Consensus conference on artificial airways in patients receiving mechanical ventilation

Comparison of the Consequences of Short- Versus Long-Term Intubation on Speech and Swallowing

INTRODUCTION

Intubated, ventilator unweanable patients with ventilatory pump failure can be extubated to continuous noninvasive positive pressure ventilatory support; however, delays may result in untoward effects on speech and swallowing.

METHODS

This is a retrospective chart review of ventilatory pump failure patients to determine need for postextubation gastrostomy tubes and consequences on speech for intubations less than (short) versus greater than (long) 3 wks.

RESULTS

One hundred sixty-five patients were intubated for a mean 20.7 ± 23.5 (range = 1-240) days. All recovered prehospitalization speech status within 2 hrs to 3 days. One hundred four of the short group were intubated 1.6 ± 1.3 (range = 1-9) times for 9.9 ± 5.1 (range = 1-20) days versus 61 of the long group intubated 2.4 ± 3.3 (range = 1-26) times for 39.0 ± 30.5 (range = 21-210) days, 10.6% vs. 8.2%, respectively, required postextubation gastrostomy tubes indefinitely.

DISCUSSION

There was no difference in untoward effects on speech or swallowing from short- versus long-term intubation. Had the patients undergone tracheotomies, the majority would have had gastrostomy tubes placed permanently and suffer morbidity and mortality from the tubes. Thus, an option is to permit patients to remain intubated and, even if unweanable, extubate them to continuous noninvasive positive pressure ventilatory support rather than tracheotomy.

Timing of Tracheostomy in ICU Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: The ideal timing for tracheostomy in critically ill patients is still debated. This systematic review and meta-analysis examined whether early tracheostomy improves clinical outcomes compared to late tracheostomy or prolonged intubation in critically ill patients on mechanical ventilation. Methods: We conducted a comprehensive search of randomized controlled trials (RCTs) assessing the risk of clinical outcomes in intensive care unit (ICU) patients who underwent early (within 7-10 days of intubation) versus late tracheostomy or prolonged intubation. Databases searched included PubMed, Embase, and the Cochrane Library up to June 2023. The primary outcome evaluated was mortality, while secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), ICU length of stay, and duration of mechanical ventilation. No language restriction was applied. Eligible studies were RCTs comparing early to late tracheostomy or prolonged intubation in critically ill patients that reported on mortality. The risk of bias was evaluated using the Cochrane Risk of Bias Tool for RCTs, and evidence certainty was assessed via the GRADE approach. Results: This systematic review and meta-analysis included 19 RCTs, covering 3586 critically ill patients. Early tracheostomy modestly decreased mortality compared to the control (RR -0.1511 [95% CI: -0.2951 to -0.0070], p = 0.0398). It also reduced ICU length of stay (SMD -0.6237 [95% CI: -0.9526 to -0.2948], p = 0.0002) and the duration of mechanical ventilation compared to late tracheostomy (SMD -0.3887 [95% CI: -0.7726 to -0.0048], p = 0.0472). However, early tracheostomy did not significantly reduce the duration of mechanical ventilation compared to prolonged intubation (SMD -0.1192 [95% CI: -0.2986 to 0.0601], p = 0.1927) or affect VAP incidence (RR -0.0986 [95% CI: -0.2272 to 0.0299], p = 0.1327). Trial sequential analysis (TSA) for each outcome indicated that additional trials are needed for conclusive evidence. Conclusions: Early tracheostomy appears to offer some benefits across all considered clinical outcomes when compared to late tracheostomy and prolonged intubation.

A Novel Imaging Device for Percutaneous Dilatational Tracheostomy

Objective: The purpose of this article is to introduce a novel imaging device and technique for percutaneous dilatational tracheostomy (PDT) and evaluate its clinical application. Methods: We have modified the bronchoscope to generate a novel imaging device. The handle of the bronchoscope was removed and replaced with added fixation pieces to secure the new device to the endotracheal tube. Nine mechanically ventilated patients admitted to the intensive care department of Shandong Public Health Clinical Center who underwent PDT between July 2023 and January 2024 have been treated with this novel imaging device. The number of medical staff members needed for the operation, number of needle interventions, operation time, arterial blood gas analysis, and intraoperative complications were observed. Results: Three medical staff were involved in the procedure: an operator, an assistant, and a nurse. The first attempted needle intervention was successful in all patients, and no serious complications such as major bleeding, pneumothorax, mediastinal emphysema, accidental extubation, desaturation, hypercarbia, respiratory acidosis, hemodynamic abnormality, or posterior tracheal puncture occurred. The average time was 11.63 ± 1.56 minutes from skin incision to the needle insertion and 4.43 ± 1.99 minutes from needle insertion to tracheal placement. Conclusions: PDT guided by the novel device is safe, preserves human resources, saves operating space, keeps the view stable, and makes the procedure easy. It is worthy of further research and application.

Limitation of life sustaining therapy in disorders of consciousness: ethics and practice

Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.

Early versus late tracheostomy in people with multiple trauma

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of early tracheostomy compared to late tracheostomy in people with multiple trauma in the intensive care unit.

Therapeutic approach to dysphagia in post-COVID patients in a rehabilitation unit: a descriptive longitudinal study

BACKGROUND

A high rate of hospitalized patients for COVID-19 had dysphagia, frequently underdiagnosed, and not treated, inducing a prolonged dysphagia with protracted recovery. Specific treatments and protocols have not been well described yet.

AIM

Given the potential benefits of respiratory muscle training (IEMT) and neuromuscular stimulation (NMES) in dysphagia treatment, this study aimed to assess the feasibility of the protocol used for treating dysphagia in patients who experienced prolonged hospitalization for COVID-19.

DESIGN

Observational, descriptive, prospective study.

SETTING

Department of Physical Medicine and Rehabilitation of a tertiary University hospital.

POPULATION

Fifty-eight COVID-19 patients were admitted for intensive rehabilitation (March 2020 to October 2021) were prospectively studied.

METHODS

Dysphagia was diagnosed using videofluoroscopy and treated with a 3-week protocol adapted from neuromuscular stimulation (NMES) in a motor threshold and inspiratory/expiratory muscle strength training (IEMST), five sets of five repetitions three times daily for 3 weeks. Feasibility was assessed with adherence, outcomes achieved, and occurrence of adverse/unexpected events. Respiratory function (peak cough flow, maximal inspiratory/expiratory pressures) and swallow function (Penetration-Aspiration Scale and Bolus Residue Scale measured by videofluoroscopy) were recorded descriptive statistics, Student's t test for numerical data, and Wilcoxon Test for ordinal variables were applied. SPPSS vs28 and STATA version 15.1 (StataCorp, College Station, TX, USA) were used for statistical analysis. P values 0.05 were considered significant.

RESULTS

Dysphagia was highly prevalent in severe COVID-19 patients (86.6%); all respiratory and swallow parameters improved after a 3-week intervention and 12 of 18 patients dependent on tube feeding resumed a normal diet (66.7%; McNemar P=0.03), and 84.09% attended a no restriction diet at discharge. Adherence to treatment was 85%. No significant adverse events were detected.

CONCLUSIONS

We conclude that a structured swallowing-exercise training intervention based on IEMT and NMES is feasible and safe in prolonged hospitalization post-COVID patients.

CLINICAL REHABILITATION IMPACT

To describe rehabilitation protocols used to treat dysphagia in post-COVID patients will help us to optimize the available techniques in each center and to induce a faster recovery avoiding potential complications.

Sociodemographic Disparities in Tracheostomy Timing and Outcomes

OBJECTIVE

Tracheostomies are commonly performed in critically ill patients requiring prolonged mechanical ventilation. Although early tracheostomy has been associated with improved outcomes, the reasons for delayed tracheostomy are complex. We examined the impact of sociodemographic factors on tracheostomy timing and outcomes.

METHODS

Medical records were retrospectively reviewed of ventilator-dependent adult patients who underwent tracheostomy from 2021 to 2022. Tracheostomy timing was defined as routine (<21 days) versus late (21 days or more). Sociodemographic variables were compared between cohorts using univariate and multivariate models. Secondary outcomes included hospital length of stay (LOS), decannulation, tracheostomy-related complications, and inhospital mortality.

RESULTS

One hundred forty-two patients underwent tracheostomy after initial intubation: 74.7% routine (n = 106) and 25.4% late (n = 36). In a multivariate model adjusted for age, race, surgical service, tracheostomy technique, and time between consultation and surgery, non-English speaking patients and women were more likely to receive a late tracheostomy compared with English speaking patients and men, respectively (odds ratio [OR] 3.18, 95% confidence interval [CI] 1.03, 9.81, p < 0.05), (OR 3.15, 95% CI 1.18, 8.41, p < 0.05). Late tracheostomy was associated with longer median hospital LOS (62 vs. 52 days, p < 0.05). Tracheostomy timing did not significantly impact mortality, decannulation or tracheostomy-related complications.

CONCLUSION

Despite an association between earlier tracheostomy and shorter LOS, non-English speaking patients and female patients are more likely to receive a late tracheostomy. Standardized protocols for tracheostomy timing may address bias in the referral and execution of tracheostomy and reduce unnecessary hospital days.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:582-587, 2024.

Factors Associated with Self-Reported Voice Change in the Hospitalized Burn Population: A Burn Model System National Database Study

Voice plays a prominent role in verbal communication and social interactions. Acute burn care often includes intubation, mechanical ventilation, and tracheostomy, which could potentially impact voice quality. However, the issue of long-term dysphonia remains underexplored. This study investigates long-term self-reported voice changes in individuals with burn injuries, focusing on the impact of acute burn care interventions. Analyzing data from a multicenter longitudinal database (2015-2023), self-reported vocal changes were examined at discharge and 6, 12, 24, and 60 months after injury. Out of 582 participants, 65 reported voice changes at 12 months. Changes were prevalent at discharge (16.4%) and persisted over 60 months (11.6-12.7%). Factors associated with voice changes included flame burn, inhalation injury, tracheostomy, outpatient speech-language pathology, head/neck burn, larger burn size, mechanical ventilation, and more ventilator days (p < 0.001). For those on a ventilator more than 21 days, 48.7% experience voice changes at 12 months and 83.3% had received a tracheostomy. The regression analysis demonstrates that individuals that were placed on a ventilator and received a tracheostomy were more likely to report a voice change at 12 months. This study emphasizes the need to understand the long-term voice effects of intubation and tracheostomy in burn care.

Accuracy of the volume-viscosity swallow test for clinical screening of dysphagia in post COVID-19 patients

BACKGROUND & AIMS

Up to 30% of patients hospitalized for COVID-19 had oropharyngeal dysphagia, particularly those in the ICU. Many cases remained underdiagnosed due to difficulties in conducting instrumental evaluations during the pandemic. Consequently, screening tests were mandatory during this period.

OBJECTIVES

To evaluate the accuracy of the volume-viscosity swallow test (V-VST), compared to gold standard videofluoroscopy, for screening dysphagia in a post-COVID cohort of patients.

MATERIAL AND METHODS

We conducted a prospective single-center study involving 58 post-COVID adult patients with no previous history of dysphagia. Blinded raters performed the index V-VST upon admission and a standardized videofluoroscopy (VFSS, the reference test) within 72 h of patient intake. Oropharyngeal residue was considered a sign of impaired efficacy. Cough, decreased oxygen saturation, and voice changes were noted as signs of impaired safety. Accuracy, sensitivity, specificity, positive, and negative predictive values, and likelihood ratios were calculated for V-VST results and compared to the gold standard.

RESULTS

Patients (aged 59.98 (SD11.53) years) spent a mean of 46.98 (SD 28.43) days in ICU, 33.76 (SD34.88) days with tracheostomy, and 19.46 (SD13.26) days in the NeuroRehabilitation Unit. The V-VST showed the following properties, compared to VFSS: sensitivity 55.6%, specificity 62.9%, positive predictive value 44.5%, negative predictive value 37.1%, and accuracy 61.5%.

CONCLUSION

The V-VST showed mild accuracy, sensitivity, and specificity, compared to VFSS. Therefore, it should not be used as a stand-alone test for screening dysphagia in patients with a history of COVID.

Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis

OBJECTIVES

We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies.

DATA SOURCES

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted.

REVIEW METHODS

Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS.

RESULTS

The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference.

CONCLUSION

Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.

Early tracheostomy after cardiac surgery improves intermediate- and long-term survival

OBJECTIVE

Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study's second aim was to assess the incidence of both superficial and deep sternal wound infections.

DESIGN

Retrospective study of prospectively collected data.

SETTING

Tertiary hospital.

PATIENTS

Patients were divided into 3 groups, according to the timing of tracheostomy; early (4-10 days); intermediate (11-20 days) and late (≥21 days).

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection.

RESULTS

During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014-1.036)] and timing of tracheostomy [0.315 (0.159-0.757)] had significant impacts on mortality.

CONCLUSIONS

This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4-10 days of mechanical ventilation) is associated with better intermediate- and long-term survival.

Association between tracheostomy and survival in patients with coronavirus disease 2019 who require prolonged mechanical ventilation for more than 14 days: A multicenter cohort study

OBJECTIVE

Tracheostomy is a common procedure with potential prognostic advantages for patients who require prolonged mechanical ventilation (PMV). Early recommendations for patients with coronavirus disease 2019 (COVID-19) suggested delayed or limited tracheostomy considering the risk for viral transmission to clinicians. However, updated guidelines for tracheostomy with appropriate personal protective equipment have revised its indications. This study aimed to evaluate the association between tracheostomy and prognosis in patients with COVID-19 requiring PMV.

METHODS

This was a multicenter, retrospective cohort study using data from the nationwide Japanese Intensive Care PAtient Database. We included adult patients aged ≥16 years who were admitted to the intensive care unit (ICU) due to COVID-19 and who required PMV (for >14 days or until performance of tracheostomy). The primary outcome was hospital mortality, and the association between implementation of tracheostomy and patient prognosis was assessed using weighted Cox proportional hazards regression analysis with inverse probability of treatment weighting (IPTW) using the propensity score to address confounders.

RESULTS

Between January 2020 and February 2021, 453 patients with COVID-19 were observed. Data from 109 patients who required PMV were analyzed: 66 (60.6%) underwent tracheostomy and 38 (34.9%) died. After adjusting for potential confounders using IPTW, tracheostomy implementation was found to significantly reduce hospital mortality (hazard ratio [HR]: 0.316, 95% confidence interval [CI]: 0.163-0.612). Patients who underwent tracheostomy had a similarly decreased ICU and 28-day mortality (HR: 0.269, 95% CI: 0.124-0.581; HR 0.281, 95% CI: 0.094-0.839, respectively). A sensitivity analysis using different definitions of PMV duration consistently showed reduced mortality in patients who underwent tracheostomy.

CONCLUSION

The implementation of tracheostomy was associated with favorable patient prognosis among patients with COVID-19 requiring PMV. Our findings support proactive tracheostomy in critically ill patients with COVID-19 requiring mechanical ventilation for >14 days.

Comparative evaluation of early versus late tracheostomy for reduction of the length of ICU stay, incidence of nosocomial pneumonias, risk of laryngeal injury and mortality of mechanically ventilated patients at a Tertiary Care Hospital in Western India

Introduction

Tracheostomy is a very common procedure performed in ICU as it offers significant advantages over prolonged endotracheal intubation. It facilitates weaning by decreasing the work of breathing in patients with limited reserve by decreasing the dead space area, decreases the requirement for sedation, and may allow for earlier patient mobilization, feeding, and physical and occupational therapy as compared to prolonged intubation along with lesser oral and oropharyngeal ulcerations, improves pulmonary toileting, and lowers incidence of pulmonary infections. Tracheostomy, however, is not devoid of risks. Complications may include hemorrhage, stoma infections and granulations, pneumothorax, subcutaneous emphysema, tracheal stenosis, tracheomalacia, and rarely death. Hence, performance of tracheostomy should be considerate to outweigh benefit-risk ratio.

Aims and objectives

To evaluate the early versus late tracheostomy for reduction of the length of ICU stay, incidence of nosocomial pneumonias, risk of laryngeal injury and mortality of mechanically ventilated patients.

Materials and methods

We conducted a retrospective study from May, 2019 to April, 2021 of patients being tracheostomized in medical ICU at Civil Hospital, Ahmedabad, who were previously intubated endotracheally and were on mechanical ventilation. The decision to tracheostomize would be taken by physicians in their routine rounds in ICU.

Results

Incidence of endolaryngeal complications like laryngotracheal stenosis, stomal granulations, fistula as well as nosocomial infections have lower incidence in early tracheostomy as compared to with late. Mortality remains same in both the groups as well as hospital and ICU stay.

Association between early tracheostomy and patient outcomes in critically ill patients on mechanical ventilation: a multicenter cohort study

Background

Tracheostomy is commonly performed in critically ill patients because of its clinical advantages over prolonged translaryngeal endotracheal intubation. Early tracheostomy has been demonstrated to reduce the duration of mechanical ventilation and length of stay. However, its association with mortality remains ambiguous. This study aimed to evaluate the association between the timing of tracheostomy and mortality in patients receiving mechanical ventilation.

Methods

We performed a retrospective cohort analysis of adult patients who underwent tracheostomy during their intensive care unit (ICU) admission between April 2015 and March 2019. Patients who underwent tracheostomy before or after 29 days of ICU admission were excluded. Data were collected from the nationwide Japanese Intensive Care Patient Database. The primary outcome was hospital mortality. The timing of tracheostomy was stratified by quartile, and the association between patient outcomes was evaluated using regression analysis.

Results

Among the 85558 patients admitted to 46 ICUs during the study period, 1538 patients were included in the analysis. The quartiles for tracheostomy were as follows: quartile 1, ≤ 6 days; quartile 2, 7–10 days; quartile 3, 11–14 days; and quartile 4, > 14 days. Hospital mortality was significantly higher in quartile 2 (adjusted odds ratio [aOR]: 1.52, 95% confidence interval [CI]: 1.08–2.13), quartile 3 (aOR: 1.82, 95% CI: 1.28–2.59), and quartile 4 (aOR: 2.26, 95% CI: 1.61–3.16) (p for trend < 0.001) than in quartile 1. A similar trend was observed in the subgroup analyses of patients with impaired consciousness (Glasgow Coma Scale score < 8) and respiratory failure (PaO₂:FiO₂ ≤ 300) at ICU admission (p for trend = 0.081 and 0.001, respectively).

Conclusions

This multi-institutional observational study demonstrated that the timing of tracheostomy was significantly and independently associated with hospital mortality in a stepwise manner. Thus, early tracheostomy may be beneficial for patient outcomes, including mortality, and warrants further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00610-x.

Prospective Observational Study of Early Tracheostomy Role in Operated Severe Head Injury Patients at A Level 1 Trauma Center

Objective:

To evaluate the impact of the early tracheostomy on operated patients with severe head injury.

Methods:

This prospective observational study was conducted at a level 1 trauma center and medical college over one-year period. The study included all surgically managed severe head injury patients without any other life-threatening major injuries. Patients who underwent tracheostomy within 7 days were classified as early tracheostomy.

Results:

The patient’s mean age of this cohort study was 43.4±14.5 years. Motor-vehicle accidents were being the most common cause of severe head injury. Operated patients were undergoing early tracheostomy on an average of 2.9 days. We were observed that the patients spent on a mechanical ventilation on an average 3.67±2.26 days. This was significantly lower than previous four published studies (p<0.05) which had a range of mean 9.8-15.7 days.

Conclusion:

We have shown that it is possible to decrease mechanical ventilation (MV) time, intensive care unit (ICU) stay and total hospital stay by doing early tracheostomy in operated severe head injury patients.

Long-Term Survival and Medical Costs of Patients with Prolonged Mechanical Ventilation and Tracheostomy: A Nationwide Cohort Study

Few large-scale studies have focused on tracheostomy in patients with prolonged mechanical ventilation. This retrospective population-based study extracted data from the longitudinal National Health Insurance Research Database in Taiwan to compare long-term mortality between patients on prolonged mechanical ventilation with and without tracheostomy and their related medical expenditures. Data on newly developed respiratory failure in patients on ventilator support were extracted from 1 January 2002 to 31 December 2008. Of 10,705 patients included, 1372 underwent tracheostomy (n = 563) or translaryngeal intubation (n = 779). Overall survival of the patients with tracheostomy was followed for 5 years. Average survival was 4.98 years for the patients with tracheostomy and 5.48 years for the patients with translaryngeal intubation (not significant). Sex, age, premium-based monthly salary difference, occupation, urbanization level, chronic obstructive pulmonary disease, chronic heart failure, chronic renal disease, and cerebrovascular diseases were significantly associated with mortality for endotracheal intubation. Male sex, chronic heart failure, chronic renal disease, age ≥45 years, and low income were associated with significantly higher mortality. Although total medical expenditures were higher for the patients with tracheostomy, annual medical expenditures were not significantly different. There were no differences in long-term mortality between the two groups.

Comparing Long-Term Outcomes in Tracheostomy Placed in the First Year of Life

OBJECTIVES//HYPOTHESIS

To characterize long-term outcomes in pediatric patients requiring tracheotomy in the first year of life.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective longitudinal registry of tracheostomy patients was queried for patients who underwent tracheotomy from birth to 11 months. Primary outcomes were decannulation and survival. Secondary outcomes included neurocognitive quality of life assessed with the PedsQL Family Impact Module (scored from worst to best, 0 to 100 points).

RESULTS

The study included 337 children. Thirty (8.90%) were neonates and 307 (91.10%) were infants. The population was 56.08% male (n = 189), and the racial and ethnicity composition were equally distributed (29.97% White, 31.45% Black, and 31.16% Hispanic). Significant differences between neonates and postneonates included birth weight in grams (2,731.40 vs. 1,950.44, P < .05), extreme prematurity (13.33% vs. 38.88%, P = .01), upper airway obstruction (80.00% vs. 42.67%, P < .05), and the need for mechanical ventilation (40.00% vs. 83.71%, P < .05). Despite these differences, long-term outcomes were similar: decannulation (X²  = 2.19, P = .14), death (X²  = 2.63, P = .11), and neurocognitive quality of life (X²  = 2.63, P = .27). Having a child with a tracheostomy caused the most problems with being physically tired (mean = 75.32 ± 3.90), emotional frustration (mean = 77.31 ± 5.05), and worry (mean standard deviation = 74.23 ± 6.48).

CONCLUSION

There were demographic differences between neonatal and infantile tracheostomy patients, but they did not affect long-term outcomes. The presence of a tracheostomy caused a significant impact on a family's quality of life.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:2115-2120, 2021.

Early versus late tracheotomy in ICU patients: A meta-analysis of randomized controlled trials

BACKGROUND

This study aimed to quantitatively analyze the available randomized controlled trials (RCTs) and investigate whether early tracheotomy can improve clinical endpoints compared with late tracheotomy in critically ill patients undergoing mechanical ventilation.

METHODS

The electronic databases of PubMed, Embase, and the Cochrane library were systematically searched in August 2019. The investigated outcomes were calculated using relative risks (RRs) and standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) through the random-effects model for categories and continuous data, respectively.

RESULTS

The electronic searches yielded 2289 records, including 15 RCTs comprising a total of 3003 patients and found to be relevant for the final quantitative analysis. The summary RRs that indicated early versus late tracheotomy were not associated with the risk of short-term mortality (RR: 0.87; 95% CI: 0.74-1.03; P = .114) and ventilator-associated pneumonia (RR: 0.90; 95% CI: 0.78-1.04; P = .156). Moreover, early tracheotomy was associated with shorter intensive care unit (ICU) stay (SMD: -1.81; 95% CI: -2.64 to -0.99; P < .001) and mechanical ventilation duration (SMD: -1.17; 95% CI: -2.10 to -0.24; P = .014). Finally, no significant difference was observed between early and late tracheotomy for hospital stay (SMD: -0.42; 95% CI: -1.36-0.52; P = .377).

CONCLUSIONS

The present meta-analysis suggests that early tracheotomy can reduce the length of ICU stay and mechanical ventilation duration, but the timing of the tracheotomy was not associated with the short-term clinical endpoints in critically ill patients undergoing mechanical ventilation.

Critical Care and Postoperative Management of the Head and Neck Patient

Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.

Illustration of the current practice and outcome comparison of early versus late tracheostomy after pediatric ECMO

OBJECTIVE

Pediatric extracorporeal membrane oxygenation typically necessitates protracted ventilator support, yet not much is known about the use of tracheostomy in the pediatric subpopulation. The study was designed with an objective to quantify the prevalence of tracheostomy in children with respiratory/cardiac failure requiring extracorporeal membrane oxygenation and to compare outcomes for patients undergoing early, late, and no tracheostomy.

METHODS

Data of patients <18 years of age who underwent extracorporeal membrane oxygenation for respiratory/cardiac failure between 2009 and 2015 were obtained from the Virtual Pediatric Systems (VPS, LLC) Database. Patients who underwent post-operative cardiac ECMO were excluded. Early versus late tracheostomy was defined as ⩽21 or >21 days after intensive care unit admission.

RESULTS

Data were analyzed for 2127 patients meeting inclusion and exclusion criteria. Five percent (107/2127) underwent a tracheostomy. Of these, 28% (30/107) underwent early and 72% (77/107) late tracheostomy. A higher mortality was found in the no tracheostomy group (41.3%) compared to early (13.3%) and late tracheostomy (14.3%) groups. Late tracheostomy was associated with 2.4 times the expected intensive care unit length of stay and 1.87 times the expected ventilator days as compared to patients with no tracheostomy. Early tracheostomy was associated with a shorter intensive care unit length of stay (p value < 0.001) and ventilator days (p value = 0.04) compared to late tracheostomy and no difference with the no tracheostomy group.

CONCLUSIONS

Late tracheostomy (>21 days) is associated with worse outcomes in the cohort of children who underwent Pediatric extracorporeal membrane oxygenation compared to patients who did not undergo tracheostomy. Early tracheostomy is associated with shorter intensive care unit stay and ventilator duration when compared to late tracheostomy.

Development of clinical tracheostomy score to identify cervical spinal cord injury patients requiring prolonged ventilator support

BACKGROUND

Cervical spinal cord injuries often necessitate ventilator support (VS). Prolonged endotracheal tube use has conveyed substantial morbidity in prospective study. Tracheostomy is recommended if VS is anticipated to be 7 days or longer, which defines prolonged ventilation (PV). Identifying these patients on arrival and before tracheostomy need is readily evident could prevent morbidity while lowering hospital costs. We aimed to create a tracheostomy score (trach score) to identify patients requiring PV and who could benefit from immediate tracheostomy.

METHODS

A review of patients with cervical spine fractures and cervical spinal cord injuries from 2005 to 2017 from the Pennsylvania Trauma Outcome Study database was performed. Patients were excluded for missing data, no use of VS or death in less than 7 days. Patients were selected for a training set or validation set by state identification number. We used automated forward stepwise selection to select a logistic model. Significant continuous variables were dichotomized to create a simplified screening score (trach score) and this was applied to the validation set.

RESULTS

Needing ventilation for 7 or more days was positively associated with higher Injury Severity Scores having a complete or anterior injury, and having a motor cord injury from C1 to C4. Application of the logistic model to the validation data produced a receiver operating characteristic curve with area under the curve of 0.7712, with 95% confidence limit (CL) of 0.6943 to 0.8481. The validation receiver operating characteristic curve was statistically better than chance using a contrast test with χ with p value less than 0.01. In the validation set, a trach score of 0 correlated to 33% needing PV, a score of 1 with 67% needing PV, 2 with 85%, and 3 with 98%.

CONCLUSION

Use of the trach score identified the majority of patients requiring prolonged VS in our study. An early tracheostomy protocol using predictive modeling could aid in reduction of intensive care unit length of stay and improving ventilator weaning in these patients. External verification of this predictive tool and of an early tracheostomy protocol is needed.

LEVEL OF EVIDENCE

This work is a retrospective prognostic cohort study and meets evidence Level III criteria.

The Impact of Tracheostomy Timing on the Duration and Complications of Mechanical Ventilation

Background:

Mechanical ventilation is a life support for ICU patients and is indicated in case of acute or chronic respiratory failure. 75% of patients admitted to ICU require this support and most of them stay on prolonged MV. Tracheostomy plays a fundamental role in airway management, facilitating ventilator weaning and reducing the duration of MV. Early tracheostomy is defined when the procedure is conducted up to 10 days after the beginning of MV and late tracheostomy when the procedure is performed after this period. Controversy still exists over the ideal timing and classification of early and late tracheostomy.

Objective:

Evaluate the impact of timing of tracheostomy on ventilator weaning.

Method:

Single-center retrospective study. Patients were divided into three groups: very early tracheostomy (VETrach), intermediate (ITrach) and late (LTrach): >10 days.

Results:

One hundred two patients were included: VETrach (n=21), ITrach (n=15), and LTrach (n=66). ITrach group had lower APACHE II (p=0.004) and SOFA (p≤0.001). Total ICU length of stay, and incidence of post-tracheostomy ventilator-associated pneumonia were significantly lower in the VETrach and ITrach groups. The GCS and RASS scores improved in all groups, while the maximal inspiratory pressure and rapid shallow breathing index showed a tendency towards improvement on discharge from the ICU.

Conclusion:

Very early tracheostomy did not reduce the duration of MV or length of ICU stay after the procedure when compared to late tracheostomy, but was associated with low rates of ventilatorassociated pneumonia. Neurological patients benefitted more from tracheostomy, particularly very early and intermediate tracheostomy.

Laryngotracheal Stenosis in Early vs Late Tracheostomy: A Systematic Review

OBJECTIVE

For critically ill patients undergoing long-term mechanical ventilation, to determine whether early conversion from endotracheal intubation to tracheostomy reduces the incidence of laryngotracheal stenosis.

DATA SOURCES

MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature.

REVIEW METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and an assessment of bias were performed. Included studies reported outcomes of patients who were converted from endotracheal intubation to tracheostomy, compared early vs late tracheostomy, and reported the incidence of laryngotracheal stenosis and details of postoperative surveillance. Data were also collected for intensive care setting, method of tracheostomy, and timing of tracheostomy.

RESULTS

Seven articles met inclusion criteria: 2 randomized trials, 2 quasi-randomized trials, 1 prospective cohort, and 2 retrospective cohorts. A total of 966 patients were included in this analysis (496 in the early tracheostomy group and 470 in the late tracheostomy group). The mean incidence of laryngotracheal stenosis was 8.9% (range, 0%-20.8%), with a mean incidence of 8.1% in early tracheostomy groups and 10.9% in late tracheostomy groups. In studies with the least risk of bias, there were no differences in the incidence of laryngotracheal stenosis in patients who underwent early vs late tracheostomy.

CONCLUSION

In critically ill patients undergoing long-term mechanical ventilation, early conversion to tracheostomy within 7 days of intubation does not significantly decrease the risk of laryngotracheal stenosis compared to later conversion as defined by the included studies.

Safety of early tracheostomy in trauma patients after anterior cervical fusion

BACKGROUND

Cervical spine injuries (CSIs) can have major effects on the respiratory system and carry a high incidence of pulmonary complications. Respiratory failure can be due to spinal cord injuries, concomitant facial fractures or chest injury, airway obstruction, or cognitive impairments. Early tracheostomy (ET) is often indicated in patients with CSI. However, in patients with anterior cervical fusion (ACF), concerns about cross-contamination often delay tracheostomy placement. This study aimed to demonstrate the safety of ET within 4 days of ACF.

METHODS

Retrospective chart review was performed for all trauma patients admitted to our institution between 2001 and 2015 with diagnosis of CSI who required both ACF and tracheostomy, with or without posterior cervical fusion, during the same hospitalization. Thirty-nine study patients with ET (within 4 days of ACF) were compared with 59 control patients with late tracheostomy (5-21 days after ACF). Univariate and logistic regression analyses were performed to compare risk of wound infection, length of intensive care unit and hospital stay, and mortality between both groups during initial hospitalization.

RESULTS

There was no difference in age, sex, preexisting pulmonary or cardiac conditions, Glasgow Coma Scale score, Injury Severity Score, Chest Abbreviated Injury Scale score, American Spinal Injury Association score, cervical spinal cord injury levels, and tracheostomy technique between both groups. There was no statistically significant difference in surgical site infection between both groups. There were no cases of cervical fusion wound infection in the ET group (0%), but there were five cases (8.47%) in the late tracheostomy group (p = 0.15). Four involved the posterior cervical fusion wound, and one involved the ACF wound. There was no statistically significant difference in intensive care unit stay (p = 0.09), hospital stay (p = 0.09), or mortality (p = 0.06) between groups.

CONCLUSION

Early tracheostomy within 4 days of ACF is safe without increased risk of infection compared with late tracheostomy.

LEVEL OF EVIDENCE

Evidence, level III.

Effect of early tracheostomy in mechanically ventilated patients

Objective

To investigate the effect of the timing of tracheostomy in patients who required prolonged mechanical ventilation using two methods: analysis of early versus late tracheostomy and landmark analysis.

Study Design

Retrospective cohort study.

Methods

Patients who were emergently intubated and admitted into the intensive care unit or high dependency unit between January 2011 and August 2016, with or without tracheostomy, were included. In the early and late tracheostomy analysis, all patients were divided into early (≤10 days, n = 88) and late (>10 days, n = 132) groups. In the landmark analysis, 198 patients requiring ventilation for more than 10 days were divided into early tracheostomy (≤10 days, n = 57) and nonearly tracheostomy (>10 days, n = 141) groups. We compared 60‐day ventilation withdrawal rate and 60‐day mortality.

Results

Early tracheostomy was a significant factor for early ventilation withdrawal, as shown by log‐rank test results (early and late tracheostomy: P = .001, landmark: P = .021). Multivariable analysis showed that the early group was also associated with a higher chance of ventilation withdrawal in each analysis (early and late tracheostomy: adjusted hazard ratio [aHR] = 1.69, 95% confidence interval [CI] = 1.20–2.39, P = .003; landmark: aHR = 1.61, 95% CI = 1.06–2.38, P = .027). Early tracheostomy, however, was not associated with improved 60‐day mortality (early and late tracheostomy: aHR = 0.88, 95% CI = 0.46–1.69, P = .71; landmark: aHR = 1.46; 95% CI = 0.58–3.66; P = .42).

Conclusion

For patients requiring ventilation, performing tracheostomy within 10 days of admission was independently associated with shortened duration of mechanical ventilation; 60‐day mortality was not associated with the timing of tracheostomy.

Level of Evidence

2b

Percutaneous Dilational Tracheostomy

Tracheostomy tubes can be inserted surgically or percutaneously via percutaneous dilational tracheostomy (PDT). Tracheostomy is performed for upper airway obstruction, though more often to allow prolonged mechanical ventilation in place of endotracheal tubes. Preparation, performance, and postoperative management for PDT are best provided by a multidisciplinary team. Although PDT is a safe procedure in the hands of experienced operators, both early and late complications can arise. Caution must also be taken during early tracheostomy tube exchange given that immaturity of the stomal tract can risk loss of the airway.

The impact of tracheotomy timing in critically ill patients undergoing mechanical ventilation: A meta-analysis of randomized controlled clinical trials with trial sequential analysis

BACKGROUND

The optimal timing of tracheotomy in critically ill ventilated patients remains controversial.

OBJECTIVES

The objective of this meta-analysis was to assess tracheotomy timing for critically ill ventilated patients and determine the outcomes' reliability.

METHODS

We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials.

RESULTS

Compared with late tracheotomy, early tracheotomy presented a lower incidence of ventilator-associated pneumonia (VAP), shorter duration of mechanical ventilation (MV), and shorter intensive care unit (ICU) stay. However, trial sequential analysis (TSA), a kind of cumulative meta-analysis, indicated that the evidence was unreliable and inconclusive.

CONCLUSIONS

The Findings suggest that early tracheotomy seems to be associated with a lower incidence of VAP, shorter duration of MV, shorter duration of sedation, and shorter ICU stay. However, the apparent benefits revealed in traditional meta-analysis contrast with the post-TSA results. More fully powered, randomized controlled trials focused on the outcomes of tracheotomy are highly warranted.

Timing of Tracheostomy in Intensive Care Unit Patients

Introduction  The ideal timing of tracheostomy in intensive care units (ICUs) for critically ill patients undergoing prolonged mechanical ventilation (MV) is still a controversial issue.

Objectives  To determine the proper timing of tracheostomy and its impact on various clinical outcomes of adult patients in ICUs undergoing prolonged MV.

Methods  The present study consisted of a sample of 67 ICU adult patients who were submitted to open surgical tracheostomy and divided into two groups: 30 patients in the early tracheostomy (ET) group (within 1–10 days post intubation), and 37 patients in the late tracheostomy (LT) group (within 11–21 days post intubation). The correlation between the timing of tracheostomy of each group and various associated ICU clinical parameters were analyzed.

Results  The sample consisted of 61.19% male and 38.81% female patients, with a mean age of 47.263 ± 7.581 years. The mean MV duration in days was 7.91 ± 4.937 standard deviation (SD) in the ET group, and 15.32 ± 7.472 SD in the LT group ( p  = 0.001), with a mean sedation time of 6.13 ± 4.647 SD in the ET group, and of 11.98 ± 6.596 SD in the LT group ( p  = 0.001). The duration of the weaning process duration had a mean of 2.75 ± 2.586 SD days in the ET group, and of 5.39 ± 5.817 SD days in the LT group ( p  = 0.025), with a weaning failure rate of 28.57% in the ET group and 71.42% in the LT group ( p  = 0.01). The Mean ICU stay was 26.18 ± 4.732 SD in the ET group, and 11.98 ± 6.596 SD in the LT group ( p  = 0.879), and the incidence of ventilator-associated pneumonia (VAP) of 23.33% in the ET group and of 27.02% in the LT group ( p  = 0.15).

Conclusion  Early tracheostomy had a notable benefit in shortening the duration of the MV, lessening the sedation time and minimizing the risks of weaning failure, but it had no significant impact on both the overall duration of ICU stay and VAP incidence.

Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review

The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.

[Tracheostomy performed in ICU: Professional practice assessment and patient outcome]

INTRODUCTION

Tracheostomy is a commonly performed procedure. The aim of this study was to assess professional practice, describe patient characteristics and examine short and long-term outcomes.

METHODS

All patients with CCAM GEPA004 code were retrospectively included.

RESULTS

Two hundred and fourteen (7%) patients who were mecanically ventilated had a tracheostomy performed in intensive care unit (ICU). Median time to tracheostomy was 22 (14-28) days. In total, 95.3% of tracheostomy procedures were surgical. Median age was 58 (48-67) years. Eighty-three (38.8%) tracheostomies were performed for respiratory reasons. Twenty-eight-day and 90-day mortality were 4.2% and 35.5%. One-year mortality was 52.4%. Patients with tracheostomies performed for weaning from mechanical ventilation had a higher mortality rate. After ICU discharge, mortality rate was 29.8% and was higher in non-decannulated patients. Patient characteristics, timing, technique, indication and outcomes were stable over the years.

CONCLUSION

Young patients weaning from mechanical ventilation were more likely to receive a tracheostomy. More than half died during the first year. Patients discharged from ICU with a tracheostomy tube in place had higher mortality rate.

Inter-rater and intra-rater reliability of the airway diameter measured by sonography

INTRODUCTION

Sonography has gained a broad field of applications in current anesthetic practice. During airway management, it could have an important role, because it allows real-time measurement of anatomical aspects and a functional evaluation with high safety profile. However, assessment of the reliability and precision of these measurements is critical if sonography is used as a clinical diagnostic tool. The aim of the study was to estimate inter-rater and intra-rater reliability of the airway diameter measured by sonography in heathy volunteers.

METHODS

We conducted a cross-sectional study during 2015 on healthy adult volunteers. Using sonography, transverse internal diameter of subglottic space was measured twice by two blinded sonographers.

RESULTS

Agreement was classified as very good for intra-rater measurements (ICC = 0.84) and good for the inter-rater measurements (ICC = 0.71). The 95% CI of agreement limits for the intra-rater measurements were inferior to those for the inter-rater measurements.

CONCLUSIONS

Ultrasound measurement is a reliable and precise method to measure the internal subglottic diameter of the airway. Ultimately, this method may provide clinicians valuable information regarding airway diameter in adults and may help to guide treatment options.

Tracheostomy or Not: Prediction of Prolonged Mechanical Ventilation in Guillain-Barré Syndrome

BACKGROUND

Respiratory insufficiency occurs in 20 % of Guillain-Barré syndrome (GBS) patients, and the duration of mechanical ventilation (MV) ranges widely. We identified predictors of prolonged MV to guide clinical decision-making on tracheostomy.

METHODS

We analyzed prospectively collected data from 552 patients with GBS in the context of two clinical trials and three cohort studies in The Netherlands. Potential predictors for prolonged MV, defined as duration of ≥14 days, were considered using crosstabs. Selected predictors were analyzed using Cox regression analysis.

RESULTS

On a total of 150 (27 %) patients requiring MV, 106 (71 %) patients needed prolonged MV. The median duration of MV was 28 days (Interquartile Range [IQR] 12-60 days). The strongest observed predictors of prolonged MV were muscle weakness and axonal degeneration or unexcitable nerves on nerve conduction studies. Patients who are unable to lift the arms from the bed (bilateral Medical Research Council [MRC] of deltoid muscles of 0-2) at 1 week after intubation have an 87 % chance to require prolonged MV versus 69 % in patients who are able to lift the arms from the bed (bilateral MRC of deltoid muscles of 3-10). Patients in this last group who had axonal degeneration or unexcitable nerves on nerve conduction studies also have a 90 % chance to require prolonged MV.

CONCLUSIONS

Ventilated GBS patients who are unable to lift the arms from the bed and patients who have axonal degeneration or unexcitable nerves at 1 week are at high risk of prolonged MV, and tracheostomy should be considered in these patients.

Tracheostomy Update: When and How

Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.

Pediatric tracheotomy: A comparison of outcomes and lengths of hospitalization between different indications

OBJECTIVES

To assess outcomes of pediatric tracheotomy and duration of associated hospital stay according to indications.

SUBJECTS AND METHODS

In this retrospective study, subjects were 142 consecutive pediatric patients (<18 years old) who underwent tracheotomy at a tertiary referral medical center, National Taiwan University Hospital, in 1997-2012. Age, sex, indications, pre-operative status (oxygen demand, number of repeated intubations), and post-operative status (duration of weaning, length of hospital stay, mortality) were analyzed.

RESULTS

The indications included craniofacial anomalies (n = 19, 13.4%), upper airway obstruction (n = 41, 28.9%), neurological deficit (n = 58, 40.8%), prolonged ventilation (n = 15, 10.6%), and trauma (n = 9, 6.3%). Ninety-one patients (64.1%) were successfully weaned off ventilation after tracheotomy (40% in the prolonged ventilation group). Total hospital stay and duration of ventilation before tracheotomy were longest in patients with craniofacial anomalies (150.9 ± 98.8 days, p = 0.004; 108.8 ± 88.2, p < 0.001). The early tracheotomy group had a shorter duration of post-tracheotomy mechanical ventilation support than the late tracheotomy group (14.4 ± 19.0, n = 49 vs. 34.9 ± 58.6, n = 80, p = 0.004). Decannulation was successful in 20 patients (14.1%), with the highest rate in the upper airway obstruction group (n = 14, 34.1%) and lowest in the prolonged ventilation group (none). Thirteen patients (9.2%) died during admission from causes unrelated to tracheotomy.

CONCLUSION

Outcomes of pediatric tracheotomy and duration of hospitalization depend on indications. Children with craniofacial anomalies had earlier tracheotomy age and longer mechanical ventilation before tracheotomy resulted in longer hospitalization. Earlier tracheotomy can shorten the duration of post-tracheotomy mechanical ventilation in several conditions.

Percutaneous tracheostomy: a comprehensive review

Tracheostomy is a common procedure. It can be done surgically or percutaneously by dilating the stoma using Seldinger technique. Percutaneous tracheostomy (PT) is now routinely performed by surgeons and non-surgeons such as intensivists and anesthesiologists in the intensive care units (ICU) all over the world. Although obesity, emergent tracheostomy, coagulopathy, inability to extend the neck and high ventilator demand (HVD) were initially thought to be a relative contraindication, recent data suggest safety of PT in these patient population. Ultrasound can be helpful in limited cases to identify the neck structure especially in patients with a difficult anatomy. Bronchoscopy during PT can shorten the duration and avoid complications. PT has favorable complication rate, lower infection rate, shorter procedural duration and is cost-effective. Experience with the technique and careful planning is needed to minimize any avoidable potential complication.

The influence of tracheostomy timing on outcomes in trauma patients: A meta-analysis

OBJECTIVE

This study aims to assess the influence of tracheostomy timing on outcomes among trauma patients, including mortality, medical resource utility and incidence of pneumonia.

METHOD

A systematic review of the literature was conducted by internet search. Data were extracted from selected studies and analyzed using Stata to compare outcomes in trauma patients with early tracheostomy (ET) or late tracheostomy (LT)/prolonged intubation (PI).

RESULT

20 studies met our inclusion criteria with 3305 patients in ET group and 4446 patients in LT/PI group. Pooled data revealed that mortality was not lower in trauma patients with ET compared to those with LT/IP. However, ET was found to be associated with a significantly reduced length of ICU and hospital stay, shorter MV duration and lower risk of pneumonia.

CONCLUSION

Evidence of this meta-analysis supports the dimorphism in some clinical outcomes of trauma patients with different tracheostomy timing. Additional well-designed randomized controlled trials (RCTs) are needed to confirm it in future.

The effect of tracheostomy performed within 72 h after traumatic brain injury

The optimal timing of tracheostomy in patients with traumatic brain injury (TBI) remains unclear. The purpose of this study was to examine the effects of tracheostomy performed within 72 h after admission. In this retrospective cohort study, the authors reviewed the data for a series of 120 consecutive patients who underwent tracheostomy after suffering TBI with an Abbreviated Injury Scale (AIS) score of ≥4. The exclusion criteria were as follows: age <18 years, severe chest injury with an AIS score of ≥4, and a requirement for intubation because of upper airway obstruction. Patients who underwent tracheostomy ≤72 h and >72 h after admission were classified into early group and control groups, respectively. The duration of mechanical ventilation, length of stay (LOS) in intensive care unit (ICU), incidence of pneumonia, adverse event rate, unnecessary tracheostomy and outcomes were compared between the two groups. Of the 120 patients, 29 were excluded from the study, 40 were classified into the early group, and 51 were classified into the control group. The duration of mechanical ventilation and LOS in ICU were significantly less in the early group than in the control group. The 30-day mortality rates were 3% and 8% for the early and control groups, respectively. There was no significant difference in the adverse event rate, incidence of pneumonia, unnecessary tracheostomy rate and the rate of favorable outcome between groups. The results of this study suggest that the performance of tracheostomy within 72 h of admission may decrease the duration of mechanical ventilation and LOS in ICU, with acceptable mortality and morbidity rates.

Outcomes of mechanical support in a pediatric lung transplant center

Pediatric lung transplantation is a lifesaving option for patients with end stage lung disease, although the scarcity of suitable donor organs results in long wait times and increased waitlist mortality. Many pediatric centers consider mechanical ventilatory support, such as long-term invasive ventilation and ECMO, a contraindication to lung transplantation. We hypothesized that current survival rates and outcomes for patients on mechanical ventilatory support in the pre-transplant period were not remarkably different. In our retrospective analysis we included patients between the ages of 0-21 years listed for lung transplantation from deceased donors between 2007 and 2014 at our institution. One-year survival outcomes were compared between three groups of patients: (i) patients bridged to transplant on ECMO (n = 6, 1-year survival = 67%); (ii) patients needing mechanical ventilation (either through endotracheal intubation or tracheostomy) but not ECMO (n = 12, 1-year survival = 75%); and (iii) patients who did not need endotracheal ventilation, tracheostomy, or ECMO (n = 25, 1-year survival = 88%). Comparison of outcomes of transplanted patients between these three groups were not statistically different in terms of successful hospital discharge and 1-year survival rates (P > 0.05). We believe that "bridging" the end-stage lung disease patient with long-term mechanical ventilation and/or ECMO support is a reasonable option in selected patients until suitable donors become available. Pediatr Pulmonol. 2017;52:360-366. © 2016 Wiley Periodicals, Inc.

Evidence-based guides in tracheostomy use in critical patients

OBJECTIVES

Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.

METHODS

A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions.

CONCLUSION

Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Percutaneous tracheostomy

Percutaneous dilatational tracheostomy (PDT) is a commonly performed procedure in critically sick patients. It can be safely performed bedside by intensivists.This has resulted in decline in the use of surgical tracheostomy in intensive care unit (ICU) except in few selected cases. Most common indication of tracheostomy in ICU is need for prolonged ventilation. About 10% of patients requiring at least 3 days of mechanical ventilator support get tracheostomised during ICU stay. The ideal timing of PDT remains undecided at present. Contraindications and complications become fewer with increase in experience. Various methods of performing PDT have been discovered in last two decades. Preoperative work up, patient selection and post tracheostomy care form key components of a successful PDT. Bronchoscopy and ultrasound have been found to be useful procedural adjuncts, especially in presence of unfavorable anatomy. This article gives a brief overview about the use of PDT in ICU.

Early Versus Late Tracheostomy for Patients with High and Low Cervical Spinal Cord Injuries

OBJECTIVES

This study aimed to evaluate the effects of early versus late tracheostomies among patients with cervical spinal cord injuries (CSCIs).

METHODS

This retrospective study included 69 adult CSCI patients who underwent bedside percutaneous tracheostomies at the Intensive Care Unit of Khoula Hospital, Muscat, Oman, between January 2011 and October 2015. The tracheostomy was considered early if the procedure took place within one week of the CSCI. The impact of an early tracheostomy on patient outcomes was analysed in terms of duration of mechanical ventilation and intensive care unit (ICU) stay among patients with high (C1-C2 vertebrae) and low (C3-C7 vertebrae) CSCIs. Ventilator dependence, bradycardia episodes and surgical intervention outcomes were also examined.

RESULTS

Patients with a high CSCI who underwent an early tracheostomy spent significantly fewer days on mechanical ventilation compared to those who underwent a late tracheostomy (9.3 ± 7.2 days versus 13.7 ± 3.2 days; P = 0.041). Low CSCI patients who received an early tracheostomy also experienced significantly fewer days on mechanical ventilation compared to those undergoing a late tracheostomy (12.1 ± 10.4 days versus 25.2 ± 17.7 days; P = 0.035). Moreover, ICU mortality was significantly lower for high CSCI patients who underwent an early tracheostomy (P = 0.015). However, there was no association between length of ICU stay and either type of CSCI or timing of the tracheostomy procedure.

CONCLUSION

An early tracheostomy is beneficial in reducing the duration of mechanical ventilation among patients with CSCIs, irrespective of the level of injury.

Early percutaneous dilational tracheostomy does not lead to an increased risk of surgical site infection following anterior spinal surgery

BACKGROUND

Most patients with cervical spinal cord injuries require tracheostomy. The optimal timing is still a matter of debate. Previous studies showed that patients receiving early tracheostomy had fewer ventilator days and decreased rates of pneumonia and were mobilized earlier. Because of the proximity of the anterior approach to the tracheostoma, there is concern about an increased risk of surgical site infection (SSI) related to tracheostomy.

METHODS

This was a retrospective analysis at a Level I trauma center of patient records from 2008 to 2014, identifying all patients with spinal cord injury who received anterior cervical spinal surgery and had early percutaneous dilational tracheostomy (PDT). Follow-up for SSI was performed throughout hospital stay (mean, 110 days; median, 96 days, with lower quartile 89 days and upper quartile 119 days) and at 6 weeks and 3 months (clinical examination and computed tomography scans).

RESULTS

Fifty-one patients underwent anterior spinal surgery with PDT performed within a median of 5 days (range, 1-18 days). Seventy-eight percent (n = 40) of patients had anterior spinal surgery, whereas 22% (n = 11) had a combined anterior-posterior repair. All percutaneous dilational tracheostomies were performed using the Ciaglia single-step dilation technique. Despite an SSI of one patient's cannulation site, no SSI of the anterior approach was observed.

CONCLUSION

Performing a PDT in a timely fashion after anterior spinal surgery does not increase the risk of SSI.

LEVEL OF EVIDENCE

Therapeutic study, level V.

Evidence-based guidelines for the use of tracheostomy in critically ill patients

OBJECTIVES

To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research.

METHODS

A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions.

CONCLUSIONS

Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Tracheostomy risk factors and outcomes after severe traumatic brain injury

OBJECTIVE

To determine risk factors associated with tracheostomy placement after severe traumatic brain injury (TBI) and subsequent outcomes among those who did and did not receive a tracheostomy.

METHODS

This retrospective cohort study compared adult trauma patients with severe TBI (n = 583) who did and did not receive tracheostomy. A multivariable logistic regression model assessed the associations between age, sex, race, insurance status, admission GCS, AIS (Head, Face, Chest) and tracheostomy placement. Ordinal logistic regression models assessed tracheostomy's influence on ventilator days and ICU LOS. To limit immortal time bias, Cox proportional hazards models assessed mortality at 1, 3 and 12-months.

RESULTS

In this multivariable model, younger age and private insurance were associated with increased probability of tracheostomy. AIS, ISS, GCS, race and sex were not risk factors for tracheostomy placement. Age showed a non-linear relationship with tracheostomy placement; likelihood peaked in the fourth decade and declined with age. Compared to uninsured patients, privately insured patients had an increased probability of receiving a tracheostomy (OR = 1.89 [95% CI = 1.09-3.23]). Mortality was higher in those without tracheostomy placement (HR = 4.92 [95% CI = 3.49-6.93]). Abbreviated injury scale-Head was an independent factor for time to death (HR = 2.53 [95% CI = 2.00-3.19]), but age, gender and insurance were not.

CONCLUSIONS

Age and insurance status are independently associated with tracheostomy placement, but not with mortality after severe TBI. Tracheostomy placement is associated with increased survival after severe TBI.

Tracheostomy in the Intensive Care Unit: a University Hospital in a Developing Country Study

Introduction Tracheostomy is the commonest surgical procedure in intensive care units (ICUs). It not only provides stable airway and facilitates pulmonary toilet and ventilator weaning, but also decreases the direct laryngeal injury of endotracheal intubation, and improves patient comfort and daily living activity.

Objective The objective of this study is to assess the incidence, indications, timing, complications (early and late), and the outcome of tracheostomy on patients in the intensive care units (ICU) at a university hospital in a developing country.

Methods This study is an observational prospective study. It was performed at the otolaryngology department and ICU new surgery hospital on 124 ICU admitted patients. We collected patients' demographic records, cause of admission, indications of tracheostomy, mechanical ventilation, and duration of ICU stay. We also gathered patientś tracheostomy records including the incidence, timing, technique, type, early and late complications, and outcome. All tracheostomized patients received follow-up for 12 months.

Results The indication for tracheostomy in ICU patients was mostly prolonged intubation (80.5%), followed by diaphragmatic paralysis (19.5%). All tracheostomies were done by the open approach technique. Tracheostomy for prolonged intubation was done within 17 to 26 days after intubation with a mean of 19.4 ± 2.07 days. Complications after tracheostomy were 13.9% tracheal stenosis and 25% subglottic stenosis.

Conclusion Prolonged endotracheal intubation is the man indication of tracheostomy, performed after two weeks of intubation. Although there were no major early complications, laryngotracheal stenosis is still a challenging sequel for tracheostomy that needs to be investigated to be prevented.