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Lui HCH, He Z, Zhuang TF, Ng CF, Wong GKC. Tracheostomy decannulation outcomes in 131 consecutive neurosurgical patients. Br J Neurosurg 2024; 38:884-888. [PMID: 34730454 DOI: 10.1080/02688697.2021.1995591] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/02/2021] [Accepted: 10/14/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study was a retrospective study to investigate factors related to difficult tracheostomy decannulation, and to evaluate outcomes of tracheostomized neurosurgical patients. METHODS All consecutive tracheostomized neurosurgical patients in the Prince of Wales Hospital between 1st September 2016 and 31st August 2019 were reviewed retrospectively. Patients were grouped into easy decannulation and difficult decannulation groups using 3 months as cut-off time. Risk factors were analysed and outcomes were compared. RESULTS One hundred thirty-one patients were included. In univariate analyses, male gender, GCS less than or equal to 8 on admission, the presence of vocal cord palsy at 3 months, and pneumonia within 1-month post-tracheostomy were associated with difficult decannulation. In multivariable logistic regression for difficult decannulation, GCS on admission, the presence of vocal cord palsy at 3 months, and the presence of pneumonia within 1-month post-tracheostomy remained statistically significant. The easy decannulation group had a shorter length of in-patient stay, higher survival rate, and more favourable neurological outcome (GOS 4-5) than the difficult decannulation group at both 6 months and 1 year. The majority of easy decannulation group patients (54%) were discharged to home, while the majority of the difficult decannulation group (42%) of patients were discharged to the infirmary. CONCLUSION GCS less than or equal to 8 on admission, the presence of vocal cord palsy, and the presence of pneumonia were associated with difficult tracheostomy decannulation in neurosurgical patients. Difficult decannulation is associated with a longer length of in-patient stay and poor neurological outcomes.
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Affiliation(s)
- Hannaly Cheuk-Hang Lui
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zhexi He
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Neurosurgery, Tuen Mun Hospital, Hong Kong SAR, China
| | - Tin Fong Zhuang
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Neurosurgery, Queen Mary Hospital, Hong Kong SAR, China
| | - Chat Fong Ng
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - George Kwok-Chu Wong
- Division of Neurosurgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong SAR, China
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Han R, Gao X, Gao Y, Zhang J, Ma X, Wang H, Ji Z. Effect of tracheotomy timing on patients receiving mechanical ventilation: A meta-analysis of randomized controlled trials. PLoS One 2024; 19:e0307267. [PMID: 39042629 PMCID: PMC11265711 DOI: 10.1371/journal.pone.0307267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 07/01/2024] [Indexed: 07/25/2024] Open
Abstract
PURPOSE We assessed the effects of tracheostomy timing (early vs. late) on outcomes among adult patients receiving mechanical ventilation. METHODS PubMed, Embase, Web of Science and Cochrane Library were searched to identify relevant RCTs of tracheotomy timing on patients receiving mechanical ventilation. Two reviewers independently screened the literature, extracted data. Outcomes in patients with early tracheostomy and late tracheostomy groups were compared and analyzed. Meta-analysis was performed using Stata14.0 and RevMan 5.4 software. This study is registered with PROSPERO (CRD42022360319). RESULTS Twenty-one RCTs were included in this Meta-analysis. The Meta-analysis indicated that early tracheotomy could significantly shorten the duration of mechanical ventilation (MD: -2.77; 95% CI -5.10~ -0.44; P = 0.02) and the length of ICU stay (MD: -6.36; 95% CI -9.84~ -2.88; P = 0.0003), but it did not significantly alter the all-cause mortality (RR 0.86; 95% CI 0.73~1.00; P = 0.06), the incidence of pneumonia (RR 0.86; 95% CI 0.74~1.01; P = 0.06), and length of hospital stay (MD: -3.24; 95% CI -7.99~ 1.52; P = 0.18). CONCLUSION In patients requiring mechanical ventilation, the tracheostomy performed at an earlier stage may shorten the duration of mechanical ventilation and the length of ICU stay but cannot significantly decrease the all-cause mortality and incidence of pneumonia.
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Affiliation(s)
- Rongrong Han
- Department of Otolaryngology, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Xiang Gao
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Yongtao Gao
- Urology Department I, Weifang Hospital of traditional Chinese Medicine, Weifang, Shan dong Province, China
| | - Jihong Zhang
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Xiaoyan Ma
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Haibo Wang
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Zhixin Ji
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
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Shah S, Spirollari E, Ng C, Cordeiro K, Clare K, Nolan B, Naftchi AF, Carpenter AB, Dominguez JF, Kaplan I, Bass B, Harper E, Rosenberg J, Chandy D, Mayer SA, Prabhakaran K, Wang A, Gandhi CD, Al-Mufti F. Early tracheostomy in patients undergoing mechanical thrombectomy for acute ischemic stroke. J Crit Care 2023; 78:154357. [PMID: 37336143 DOI: 10.1016/j.jcrc.2023.154357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/21/2023] [Accepted: 06/05/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Respiratory failure following mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is a known complication, and requirement of tracheostomy is associated with worse outcomes. Our objective is to evaluate characteristics associated with tracheostomy timing in AIS patients treated with MT. METHODS The National Inpatient Sample was queried for adult patients treated with MT for AIS from 2016 to 2019. Baseline demographic characteristics, comorbidities, and inpatient outcomes were analyzed for associations in patients who received tracheostomy. Timing of early tracheostomy (ETR) was defined as placement before day 8 of hospital stay. RESULTS Of 3505 AIS-MT patients who received tracheostomy, 915 (26.1%) underwent ETR. Patients who underwent ETR had shorter length of stay (LOS) (25.39 days vs 32.43 days, p < 0.001) and lower total hospital charges ($483,472.07 vs $612,362.86, p < 0.001). ETR did not confer a mortality benefit but was associated with less acute kidney injury (OR, 0.697; p = 0.013), pneumonia (OR, 0.449; p < 0.001), and sepsis (OR, 0.536; p = 0.002). CONCLUSION An expected increase in complications and healthcare resource utilization is seen in AIS-MT patients receiving tracheostomy, likely reflecting the severity of patients' post-stroke neurologic injury. Among these high-risk patients, ETR was predictive of shorter LOS and fewer complications.
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Affiliation(s)
- Smit Shah
- Department of Neurology, University of South Carolina/PRISMA Health Richland, Columbia, SC, United States of America
| | - Eris Spirollari
- School of Medicine, New York Medical College, Valhalla, NY, United States of America
| | - Christina Ng
- School of Medicine, New York Medical College, Valhalla, NY, United States of America
| | - Kevin Cordeiro
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Kevin Clare
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Alexandria F Naftchi
- School of Medicine, New York Medical College, Valhalla, NY, United States of America
| | - Austin B Carpenter
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America.
| | - Ian Kaplan
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Brittany Bass
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Emily Harper
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Jon Rosenberg
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Dipak Chandy
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Kartik Prabhakaran
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Arthur Wang
- Department of Neurosurgery, Tulane University Medical Center, New Orleans, LA, United States of America
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, United States of America.
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Qiu Y, Yin Z, Wang Z, Xie M, Chen Z, Wu J, Wang Z. Early versus late tracheostomy in stroke-related patients: A systematic review and meta-analysis. J Clin Neurosci 2023; 114:48-54. [PMID: 37302372 DOI: 10.1016/j.jocn.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Tracheostomy is an operative intervention for patients who require ventilator assistance while in the intensive care unit (ICU). This study aimed to compare efficacy and safety between early tracheostomy (ET) and late tracheostomy (LT) in stroke patients. METHODS Embase, PubMed, and the Cochrane Library were searched for available studies. Stroke-related patients were categorized into ET and LT groups using seven days as the cutoff timepoint. The primary efficacy outcome was mortality; secondary efficacy outcomes were modified Rankin Scores (mRS) obtained at follow up, as well as durations of hospital stay, ICU stay, and ventilator use. Safety outcomes were total complication and ventilator associated pneumonia (VAP) incidence. RESULTS Nine studies with 3,789 patients were included in the current analysis. No statistical difference in mortality was observed. ET was associated with shorter hospital stay (MD -5.72, 95% CI -9.76 to -1.67), shorter ICU stay (MD -4.77, 95% CI -6.82 to -2.72), and shorter ventilator duration (MD -4.65, 95% CI -8.39 to -0.90); however, no statistically significant difference was found in follow-up mRS scores. Examination of safety measures found the ET group exhibited a lower rate of VAP compared with LT (OR 0.80, 95 % CI 0.68 to 0.93), while no statistical difference was found in total complications. CONCLUSION Our meta-analysis concluded that ET was associated with shorter hospital stay, less time on a ventilator, and lower incidence of VAP. Future studies are warranted to investigate the functional outcomes and the occurrence of complications of ET in stroke patients.
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Affiliation(s)
- Youjia Qiu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Ziqian Yin
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu Province 215002, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China.
| | - Minjia Xie
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Jiang Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China.
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Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study. Brain Sci 2022; 12:brainsci12121664. [PMID: 36552123 PMCID: PMC9775301 DOI: 10.3390/brainsci12121664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Methods: Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. Results: There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966−12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084−0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087−8.148, p = 0.034) were risk factors for pneumonia. Spearman’s correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Conclusions: Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.
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Early prediction of hospital outcomes in patients tracheostomized for complex mechanical ventilation weaning. Ann Intensive Care 2022; 12:73. [PMID: 35934745 PMCID: PMC9357593 DOI: 10.1186/s13613-022-01047-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Tracheostomy is often performed in the intensive care unit (ICU) when mechanical ventilation (MV) weaning is prolonged to facilitate daily care. Tracheostomized patients require important healthcare resources and have poor long-term prognosis after the ICU. However, data lacks regarding prediction of outcomes at hospital discharge. We looked for patients’ characteristics, ventilation parameters, sedation and analgesia use (pre-tracheostomy) that are associated with favorable and poor outcomes (post-tracheostomy) using univariate and multivariate logistic regressions. Results Eighty tracheostomized patients were included (28.8% women, 60 [52–71] years). Twenty-three (28.8%) patients were intubated for neurological reasons. Time from intubation to tracheostomy was 14.7 [10–20] days. Thirty patients (37.5%) had poor outcome (19 patients deceased and 11 still tracheostomized at hospital discharge). All patients discharged with tracheostomy (n = 11) were initially intubated for a neurological reason. In univariate logistic regressions, older age and higher body-mass index (BMI) were associated with poor outcome (OR 1.18 [1.07–1.32] and 1.04 [1.01–1.08], p < 0.001 and p = 0.025). No MV parameters were associated with poor outcome. In the multiple logistic regression model higher BMI and older age were also associated with poor outcome (OR 1.21 [1.09–1.36] and 1.04 [1.00–1.09], p < 0.001 and p = 0.046). Conclusions Hospital mortality of patients tracheostomized because of complex MV weaning was high. Patients intubated for neurological reasons were frequently discharged from the acute care hospital with tracheostomy in place. Both in univariate and multivariate logistic regressions, only BMI and older age were associated with poor outcome after tracheostomy for patients undergoing prolonged MV weaning. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01047-z.
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Bösel J, Niesen WD, Salih F, Morris NA, Ragland JT, Gough B, Schneider H, Neumann JO, Hwang DY, Kantamneni P, James ML, Freeman WD, Rajajee V, Rao CV, Nair D, Benner L, Meis J, Klose C, Kieser M, Suarez JI, Schönenberger S, Seder DB. Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA 2022; 327:1899-1909. [PMID: 35506515 PMCID: PMC9069344 DOI: 10.1001/jama.2022.4798] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Many patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation. OBJECTIVE To test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020. INTERVENTIONS Patients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194). MAIN OUTCOMES AND MEASURES The primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death). RESULTS Among 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, -3.6% [95% CI, -14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy. CONCLUSIONS AND RELEVANCE Among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02377167.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, Freiburg University Hospital, Freiburg im Breisgau, Germany
| | - Farid Salih
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Jeremy T. Ragland
- Department of Neurosurgery, University of Texas Health Science Center, Houston
| | - Bryan Gough
- Department of Neurology, Ohio State University, Wexner Medical Center, Columbus
| | - Hauke Schneider
- Department of Neurology, Dresden University Hospital, Dresden, Germany
- Now with the Department of Neurology, Augsburg University Hospital Augsburg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Phani Kantamneni
- Department of Medicine, Kadlec Regional Medical Center, Richland, Washington
| | - Michael L. James
- Departments of Anesthesiology and Neurology, Duke University Hospital, Durham, North Carolina
| | - William D. Freeman
- Departments of Neurology, Neurologic Surgery, and Critical Care, Mayo Clinic, Jacksonville, Florida
| | | | - Chethan Venkatasubba Rao
- Department of Neurology, Neurosurgery and Center for Space Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Laura Benner
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - José I. Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David B. Seder
- Department of Critical Care Services, Maine Medical Center, Portland, Maine
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Craven J, Slaughter A, Potter KF. Early tracheostomy: on the cutting edge, some benefit more than others. Curr Opin Anaesthesiol 2022; 35:236-241. [PMID: 35131970 DOI: 10.1097/aco.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The decision to undergo early tracheostomy in critically ill patients has been the subject of multiple studies in recent years, including several meta-analyses and a large-scale examination of the National in-patient Sampling (NIS) database. The research has focused on different patient populations, and identified common outcomes measures related to ventilation. At the crux of the new research is the decision to undergo an additional invasive procedure, mainly tracheostomy, rather than attempt endotracheal tube ventilation with or without early extubation. Notably, recent research indicates that neurological and SARS-CoV-2 (COVID-19) patients seem to have an exaggerated benefit from early tracheostomy. RECENT FINDINGS Recent studies of patients undergoing early tracheostomy have shown decreases in ventilator associated pneumonia, ventilator duration and duration of ICU stay. However, these studies have shown mixed data with respect to mortality and length of hospitalization. Such advantages only become apparent with large-scale examination. Confounding the overall discussion is that the research has focused on heterogeneous groups, including neurosurgical ICU patients, general ICU patients, and most recently, intubated COVID-19 patients. SUMMARY Specific populations such as neurosurgical and COVID-19 patients have clearly defined benefits following early tracheostomy. Although the benefit is less pronounced, there does seem to be an advantage in general ICU patients with regards to ventilator-free days and lower incidence of ventilator-associated pneumonia. In these patients, large-scale examination points to a clear mortality benefit.
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Affiliation(s)
- Jack Craven
- Virginia Commonwealth University Health System, Department of Anesthesiology
| | - Ashley Slaughter
- Virginia Commonwealth University Health System, Department of Surgery, Richmond, Virginia, USA
| | - Kenneth F Potter
- Virginia Commonwealth University Health System, Department of Anesthesiology - Division of Critical Care Medicine
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Goo ZQ, Muthusamy KA. Early versus standard tracheostomy in ventilated patients in neurosurgical intensive care unit: A randomized controlled trial. J Clin Neurosci 2022; 98:162-167. [PMID: 35182846 DOI: 10.1016/j.jocn.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Tracheostomy is performed in patients with prolonged mechanical ventilation, who suffered catastrophic neurologic insult or upper airway obstruction. Thus far, there is no consensus on the optimal timing in performing a tracheostomy. This study aims to test whether early tracheostomy in mechanically ventilated patients in a neurosurgical setting would be associated with a shorter time of mechanical ventilation as compared to standard tracheostomy. METHODS This single-center prospective randomized controlled trial was conducted at University Malaya Medical Centre from July 2019 to July 2021. The likelihood of prolonged ventilation was determined objectively using the TRACH score and the patient's clinical presentation. The outcomes measured were days of mechanical ventilation post-tracheostomy, days of neuro-intensive care unit stay, and days of hospital stay. Tracheostomy-related complications were collected. The data collected were analyzed using Statistical Package for the Social Sciences version 25 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS In all, 39 patients were randomly assigned. Of these, 20 were allocated to the early tracheostomy group (ET) and 19 were allocated to the standard tracheostomy group (ST). The demographic characteristics were similar between the groups. The primary outcome, mean (SD) days of mechanical ventilation post-tracheostomy, was statistically different in the 2 groups- early 11.9 (9.3) days, standard 18.9 (32.5) days; p = 0.014. There were comparable tracheostomy-related complications in both groups. CONCLUSION Early tracheostomy is associated with a shorter duration of mechanical ventilation in a neurosurgical intensive care unit setting.
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Affiliation(s)
- Zhen Qiang Goo
- Division of General Surgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Kalai Arasu Muthusamy
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Shen Y, Cao Q, Zhuo H, Hu M, Chen S. Early Versus Late Tracheostomy in Stroke Patients: A Retrospective Analysis. Neuropsychiatr Dis Treat 2022; 18:2713-2723. [PMID: 36419859 PMCID: PMC9677992 DOI: 10.2147/ndt.s388062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The timing of tracheostomy (TR) in severe stroke patients receiving mechanical ventilation has not been determined. In this study, we compared some prognostic indicators of early tracheostomy (ET) and late tracheostomy (LT). A meta-analysis was performed to obtain a higher level of evidence of the timing of TR in patients with severe stroke receiving mechanical ventilation. METHODS The study was a retrospective single-center study. We divided the severe stroke patients who received TR from June 2020 to June 2022 into the ET group and LT group. The demographic characteristics, clinical characteristics and prognostic indices were compared. For this meta-analysis, we systematically searched PubMed and other databases. The compared prognostic indicators included mechanical ventilation time, ICU length of stay (LOS), total LOS, ventilator-related pneumonia (VAP) incidence, and mortality. RESULTS A total of 61 patients were included in our study, including 32 patients in the ET group and 29 patients in the LT group. Univariate and multivariate analyses showed that the NIHSS score in the ET group was higher than that in the LT group (P < 0.05). In terms of outcome indicators, compared with the LT group, the median mechanical ventilation time in the ET group was shortened by 5.5 days (P = 0.034). The ICU LOS and total LOS in the ET group were significantly lower than those in the LT group (median 14.5 days vs 22 days, P = 0.004; 21 days vs 27 days, P = 0.019). The meta-analysis showed that ET could significantly shorten the ICU LOS (MD -3.89 [95% CI: -6.86, -0.92]) and the total LOS (MD -7.70 [95% CI: -8.57, -6.83]) and significantly reduce the occurrence of VAP (OR 0.75 [95% CI: 0.64, 0.87]). CONCLUSION The results of our retrospective study and meta-analysis support that ET can shorten the ICU LOS and total LOS and reduce the occurrence of VAP. Therefore, it has a positive effect on the prognosis of patients with severe stroke who need mechanical ventilation support.
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Affiliation(s)
- Yu Shen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qian Cao
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Hou Zhuo
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Mengyao Hu
- The Medical Imaging Center, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Shenjian Chen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Neurology Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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