Tracheostomy and mortality in patients with severe burns: A nationwide observational study

Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care

Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.

An Introduction to Burn Care: The Sequel

GENERAL PURPOSE

To review burn care, with an emphasis on burn-specific issues and treatment.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Select the appropriate treatment guidelines for patients who have burn injuries.2. Identify common complications of major burns.3. Choose the recommended pharmacologic approaches to burn care.

Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis

OBJECTIVES

To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models.

DESIGN

A retrospective observational study.

SETTING

Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients.

INTERVENTIONS

An ET versus late tracheostomy (LT).

MEASUREMENTS AND MAIN RESULTS

Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups.

CONCLUSIONS

The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.

Traumatic main airway rupture successfully rescued by extracorporeal membrane oxygenation: A case report

The chest is a common site for traumatic injury; however, rupture of the main airway after chest trauma is a rare and potentially fatal condition. The present study demonstrated that extracorporeal membrane oxygenation (ECMO) may serve a crucial role in the effective conventional treatment of patients with severe chest trauma, ECMO was used before tracheal repair surgery to prevent hypoxia during surgery. When effective ventilation of the patient cannot occur without assistance, ECMO support is considered to be essential in ensuring effective gas exchange. This rescue procedure can provide guidance for the treatment of patients suffering from traumatic tracheal rupture and respiratory failure. To summarize, ECMO may be able to improve the treatment experience of patients with traumatic tracheal rupture and increase the treatment success rate of such patients.

Preliminary Exploration of Long-Term Patient Outcomes After Tracheostomy in Burns: A Burn Model System Study

INTRODUCTION

Upper airway management is crucial to burn care. Endotracheal intubation is often performed in the setting of inhalation injury, burns of the face and neck, or large burns requiring significant resuscitation. Tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term, patient-reported outcomes in burn patients with and without tracheostomy.

MATERIALS AND METHODS

Data from the Burn Model System Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcomes, collected at 6-, 12-, and 24-mo follow-up, were analyzed: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life, Community Integration Questionnaire, Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure, employment status, and days to return to work. Regression models and propensity-matched analyses were used to assess the associations between tracheostomy and each outcome.

RESULTS

Of 714 patients included in this study, 5.5% received a tracheostomy. Mixed model regression analyses demonstrated that only VR-12 Physical Component Summary scores at 24-mo follow-up were significantly worse among those requiring tracheostomy. Tracheostomy was not associated with VR-12 Mental Component Summary, Satisfaction with Life, Community Integration Questionnaire, or Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure scores. Likewise, tracheostomy was not found to be independently associated with employment status or days to return to work.

CONCLUSIONS

This preliminary exploration suggests that physical and psychosocial recovery, as well as the ability to regain employment, are no worse in burn patients requiring tracheostomy. Future investigations of larger scale are still needed to assess center- and provider-level influences, as well as the influences of various hallmarks of injury severity. Nonetheless, this work should better inform goals of care discussions with patients and families regarding the use of tracheostomy in burn injury.

Threshold of BMI for the Development of Hypertension among Japanese Adults

BACKGROUND

The optimal value of BMI for the development of hypertension and the influence of BMI on the development of stage 1 or stage 2 hypertension remain unclear.

OBJECTIVES

We sought to identify the BMI threshold for the prevention of hypertension and how changes in BMI would influence the risk of developing hypertension.

METHODS

We analyzed 1,262,356 participants (median age: 43 y; 50.9% men) with normal blood pressure [BP; systolic BP (SBP) <120 mmHg and diastolic BP (DBP) <80 mmHg] or elevated BP (SBP: 120-129 mmHg and DBP <80 mmHg). The primary outcome was stage 1 (SBP 130-139 mmHg or DBP 80-89 mmHg) or stage 2 hypertension (SBP ≥140 mmHg or DBP ≥90 mmHg). We analyzed the relation between baseline BMI, change in BMI, and the risk of developing hypertension using generalized additive models with a smoothing spline.

RESULTS

During the median follow-up of 851 d, 341,212 cases of stage 1 hypertension and 70,968 cases of stage 2 hypertension were detected. The risk of developing stage 1 or stage 2 hypertension increased steeply after BMI (kg/m²) exceeded 20. The annual change in BMI was positively correlated with the risk of developing stage 1 or 2 hypertension. Contour mapping using generalized additive models demonstrated an additive increase in the risk of developing hypertension with higher baseline BMI and increases in BMI over 1 y. Body-weight gain increases the risk of developing hypertension even in underweight or normal-weight individuals based on the WHO classification.

CONCLUSIONS

In Japanese adults with normal or elevated BP, the risk of developing hypertension increased with BMI when baseline BMI was >20. Body-weight gain additively interacted with baseline BMI during hypertension development. Our results underscore the importance of maintaining body weight in preventing the development of hypertension.

Association of Cardiovascular Health Metrics With Risk of Transition to Hypertension in Non-Hypertensive Young Adults

BACKGROUND

The risk of developing hypertension in young adults and its relationship to modifiable lifestyle factors are unclear. We aimed to examine the association of cardiovascular health (CVH) metrics with the risk of hypertension.

METHODS

We analyzed 66,876 participants aged 20-39 years, with available blood pressure (BP) data for 5 consecutive years, who had normal or elevated BP at the initial health check-up, enrolled in the JMDC Claims Database. Ideal CVH metrics included nonsmoking, body mass index <25 kg/m2, physical activity at goal, optimal dietary habits, untreated fasting glucose <100 mg/dL, and untreated total cholesterol <200 mg/dL. The primary endpoint was defined as stage 1 or stage 2 hypertension. We defined normal BP, elevated BP, stage 1 hypertension, and stage 2 hypertension according to the 2017 American College of Cardiology/American Heart Association (ACC/AHA) BP guideline.

RESULTS

The median age was 35 years, and 62% were men. Number of non-ideal CVH metrics was associated with an increasing risk for the development of stage 1 and stage 2 hypertension. Non-ideal body mass index was most strongly associated with a risk for hypertension. This association was more pronounced in women. An annual increase in the number of non-ideal CVH metrics was associated with an elevated risk for the hypertension development.

CONCLUSIONS

CVH metrics can stratify the risk for hypertension in non-hypertensive adults aged 20-39 years. These findings have important public health implications for the screening and prevention of hypertension. Improving CVH metrics may prevent the risk of developing hypertension in young adults.

Prediction of factors influencing the timing and prognosis of early tracheostomy in patients with multiple rib fractures: A propensity score matching analysis

Objective

To investigate the factors affecting the timing and prognosis of early tracheostomy in multiple rib fracture patients.

Methods

A retrospective case-control study was used to analyze the clinical data of 222 patients with multiple rib fractures who underwent tracheotomy in the Affiliated Hospital of Yangzhou University from February 2015 to October 2021. According to the time from tracheal intubation to tracheostomy after admission, the patients were divided into two groups: the early tracheostomy group (within 7 days after tracheal intubation, ET) and late tracheostomy group (after the 7th day, LT). Propensity score matching (PSM) was used to eliminate the differences in baseline characteristics Logistic regression was used to predict the independent risk factors for early tracheostomy. Kaplan–Meier and Cox survival analyses were used to analyze the influencing factors of the 28-day survival.

Results

According to the propensity score matching analysis, a total of 174 patients were finally included in the study. Among them, there were 87 patients in the ET group and 87 patients in the LT group. After propensity score matching, Number of total rib fractures (NTRF) (P < 0.001), Acute respiratory distress syndrome (ARDS) (P < 0.001) and Volume of pulmonary contusion(VPC) (P < 0.000) in the ET group were higher than those in the LT group. Univariate analysis showed that the patients who underwent ET had a higher survival rate than those who underwent LT (P = 0.021). Pearson's analysis showed that there was a significant correlation between NTRF and VPC (r = 0.369, P = 0.001). A receiver operating characteristic(ROC)curve analysis showed that the areas under the curves were 0.832 and 0.804. The best cutoff-value values of the VPC and NTRF were 23.9 and 8.5, respectively. The Cox survival analysis showed that the timing of tracheostomy (HR = 2.51 95% CI, 1.12–5.57, P = 0.004) and age (HR = 1.53 95% CI, 1.00–2.05, P = 0.042) of the patients had a significant impact on the 28-day survival of patients with multiple rib fractures. In addition, The Kaplan–Meier survival analysis showed that the 28-day survival of patients in the ET group was significantly better than that of the LT group, P = 0.01.

Conclusions

NTRF, ADRS and VPC are independent risk factors for the timing and prognosis of early tracheotomy. A VPC ≥ 23.9% and/or an NTRF ≥ 8.5 could be used as predictors of ET in patients with multiple rib fractures. Predicting the timing of early tracheostomy also need prediction models in the future.

Outcomes of Patients with Burns Associated with Home Oxygen Therapy: An Institutional Retrospective Review

Home oxygen therapy (HOT) burns carry high morbidity and mortality. Many patients are active smokers, which is the most frequent cause of oxygen ignition. We conducted a retrospective review at our institution to characterize demographics and outcomes in this patient population. An IRB-approved single-institution retrospective review was conducted for home oxygen therapy burn patients between July 2016 and January 2021. Demographic and clinical outcome data were compared between groups. We identified 100 patients with oxygen therapy burns. Mean age was 66.6 years with a male to female ratio of 1.3:1 and median burn surface area of 1%. In these patients, 97% were on oxygen for COPD and smoking caused 83% of burns. Thirteen were discharged from the emergency department, 35 observed for less than 24 hours, and 52 admitted. For admitted patients, 69.2% were admitted to the ICU, 37% required intubation, and 11.5% required debridement and grafting. Inhalational injury was found in 26.9% of patients, 3.9% underwent tracheostomy, and 17.3% experienced hospital complications. In-hospital mortality was 9.6% and 7.7% were discharged to hospice. 13.5% required readmission within 30 days. Admitted patients had significantly higher rates of admission to the ICU, intubation, and inhalational injury compared to those that were not admitted (p &lt; .01). Most HOT-related burns are caused by smoking and can result in significant morbidity and mortality. Efforts to educate and encourage smoking cessation with more judicious HOT allocation would assist in preventing these unnecessary highly morbid injuries.

Risk for Proteinuria in Newly Defined Hypertensive People Based on the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline

Whether blood pressure (BP) classification using the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP guideline can identify patients at high risk for proteinuria remains unknown. We examined the association of BP classification using the 2017 ACC/AHA guideline with the subsequent risk for the development of proteinuria. This is an observational cohort study using the JMDC Claims Database. We analyzed 914,786 participants with negative proteinuria assessed using urine dipstick tests at the initial health check-ups, not taking BP-lowering medications, and who underwent repeated urine dipstick tests within 4 years. Based on the 2017 ACC/AHA guideline, each participant was categorized as having normal BP (n = 487,020), elevated BP (n = 134,798), stage 1 hypertension (n = 197,618), or stage 2 hypertension (n = 95,350). The primary outcome was incident proteinuria. We investigated the association of BP based on the 2017 ACC/AHA guideline category with incident proteinuria using multivariable analyses. We used restricted cubic spline functions to identify the relation between systolic BP (SBP) and the risk for proteinuria. The median age was 45 years, and 59.4% were men. Multivariable analysis demonstrated that stage 1 hypertension (relative risk 1.14, 95% confidence interval 1.11 to 1.17), and stage 2 hypertension (relative risk 1.48, 95% confidence interval 1.43 to 1.52) were associated with a higher incidence of proteinuria than normal BP. The restricted cubic spline demonstrated that the risk for proteinuria increased linearly with SBP after SBP exceeded 120 mm Hg. Not only stage 2 hypertension but also stage 1 hypertension was associated with a greater risk for proteinuria, suggesting the importance of establishing the management strategy for stage 1 hypertension.

Outcomes following traumatic inhalational airway injury - Predictors of mortality and effect of procedural intervention

OBJECTIVE

Study outcomes, predictors of mortality, and effects of procedural interventions on patients following traumatic inhalational airway injury.

STUDY

Design: Retrospective study.

SETTING

National Trauma Data Bank METHODS: Patients over the age of eighteen admitted between 2008 and 2016 to NTDB-participating sites were included. In-hospital mortality and length of stay were the primary outcomes.

RESULTS

The final study cohort included 13,351 patients. History of active smoking was negatively associated with in-house mortality with an OR of 0.33 (0.25-0.44). History of alcohol use, and presence of significant medical co-morbidities were positively associated with in-house mortality with OR of 5.28 (4.32-6.46) 2.74 (19.4-3.86) respectively. There was little to no association between procedural interventions and in-house mortality. Intubation, laryngobronchoscopy, and tracheostomy had OR of 0.90 (0.67-1.20), 1.02 (0.79-1.30), and 0.94 (0.58-1.51), respectively. However, procedural intervention did affect both the median hospital and ICU lengths of stay of patients. Median hospital and ICU length of stay were shorter for patients receiving endotracheal intubation. Median hospital length of stay was longer for patients undergoing bronchoscopy and laryngoscopy, but median ICU length of stay was shorter for patients undergoing bronchoscopy and laryngoscopy. Patients receiving a tracheostomy have both significantly increased median hospital and ICU lengths of stay.

CONCLUSIONS

Active smoking was associated with decreased odds of in-hospital mortality, while presence of pre-existing medical comorbidities and history of alcohol use disorder was associated with increased odds of in-hospital mortality. Procedural intervention had little to no association with in-hospital mortality but did affect overall hospital and ICU LOS.

Early tracheostomy and active exercise programmes in adult intensive care patients with severe burns

BACKGROUND

Tracheostomy is a strategy often employed in patients requiring prolonged intubation in ICU settings. Evidence suggests that earlier tracheostomy and early active exercise are associated with better patient centered outcomes. Severe burn patients often require prolonged ventilatory support due to their critical condition, complex sedation management and multiple operating room visits. It is still unclear the optimal timing for tracheostomy in this population.

METHODS

We conducted a service evaluation where we compared Early Tracheostomy (≤10 days) with Late Tracheostomy (>10 days) in 41 severely burned patients that required prolonged respiratory support.

RESULTS

Early Tracheostomy cohort was associated with fewer days of mechanical ventilation (16 vs 33, p = 0.001), shorter hospital length of stay (65 vs 88 days, p = 0.018), earlier first day of active exercise (day 8 vs day 25, p < 0.0001) and higher Functional Assessment for Burns scores upon discharge (32 vs 28, p = 0.016).

CONCLUSION

Early tracheostomy in patients with severe burns is associated with earlier active exercise, fewer days of ventilation, shorter length of hospital stay and better physical functional independence upon discharge from hospital.

Dexmedetomidine use and mortality in mechanically ventilated patients with severe burns: A cohort study using a national inpatient database in Japan

BACKGROUND

Dexmedetomidine is an alpha 2-adrenergic receptor agonist. Apart from its sedative effects, dexmedetomidine can potentially reduce mortality through its anti-inflammatory effect. However, the impact of dexmedetomidine on in-hospital outcomes of patients with severe burns remains unclear. Therefore, we aimed to elucidate the association between dexmedetomidine use and mortality in mechanically ventilated patients with severe burns, using a Japanese nationwide database of in-hospital patients.

METHODS

We included adults with severe burns (burn index ≥ 10) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2018, started mechanical ventilation within 3 days of admission, and received any sedative drug (dexmedetomidine, midazolam, or propofol). One-to-one propensity score matching was performed between patients who received dexmedetomidine on the day of mechanical ventilation initiation (dexmedetomidine group) and those who did not receive dexmedetomidine (control group). The primary outcome was all-cause 30-day in-hospital mortality. Secondary outcomes were length of hospital stay and duration of mechanical ventilation in patients and survivors.

RESULTS

Eligible patients (n = 1888) were classified into the dexmedetomidine group (n = 371) or the control group (n = 1517). After one-to-one propensity score matching, we compared 329 patients from both groups. No significant difference was observed in the 30-day mortality between patients in the dexmedetomidine and control groups (22.8% vs. 22.5%, respectively; odds ratio, 1.02; 95% confidence interval, 0.71-1.46). Moreover, there were no significant differences between patients in the dexmedetomidine and control groups in terms of the length of hospital stay or the duration of mechanical ventilation.

CONCLUSIONS

We found no significant association between dexmedetomidine use and in-hospital outcomes (mortality, length of hospital stay, and length of mechanical ventilation) in mechanically ventilated patients with severe burns. Dexmedetomidine use may not improve the aforementioned outcomes; therefore, its selection should be based on the patient's general condition and the target level of sedation.

A new nomogram to predict the need for tracheostomy in burned patients

Purpose

To evaluate the impact of tracheostomy on complications, dysphagia and outcome in second and third degree burned patients.

Methods

Inpatient mortality, dysphagia, severity of burn injury (ABSI, TBSA) and complications in tracheotomized burn patients were compared to (I) non-tracheotomized burn patients and (II) matched tracheotomized non-burn patients.

Results

134 (30.9%) out of 433 patients who underwent tracheostomy, had a significantly higher percentage of inhalation injury (26.1% vs. 7.0%; p < 0.001), higher ABSI (8.9 ± 2.1 vs. 6.0 ± 2.7; p < 0.001) and TBSA score (41.4 ± 19.7% vs. 18.6 ± 18.8%; p < 0.001) compared to 299 non-tracheotomized burn patients. However, complications occurred equally in tracheotomized burn patients and matched controls and tracheostomy was neither linked to dysphagia nor to inpatient mortality at multivariate analysis. In particular, dysphagia occurred in 6.2% of cases and was significantly linked to length of ICU stay (OR 6.2; p = 0.021), preexisting neurocognitive impairments (OR 5.2; p = 0.001) and patients’ age (OR 3.4; p = 0.046). A nomogram was calculated based on age, TBSA and inhalation injury predicting the need for a tracheostomy in severely burned patients.

Conclusion

Using the new nomogram we were able to predict with significantly higher accuracy the need for tracheostomy in severely burned patients. Moreover, tracheostomy is safe and is not associated with higher incidenc of complications, dysphagia or worse outcome.