Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study

Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study

BACKGROUND

Long-term ventilation in intensive care units (ICUs) is associated with several problems such as increased mortality, increased rates of ventilator-associated pneumonia (VAP), and prolonged time of hospitalization, and thus leads to enormous healthcare expenditure. While the influence of tracheostomy on VAP incidence, duration of ventilation, and time of hospitalization has already been analyzed in several studies, the timing of the tracheostomy procedure on patient's mortality is still controversial. The aim of our study was to investigate whether early tracheostomy improved outcome in critically ill patients.

MATERIALS AND METHODS

Within 2 years, 100 critically ill, predominantly surgical patients entered this prospective randomized study. A percutaneous dilatational tracheostomy was performed either early (≤4 days, 2.8 days median) or late (≥6 days, 8.1 days median) after intubation.

RESULTS

We could demonstrate that mortality was not significantly reduced in the early tracheostomy (ET) group in contrast to the late tracheostomy (LT) group. ET was associated with decreased VAP incidence (ET 38% vs. LT 64%), decreased duration of ventilation (ET 367.5 h vs LT 507.5 h), and shorter time of hospitalization both in hospital (ET 31.5 days vs LT 68 days) and in ICU (ET 21.5 days vs LT 27 days).

CONCLUSION

Despite many advantages like reduced time of ventilation and hospitalization, early tracheostomy is not associated with decreased mortality in critically ill patients.

Effect of technique and timing of tracheostomy in patients with acute traumatic spinal cord injury undergoing mechanical ventilation

OBJECTIVE

To assess the effect of timing and techniques of tracheostomy on morbidity, mortality, and the burden of resources in patients with acute traumatic spinal cord injuries (SCls) undergoing mechanical ventilation.

DESIGN

Review of a prospectively collected database.

SETTING

Intensive and intermediate care units of a monographic hospital for the treatment of SCI.

PARTICIPANTS

Consecutive patients admitted to the intensive care unit (ICU) during their first inpatient rehabilitation for cervical and thoracic traumatic SCI. A total of 323 patients were included: 297 required mechanical ventilation and 215 underwent tracheostomy.

OUTCOME MEASURES

Demographic data, data relevant to the patients' neurological injuries (level and grade of spinal cord damage), tracheostomy technique and timing, duration of mechanical ventilation, length of stay at ICU, incidence of pneumonia, incidence of perioperative and early postoperative complications, and mortality.

RESULTS

Early tracheostomy (<7 days after orotracheal intubation) tracheostomy was performed in 101 patients (47%) and late (> or = 7 days) in 114 (53%). Surgical tracheostomy was employed in 119 cases (55%) and percutaneous tracheostomy in 96 (45%). There were 61 complications in 53 patients related to all tracheostomy procedures. Two were qualified as serious (tracheoesophageal fistula and mediastinal abscess). Other complications were mild. Bleeding was moderate in one case (late, percutaneous tracheostomy). Postoperative infection rate was low. Mortality of all causes was also low.

CONCLUSION

Early tracheostomy may have favorable effects in patients with acute traumatic SC. Both techniques, percutaneous and surgical tracheostomy, can be performed safely in the ICU.

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.

Clinical review: liberation from mechanical ventilation

Mechanical ventilation is the defining event of intensive care unit (ICU) management. Although it is a life saving intervention in patients with acute respiratory failure and other disease entities, a major goal of critical care clinicians should be to liberate patients from mechanical ventilation as early as possible to avoid the multitude of complications and risks associated with prolonged unnecessary mechanical ventilation, including ventilator induced lung injury, ventilator associated pneumonia, increased length of ICU and hospital stay, and increased cost of care delivery. This review highlights the recent developments in assessing and testing for readiness of liberation from mechanical ventilation, the etiology of weaning failure, the value of weaning protocols, and a simple practical approach for liberation from mechanical ventilation.

Weaning Strategies in Problem Patients

Weaning usually accounts for approximately 40–50% of the total duration of mechanical ventilation. Approximately two-thirds of patients can tolerate withdrawal of ventilation without the need for more gradual weaning, but there are a significant number of patients for whom weaning is difficult. Weaning failure is defined as the failure of a spontaneous breathing trial, or the need for re-intubation within 48 hours of extubation. This article reviews the causes of failure to wean, and outlines a practical approach to dealing with the difficult-to-wean patient. The key to successful weaning combines an approach which optimises ventilation at night, adopts a stepwise approach to reducing ventilatory dependence during the day, and uses non-invasive ventilation as a ‘bridge’ out of the ICU. Having a weaning protocol and ensuring it is initiated in a timely manner is likely to be as important as what is in the protocol.

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.

[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.

Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?

OBJECTIVE

To evaluate the effect of tracheostomy on intensive care unit (ICU) and in-hospital mortality for patients requiring prolonged (> 3 days) mechanical ventilation (MV).

DESIGN, SETTING, AND PATIENTS

We retrospectively reviewed the charts of all consecutive patients admitted to our 18-bed tertiary care ICU over 3 yrs (2002-2004) and who received prolonged MV. Outcomes of tracheostomized and nontracheostomized patients were evaluated using univariable and multivariable logistic-regression analyses and by constructing a case-control cohort using a propensity score for performing tracheostomy. MV duration for controls was at least equal to the time from MV onset to tracheostomy for the matched case.

MEASUREMENTS AND MAIN RESULTS

Of the 506 patients requiring prolonged MV, 166 were tracheostomized after a median of 12 days of MV. Nontracheostomized patients had higher ICU (42% vs. 33%, p = .06) and in-hospital (48% vs. 37%, p = .03) mortality rates and shorter MV durations and ICU lengths of stay. Performing a tracheostomy (odds ratio, 0.58; 95% CI, 0.37-0.90) was independently associated with a lower probability of ICU death, even after adjusting for other important prognostic factors. No significant differences were detected between the 120 cases and their matched controls regarding ICU admission and day-3 clinical characteristics. After conditional logistic-regression analysis, tracheostomy was associated with lower risk of ICU (odds ratio, 0.47; 95% CI, 0.24-0.89) and in-hospital (odds ratio, 0.48; 95% CI, 0.25-0.90) death.

CONCLUSIONS

Tracheostomy performed in our ICU for long-term MV patients was associated with lower ICU and in-hospital mortality rates, even after carefully controlling for ICU admission and day-3 clinical and physiologic differences between groups. Whether these results reflect that physicians were able to adequately select for tracheostomy patients who, despite having similar physiologic and demographic variables, had the highest probabilities of survival or that the procedure itself really affected the outcomes of these patients will remain speculative.

Recent developments in percutaneous tracheostomy: improving techniques and expanding roles

PURPOSE OF REVIEW

The purpose of this review is to provide an update of recent developments pertaining to the use of percutaneous tracheostomy. Percutaneous tracheostomy has been established as an alternative to open surgical tracheostomy, but many key questions about the optimal use of this procedure remain unanswered.

RECENT FINDINGS

Issues in percutaneous tracheostomy that have been addressed in the recent literature include the optimal method, timing, use of percutaneous tracheostomy in emergencies, safety in high-risk populations, confirmation of tracheal puncture, and outcomes.

SUMMARY

Recent literature suggests that percutaneous tracheostomy is safe to use in an expanding population of patients, including patients with airway compromise and thrombocytopenia. Several methods seem to be safe alternatives to that originally described. Capnography has arisen as an alternative to bronchoscopy for confirmation of tracheal puncture. Recent evidence highlights that although tracheostomy may improve short-term outcome, these critically ill patients have a significant long-term risk of poor outcome. This must be taken into consideration when this procedure is offered.

Recently published papers: an ancient debate, novel monitors and post ICU outcome in the elderly

Tracheostomies have been around for close to 3000 years, so one would hope that the controversies might have been thrashed out by now, but apparently not. Judging by some recent publications it would appear that we still do not know when or how to insert them. Monitoring is fundamental to critical care; two papers describe novel/modified techniques for assessing traumatic brain injury and cardiac output. The intensive care unit imposes a heavy treatment burden, particularly on the elderly. What impact does this have on the lives of the survivors?

Year in review in Critical Care, 2003 and 2004: respirology and critical care

We summarize all original research in the field of respirology and critical care published in 2003 and 2004 in Critical Care. Articles were grouped into the following categories to facilitate a rapid overview: pathophysiology, therapeutic approaches, and outcome in acute lung injury and acute respiratory distress syndrome; hypoxic pulmonary arterial hypertension; mechanical ventilation; liberation from mechanical ventilation and tracheostomy; ventilator-associated pneumonia; multidrug-resistant infections; pleural effusion; sedation and analgesia; asthma; and techniques and monitoring.