ISS (injury severity score) = 75, ISS >or=50, and age >or=55, admit/24 hour GCS (Glasgow Coma Scale) = 3 and age >or=70, AIS abdomen, chest or extremities >or=5 and age >or=60, bilateral pulmonary contusions (BPC) and >or=8 rib fractures, craniotomy and age >or=50, craniotomy with intracranial pressure (ICP) and age >or=40, or craniotomy and GCS <or=4 at 24 hour.A tracheostomy rate of >or=90% (n = 105, 10.6%) was found with ISS >or=54, ISS >or=40, and age >or=40, admit/24 hour GCS = 3 and age >or=55, paralysis and age >or=40, BPC and age >or=55.A tracheostomy rate >or=80% (n = 248, 25.0%) occurred with ISS >or=38, age >or=80, admit/24 hour GCS = 3 and age >or=45, DC and age >or=50, BPC and age >or=50, aspiration and age >or=55, craniotomy with ICP, craniotomy with GCS <or=9 at 24 hour.

CONCLUSION

Discrete risk factors predict the need for tracheostomy for trauma patients. We recommend that patients with >or=90% risk undergo early tracheostomy and that it is considered in the >or=80% risk group to potentially decreased morbidity, increased patient comfort, and optimize resource utilization.

Assessment of early tracheostomy in trauma patients: a systematic review and meta-analysis

The objective of this review was to assess outcomes in trauma patients undergoing early tracheostomy (ET). Abstract databases for the Eastern and American Associations for the Surgery of Trauma and Medline were searched to find trauma patient studies comparing ET and late tracheostomy (LT) or ET and no ET. Fixed-effects meta-analyses were performed on the randomized controlled trial (RCT) studies. Of five retrospective and four RCT studies, none demonstrated survival benefit or harm with ET (P > 0.05). In five RCT studies of ET and no ET, ET pneumonia rates were similar to the no ET group (relative risk 1.00 [95% confidence intervals 0.88-1.15], P = 0.97). In five RCT studies of ET and no ET, ET ventilator/intensive care unit (ICU) days were similar to the no ET group (P = 0.27). In the two severe brain injury studies, ET ventilator/ICU days were lower than the no ET group (P = 0.06). In the three nonbrain injury studies, ET ventilator/ICU days were similar to the no ET group (P = 0.79). Five studies described similar laryngotracheal pathology rates with ET and no ET or LT (P > 0.05). In conclusion, ET has no influence on mortality, pneumonia, or laryngotracheal pathology rates in trauma patients. Patients with severe brain injury may be more rapidly liberated from mechanical ventilation with ET. However, additional research is needed.

Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study

BACKGROUND

Tracheostomy is a commonly performed procedure in ventilator dependent patients. Many critical care practitioners believe that performing a tracheostomy early in the postinjury period decreases the length of ventilator dependence as well as having other benefits such as better patient tolerance and lower respiratory dead space. We conducted a randomized, prospective, single institution study comparing the length ventilator dependence in critically ill multiple trauma patients who were randomized to two different strategies for performance of a tracheostomy. We hypothesized that earlier tracheostomy would reduce the number of days of mechanical ventilation, frequency of pneumonia and length of intensive care unit (ICU) stay.

METHODS

Patients were eligible if they were older than 15 years and either a Glasgow Coma Score (GCS) >4 with a negative brain computed tomography (CT) (no anatomic head injury), or a GCS >9 with a positive head CT (known anatomic head injury). Patients who required tracheostomy for facial/neck injuries were excluded. Patients were randomized to an intention to treat strategy of tracheostomy placement before day 8 or after day 28.

RESULTS

The study was halted after the first interim analysis. There were 60 enrolled patients, who had comparable demographics between groups. There was no significant difference between groups in any outcome variable including length of ventilator support, pneumonia rate, or death.

CONCLUSION

A strategy of tracheostomy before day 8 postinjury in this group of trauma patients did not reduce the number of days of mechanical ventilation, frequency of pneumonia or ICU length of stay as compared with the group with a tracheostomy strategy involving the procedure at 28 days postinjury or more.

Bench-to-bedside review: early tracheostomy in critically ill trauma patients

A significant proportion of trauma patients require tracheostomy during intensive care unit stay. The timing of this procedure remains a subject of debate. The decision for tracheostomy should take into consideration the risks and benefits of prolonged endotracheal intubation versus tracheostomy. Timing of tracheostomy is also influenced by the indications for the procedure, which include relief of upper airway obstruction, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation. This review summarizes the potential advantages of tracheostomy versus endotracheal intubation, the different indications for tracheostomy in trauma patients and studies examining early versus late tracheostomy. It also reviews the predictors of prolonged mechanical ventilation, which may guide the decision regarding the timing of tracheostomy.

[Percutaneous dilational tracheostomy. Indications--techniques--complications]

Tracheostomy is a generally accepted procedure that assures free access to the airways in long-term lung ventilation. Apart from surgical tracheostomy, percutaneous dilational tracheostomy (PDT) has been increasingly employed in intensive care units. Presently, five dilatation methods are available, all equally allowing the performance of a secure and low-risk, bedside tracheostomy in the intensive care unit. Exact knowledge of the anatomy of the neck region and of the entire procedure are preconditions for a safe intervention. Percutaneous procedures offer advantages over surgical tracheostomy in terms of complications. To minimize the risks, expertise in airway management during PDT and knowledge of the particularities of cannula replacement in dilational tracheostoma, are compulsory. Endoscopic control assures that the tracheostoma can be placed correctly and that possible complications can be recognised early. The incidence of a serious tracheal stenosis after PDT is low.

Early tracheostomy for primary airway management in the surgical critical care setting

During a 12-month period, 264 patients with multiple injuries who required mechanical ventilation were admitted to the surgical intensive care unit. One hundred twenty patients (46%) were disengaged from the ventilator, and 38 patients (14%) died. Of the remaining 106 patients (40%) 51 patients (group I) were to receive tracheostomy within 1 to 7 days, and 55 patients (group II) underwent late (8 or more days after admission) tracheostomy. Multiple variables in four categories (admission, operative, ventilatory, and outcome) were analyzed prospectively to define the impact that early tracheostomy had on duration of mechanical ventilation, intensive care stay, and hospital stay. Morbidity and mortality rates of the procedures were assessed. Early tracheostomy, in a homogeneous group of critically ill patients, is associated with a significant decrease in duration of mechanical ventilation, as well as shorter intensive care unit and hospital stays, compared with translaryngeal endotracheal intubation. There were no deaths attributable to tracheostomy, and overall morbidity of the procedures was 4%. We conclude that early tracheostomy has an overall risk equivalent to that of endotracheal intubation. Furthermore, early tracheostomy shortens days on the ventilator and intensive care unit and hospital days and should be considered for patients in the intensive care unit at risk for more than 7 days of intubation. (Surgery 1990;108:655–9.)

Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country--a prospective study

BACKGROUND

An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving. Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury.

METHODS

The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy. All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version. The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant.

RESULTS

At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score. The average day of tracheostomy was 2.18 +/- 1.0038 days. The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group. Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury.

CONCLUSION

It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.

Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation

OBJECTIVE

To compare outcomes in critically ill patients undergoing artificial ventilation who received a tracheostomy early or late in their treatment.

DATA SOURCES

The Cochrane Central Register of Clinical Trials, Medline, Embase, CINAHL, the National Research Register, the NHS Trusts Clinical Trials Register, the Medical Research Council UK database, the NHS Research and Development Health Technology Assessment Programme, the British Heart Foundation database, citation review of relevant primary and review articles, and expert informants.

STUDY SELECTION

Randomised and quasi-randomised controlled studies that compared early tracheostomy with either late tracheostomy or prolonged endotracheal intubation. From 15,950 articles screened, 12 were identified as "randomised or quasi-randomised" controlled trials, and five were included for data extraction.

DATA EXTRACTION

Five studies with 406 participants were analysed. Descriptive and outcome data were extracted. The main outcome measure was mortality in hospital. The incidence of hospital acquired pneumonia, length of stay in a critical care unit, and duration of artificial ventilation were also recorded. Random effects meta-analyses were performed.

RESULTS

Early tracheostomy did not significantly alter mortality (relative risk 0.79, 95% confidence interval 0.45 to 1.39). The risk of pneumonia was also unaltered by the timing of tracheostomy (0.90, 0.66 to 1.21). Early tracheostomy significantly reduced duration of artificial ventilation (weighted mean difference -8.5 days, 95% confidence interval -15.3 to -1.7) and length of stay in intensive care (-15.3 days, -24.6 to -6.1).

CONCLUSIONS

In critically ill adult patients who require prolonged mechanical ventilation, performing a tracheostomy at an earlier stage than is currently practised may shorten the duration of artificial ventilation and length of stay in intensive care.

Techniken der Tracheotomie/Tracheostomie

Tracheostomy has become the method of choice in managing patients requiring long-term mechanical ventilation. At present, there are several alternatives to conventional surgical tracheostomy such as percutaneous dilatational techniques according to Ciaglia, Frova, and Fantoni. The basic principle of these new techniques is percutaneous puncture of the trachea and subsequent dilatation of the puncture channel until the tracheal cannula can be inserted. The advantages are "bedside" performance in the intensive care unit and the use of minimal technical equipment. Nevertheless, dilatation tracheostomy is not always technically feasible and safe. Some significant complications and contraindications have been recognized recently. This should be taken into account when planning tracheostomy in long-term ventilated patients. Compared to conventional surgical tracheostomy, this new procedure retains its value and benefit only if these contraindications are carefully observed.

Outcome of mechanically ventilated patients who require a tracheostomy

OBJECTIVE

To estimate the prevalence of, the risk factors associated with, and the outcome of tracheostomy in a heterogeneous population of mechanically ventilated patients.

DESIGN

Prospective, observational cohort study.

SETTING

A total of 361 intensive care units from 12 countries.

PATIENTS

A cohort of 5,081 patients mechanically ventilated for >12 hrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 546 patients (10.7%) had a tracheostomy during their stay in the intensive care unit. Tracheostomy was performed at a median time of 12 days (interquartile range, 7-17) from the beginning of mechanical ventilation. Variables associated with the performance of tracheostomy were duration of mechanical ventilation, need for reintubation, and neurologic disease as the primary reason of mechanical ventilation. The intensive care unit stay of patients with or without tracheostomy was a median of 21 days (interquartile range, 12-32) vs. 7 days (interquartile range, 4-12; p < .001), respectively, and the hospital stay was a median 36 days (interquartile range, 23-53) vs. 15 days (interquartile range, 8-26; p < .001), respectively. Adjusting by other variables, tracheostomy was independently related with survival in the intensive care unit (odds ratio, 2.22; 95% confidence interval, 1.72-2.86). Mortality in the hospital was similar in both groups (39% vs. 40%, p = .65).

CONCLUSIONS

Tracheostomy is a common surgical procedure in the intensive care unit that is associated with a lower mortality in the unit but with a longer stay and a similar mortality in the hospital than in patients without tracheostomy.

Shock on Admission Day Is the Best Predictor of Prolonged Mechanical Ventilation in the ICU

STUDY OBJECTIVES

To determine the incidence of prolonged mechanical ventilation (PMV), which is associated with increased health-care costs and risks of adverse events, and to identify its early predictors.

DESIGN

Retrospective cohort.

SETTING

A medical-surgical ICU in a university-affiliated hospital.

PATIENTS OR PARTICIPANTS

All patients admitted to the ICU over 3 years who received mechanical ventilation (MV) for > 12 h.

INTERVENTIONS

None.

MEASUREMENTS

PMV was defined as MV lasting > 21 days. We recorded epidemiologic data, severity scores, worst Pao(2)/fraction of inspired oxygen (Fio(2)), presence of shock on ICU admission day, cause for MV, length of MV, ICU length of stay (LOS), and hospital LOS. PMV patients were compared to patients weaned before 21 days (non-PMV group) to determine predictors of PMV.

RESULTS

Of 551 hospital admissions, 319 patients (58%) required MV > 12 h. One hundred thirty patients died early and were excluded. Seventy-nine patients (14%) required PMV. The non-PMV group consisted of 110 patients. Simplified acute physiology score (SAPS) II, APACHE (acute physiology and chronic health evaluation) II, therapeutic intervention scoring system, Pao(2)/Fio(2), shock, ICU LOS, and hospital LOS differed significantly between groups. However, logistic regression identified shock on ICU admission day as the only independent predictor of PMV (odds ratio, 3.10; p = 0.001). SAPS II and Pao(2)/Fio(2) had the nearest coefficients and were used to build the predictive model. Sensitivity analysis was performed including the 130 patients who died early, and shock remained the most powerful predictor.

CONCLUSIONS

PMV was a frequent event in this cohort. The presence of shock on ICU admission day was the only prognostic factor, even adjusting for severity of illness and hypoxemia.

Percutaneous dilational tracheostomy in neurosurgical patients

INTRODUCTION

Tracheostomy is often performed in patients requiring long-term mechanical ventilation after severe neurological injury. Percutaneous dilational tracheostomy (PDT) is an alternative to traditional surgical tracheostomy (TST) for creating a tracheostomy. We compared these techniques in neurosurgical patients and assessed the impact on cost and clinical course.

METHODS

We conducted a retrospective chart review of 81 neurosurgical patients treated with either PDT (n = 43) or TST (n = 38). Several clinical endpoints were examined, including days intubated prior to tracheostomy, length of hospital stay, procedural complications, and overall procedure costs.

RESULTS

No serious complications occurred with PDT, whereas two minor postoperative complications occurred in the TST group. The time from intubation to tracheostomy was 8 days for the PDT group versus 13 days for the TST group (p < 0.001), and the time from intubation to discharge from the hospital was 20 days for the PDT group compared to 27 days for the TST group (p < 0.005). In our institution, the average cost of PDT was $980.69 less than the cost for TST.

CONCLUSION

PDT appears to have a low incidence of complications in neurosurgical patients and may shorten the length of hospitalization and the overall cost compared with TST.