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Huang C. The Age of Older Patients Requiring Prolonged Mechanical Ventilation Is Not the Sole Determinant of Their Long-Term Survival. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:211. [PMID: 38399499 PMCID: PMC10890100 DOI: 10.3390/medicina60020211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/06/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: There are few data on the effects of prolonged mechanical ventilation on elderly patients. Our objective is to investigate the effects of prolonged mechanical ventilation on older patients' successful weaning and long-term survival. Methods: We examined how aging affected the course and results of elderly patients on prolonged mechanical ventilation by contrasting five age groups. Age, sex, cause of acute respiratory failure, comorbidities, discharge status, weaning status, and long-term survival outcomes were among the information we gathered. Results: Patients on prolonged mechanical ventilation who had undergone tracheostomy and had been successfully weaned had a greater one-year survival rate. The 1-year survival rate was poorer for older patients with four or more comorbidities. Regarding the 5-year survival rate, the risk of death was 45% lower in the successfully weaned patients than in the unsuccessfully weaned patients. The risk of death was 46% lower in patients undergoing tracheostomy than in those not undergoing tracheostomy. Older prolonged mechanical ventilation (PMV) patients with four or more comorbidities had an increased risk of death. Conclusions: When it comes to elderly patients on prolonged mechanical ventilation, there are other factors in addition to age that influence long-term survival. Long-term survival is likewise linked to successful weaning and undergoing tracheostomy.
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Affiliation(s)
- Chienhsiu Huang
- Division of Chest Medicine, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Min-Sheng Road, Dalin, Chiayi 62247, Taiwan
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The Survival Outcomes of Patients Requiring Prolonged Mechanical Ventilation. Medicina (B Aires) 2023; 59:medicina59030614. [PMID: 36984615 PMCID: PMC10057588 DOI: 10.3390/medicina59030614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/10/2023] [Accepted: 03/17/2023] [Indexed: 03/22/2023] Open
Abstract
Background and objectives: Patients who require prolonged mechanical ventilation typically experience poor long-term survival outcomes. However, there have been few studies conducted to investigate the five-year survival rate of these patients. This study aims to determine the factors that affect the five-year survival rate of patients who require prolonged mechanical ventilation, with the goal of improving their survival outcomes. Materials and Methods: The current retrospective, single-center study included all patients who required prolonged mechanical ventilation over a period of six years. We collected data on their age, sex, causes of acute respiratory failure leading to prolonged mechanical ventilation, comorbidities, receipt of a tracheostomy or not, weaning status, discharge conditions, and long-term outcomes. Results: The study examined the long-term outcomes of 403 patients who required prolonged mechanical ventilation until December 2018. Of the study population, 157 patients were successfully weaned from prolonged mechanical ventilation and discharged, 186 patients passed away in the hospital, and 60 patients remained ventilator-dependent. For all 403 patients receiving prolonged mechanical ventilation, the one-year and five-year survival rates were 24.3% and 14.6%, respectively. Among the 243 patients who were successfully weaned from prolonged mechanical ventilation, the corresponding rates were 32.6% and 21.0%. For the 157 discharged prolonged mechanical ventilation patients, the one-year and five-year survival rates were 50.3% and 32.6%, respectively. For the 60 ventilator-dependent patients, the one-year and five-year survival rates were 31.7% and 13.2%, respectively. The study revealed that successfully weaned from invasive mechanical ventilation and the receipt of a tracheostomy were influential factors in the five-year survival rate of patients requiring prolonged mechanical ventilation. Conclusions: Patients requiring prolonged mechanical ventilation may experience poor survival outcomes. Nevertheless, two key factors that can improve their long-term survival are successfully weaned from invasive mechanical ventilation and receipt of a tracheostomy.
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Huang C. Five years follow up of patient receiving prolonged mechanical ventilation: Data for a single center in Taiwan. Front Med (Lausanne) 2022; 9:1038915. [DOI: 10.3389/fmed.2022.1038915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/03/2022] [Indexed: 11/20/2022] Open
Abstract
BackgroundThe National Association for Medical Direction of Respiratory Care recommended tracking 1-year survival rates (the most relevant outcome) in patients treated with prolonged mechanical ventilation. However, patients treated with prolonged mechanical ventilation had higher mortality rates within the first 2 years after weaning. More knowledge regarding long-term mortality would help patients, families, and clinicians choose appropriate interventions and make end-of-life decisions. In this investigation, we attempted to determine the rates of long-term mortality for all patients treated with prolonged mechanical ventilation over a period of 10 years.ObjectiveThe purpose of this investigation was to enhance the overall survival outcomes for patients receiving prolonged mechanical ventilation by identifying the factors affecting the 5-year mortality rates for these patients.DesignRetrospective observational study.Materials and methodsIn this retrospective study, we explored the influential factors related to the overall survival outcomes of all patients treated with prolonged mechanical ventilation. We enrolled every individual admitted to the weaning unit between January 1, 2012, and December 31, 2016. The length of survival for each patient was estimated from admission to the weaning unit until death or December 31, 2021, whichever came first. We analyzed the data to investigate the survival time, mortality rates, and survival curves in these patients.ResultsLong-term follow-up information was gathered for 296 patients who received prolonged mechanical ventilation. There was better mean survival times in patients treated with prolonged mechanical ventilation with the following characteristics (in order): no comorbidities, tracheostomies, and intracranial hemorrhage. Successful weaning, receipt of tracheostomy, an age less than 75 years, and no comorbidities were associated with better long-term overall survival outcomes.ConclusionProlonged mechanical ventilation patients had abysmal overall survival outcomes. Even though prolonged mechanical ventilation patients’ long-term survival outcomes are tragic, medical professionals should never give up on the dream of enhancing long-term outcomes.
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Huang C, Wu TH, Chen JC. End-of-Life Decisions of Intracranial Hemorrhage Patients Successfully Weaned From Prolonged Mechanical Ventilation. Am J Hosp Palliat Care 2022; 39:1342-1349. [PMID: 35333660 PMCID: PMC9527450 DOI: 10.1177/10499091221074636] [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] [Indexed: 12/03/2022] Open
Abstract
Factors related to the end-of-life decisions of patients with intracranial hemorrhage who were successfully weaned from prolonged mechanical ventilation remain unclear. This study aimed to evaluate factors that influence the end-of-life decisions of these patients. Methods: This retrospective study examined patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation between January 2012 and December 2017. The following data was collected and analyzed: age, gender, comorbidities, Glasgow Coma Scale scores, receipt or non-receipt of intracranial hemorrhage surgery, discharge status, and end-of-life decisions.Results: In total, 91 patients with intracranial hemorrhage were successfully weaned from prolonged mechanical ventilation. The families of 62 (68.1%) patients signed the do-not-resuscitate order. A Glasgow Coma Scale score of ≥10 at discharge from the respiratory care center and zero comorbidities were the influencing factors between patients whose do-not-resuscitate orders were signed and those whose orders were not signed. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation had chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center with a general ward mortality rate of 83.3%.Conclusions: The families of intracranial hemorrhage patients with multiple comorbidities and higher neurologic impairment after successful weaning from the ventilator believed that palliative therapy would provide a greater benefit. Patients with intracranial hemorrhage successfully weaned from prolonged mechanical ventilation with chronic kidney disease comorbidity and Glasgow Coma Scale score of <7 on admission to respiratory care center are candidates for the consideration of hospice care with ventilator withdrawal.
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Affiliation(s)
- Chienhsiu Huang
- Department of Internal medicine, Division of Chest Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Tsung-Hsien Wu
- Department of Surgery, Division of Neurosurgery, Dalin Tzu Chi Hospital, Chia-Yi, Taiwan and school of medicine, Tzuchi University, Hualien, Taiwan
| | - Jin-Cherng Chen
- Department of Surgery, Division of Neurosurgery, Dalin Tzu Chi Hospital, Chia-Yi, Taiwan and school of medicine, Tzuchi University, Hualien, Taiwan
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Chiang DH, Huang CC, Cheng SC, Cheng JC, Wu CH, Huang SS, Yang YY, Yang LY, Kao SY, Chen CH, Shulruf B, Lee FY. Immersive virtual reality (VR) training increases the self-efficacy of in-hospital healthcare providers and patient families regarding tracheostomy-related knowledge and care skills: A prospective pre-post study. Medicine (Baltimore) 2022; 101:e28570. [PMID: 35029229 PMCID: PMC8757958 DOI: 10.1097/md.0000000000028570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Virtual reality (VR)-based simulation in hospital settings facilitates the acquisition of skills without compromising patient safety. Despite regular text-based training, a baseline survey of randomly selected healthcare providers revealed deficiencies in their knowledge, confidence, comfort, and care skills regarding tracheostomy. This prospective pre-post study compared the effectiveness of regular text- and VR-based intervention modules in training healthcare providers' self-efficacy in tracheostomy care skills. METHODS Between January 2018 and January 2020, 60 healthcare providers, including physicians, nurses, and respiratory therapists, were enrolled. For the intervention, a newly developed head-mounted display (HMD) and web VR materials were implemented in training and clinical services. Subsequently, in-hospital healthcare providers were trained using either text or head-mounted display virtual reality (HMD-VR) materials in the regular and intervention modules, respectively. For tracheostomy care skills, preceptors directly audited the performance of trainees and provided feedback. RESULTS At baseline, the degree of trainees' agreement with the self-efficacy-related statements, including the aspects of familiarity, confidence, and anxiety about tracheostomy-related knowledge and care skills, were not different between the control and intervention groups. At follow-up stage, compared with the regular group, a higher percentage of intervention group' trainees reported that they are "strongly agree" or "somewhat agree" that the HMD-VR simulation increases their self-efficacy, including the aspects of familiarity and confidence, and reduced their anxiety about tracheostomy-related knowledge and care skills. After implementation, a higher degree of trainees' average satisfaction with VR-based training and VR materials was observed in the intervention group than in the regular group. Most reported that VR materials enabled accurate messaging and decreased anxiety. The increasing trend of the average written test and hands-on tracheostomy care skills scores among the intervention group trainees was significant compared to those in the regular group. The benefits of HMD-VR simulations and web-VR material-based clinical services for in-hospital healthcare providers and patient families persisted until 3 to 4 weeks later. CONCLUSION The current study suggests that VR materials significantly enhance trainees' self-efficacy (increased familiarity, increased confidence, and reduced anxiety) and their satisfaction with the training, while motivating them to use acquired knowledge and skills in clinical practice.
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Affiliation(s)
- Dung-Hung Chiang
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Chang Huang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Chuan Cheng
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jui-Chun Cheng
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Respiratory Therapy, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Hsien Wu
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shiau-Shian Huang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Ying Yang
- Faculty of Medicine, Taipei, Taiwan
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
- Medical Innovation Research Office, Clinical Innovation Center, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ling-Yu Yang
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shou-Yen Kao
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Division of Family Dentistry, Department of Stomatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen-Huan Chen
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Fa-Yauh Lee
- National Yang-Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
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Huang C. The Long-Term Survival of Successfully Weaned Prolonged Mechanical Ventilation Patients. Int J Gen Med 2021; 14:3981-3988. [PMID: 34349547 PMCID: PMC8326220 DOI: 10.2147/ijgm.s287529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022] Open
Abstract
Background There are rare articles in the literature that addressed long-term survival in successfully weaned prolonged mechanical ventilation patients. How are the long-term outcomes of these successfully weaned prolonged mechanical ventilation patients? Our objective is to explore this issue in depth in this study and serve as the basis for us to provide suggestions for patients in long-term care of the successfully weaned prolonged mechanical ventilation patients. Methods We investigated the clinical variables, long-term survival, cause of death, receipt or not of tracheostomy and analyzed the factors association with survival in successfully weaned prolonged mechanical ventilation patients. Results We can further gather long-term follow-up data on successfully weaned prolonged mechanical ventilation patients, 243 patients. The 1-, 2-, 3-, 4- and 5-year survival rates of successfully weaned PMV patients were 32.5%, 28.0%, 24.9%, 23.9%, and 21.3%, respectively. The factors between successfully weaned prolonged mechanical ventilation patients who died in the ward and those who were discharged from the hospital revealed the poorer survival of patients who died in the ward was due to a higher percentage of end-stage renal disease comorbidity, a higher percentage of ≥4 comorbidities and a lower percentage of undergoing tracheostomy. The factors between successfully weaned discharged prolonged mechanical ventilation patients who survived <1 year and those who survived ≥1 year revealed the poorer survival of patients who survived <1 year was due to older age, a higher percentage of ≥4 comorbidities, and a lower percentage of undergoing tracheostomy. Conclusion The receipt or not of tracheostomy is the key influential factor of long-term survival of successfully weaned prolonged mechanical ventilation patients. Tracheostomy should be attempted in suitable patients for improving long-term outcomes in successfully weaned prolonged mechanical ventilation patients.
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Affiliation(s)
- Chienhsiu Huang
- Department of Internal Medicine, Division of Chest Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Chiayi County, Taiwan
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Huang CH, Chen IH. The Clinical Application of the Tracheostomy Decision-Making Program in Respiratory Care Center Prolonged Mechanical Ventilation Patients in Taiwan. Int J Gen Med 2020; 13:1487-1494. [PMID: 33328758 PMCID: PMC7735795 DOI: 10.2147/ijgm.s285795] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 11/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background We applied the tracheostomy decision-making program for respiratory care center prolonged mechanical ventilation patients. Our objectives are to correct the misconception of patients about tracheostomy. We expect to understand whether the program is effective in educating patients and whether the patients are satisfied with the results of their decision-making. We compared the prognostic differences between patients receiving tracheostomy and those who continue to have an endotracheal tube, which serves as our basis to provide suggestions for patients in the shared decision-making program. Patients and Methods A retrospective study was conducted in Dalin Tzu Chi Hospital from January 2017 to December 2019. We set up a tracheostomy decision-making program. The medical team identified eligible patients. We tracked the survival of each patient and followed up on each patient to ask whether they thought they had made an optimal decision based on the results of their participation in the tracheostomy decision-making program in January 2020. Data of respiratory care center prolonged mechanical ventilation patients who participated in the tracheostomy decision-making program were collected and analyzed. Results Fifty-seven respiratory care center patients attended the tracheostomy decision-making program. At the end of the study, 37 patients underwent tracheostomy (64.9%), and 20 patients maintained endotracheal tube intubation (35.1%). The survival rate of patients undergoing tracheostomy was 86.5% and 32 participants (86.5%) believed that they made an optimal decision after participating in the tracheostomy decision-making program. The survival rate of patients who maintained endotracheal tube intubation was 40%, and twenty (100%) participants believed that they made an optimal decision after participating in the tracheostomy decision-making program. Conclusion The clinical application of the tracheostomy decision-making program ensures that patients have a clearer understanding of the methods of tracheostomy and endotracheal tube intubation. Overall, 91.2% of the participants believed that they made an optimal decision despite the end result.
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Affiliation(s)
- Chien Hsiu Huang
- Department of Internal Medicine, Division of Chest Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - I-Hung Chen
- Department of Internal Medicine, Division of Chest Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
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Mota JDH, Rodrigues YDS, Souza FDSLD. Análise do tempo de retirada do respirador artificial no paciente submetido a traqueostomia precoce e após sete dias de ventilação mecânica invasiva. FISIOTERAPIA E PESQUISA 2020. [DOI: 10.1590/1809-2950/19035927032020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
RESUMO A realização da traqueostomia precoce pode reduzir o tempo de ventilação do paciente, facilitando o desmame da prótese ventilatória. Além disso, reduz os custos de internação. Este estudo tem como objetivo analisar o tempo de retirada do respirador no paciente traquestomizado precocemente após sete dias de ventilação. Trata-se de pesquisa documental, retrospectiva, de carácter descritivo, sendo a coleta de dados realizada nos documentos de indicadores hospitalares de unidade de terapia intensiva de um hospital da Zona da Mata mineira. Foram coletados dados de 50 pacientes que obtiveram sucesso e preencheram os critérios de desmame da ventilação mecânica, entre homens e mulheres, com média de idade de 56,6 anos. Para análise estatística, os pacientes foram divididos em dois grupos: grupo precoce, de pacientes que realizaram traqueostomia com menos de sete dias de intubação orotraqueal; e grupo tardio, de pacientes que permaneceram por mais de sete dias com tubo orotraqueal até a realização da traqueostomia. Obtivemos um resultado significativo (p=0,04) quanto aos dias em ventilação mecânica após a realização de traqueostomia, demonstrando que nos pacientes com traqueostomia precoce houve menos dias em ventilação mecânica invasiva do que nos pacientes com traqueostomia tardia. Foi constatado um resultado significativamente menor do tempo de ventilação dos pacientes traquestomizados precocemente quando comparados com a traqueostomia tardia. Ensaios clínicos randomizados de alta qualidade são necessários para avaliar melhor as possíveis diferenças da retirada da ventilação mecânica entre pacientes traqueostomizados.
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Tai HP, Lee DL, Chen CF, Huang YCT. The effect of tracheostomy delay time on outcome of patients with prolonged mechanical ventilation: A STROBE-compliant retrospective cohort study. Medicine (Baltimore) 2019; 98:e16939. [PMID: 31464931 PMCID: PMC6736483 DOI: 10.1097/md.0000000000016939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The tracheostomy timing for patients with prolonged mechanical ventilation (PMV) was usually delayed in our country. Both physician decision time and tracheostomy delay time (time from physician's suggestion of tracheostomy to procedure day) affect tracheostomy timing. The effect of tracheostomy delay time on outcome has not yet been evaluated before.Patients older than 18 years who underwent tracheostomy for PMV were retrospectively collected. The outcomes between different timing of tracheostomy (early: ≤14 days; late: >14 days of intubation) were compared. We also analyzed the effect of physician decision time, tracheostomy delay time, and procedure type on clinical outcomes.A total of 134 patients were included. There were 57 subjects in the early tracheostomy group and 77 in the late group. The early group had significantly shorter mechanical ventilation duration, shorter intensive care unit stays, and shorter hospital stays than late group. There was no difference in weaning rate, ventilator-associated pneumonia, and in-hospital mortality. The physician decision time (8.1 ± 3.4 vs 18.2 ± 8.1 days, P < .001) and tracheostomy delay time (2.1 ± 1.9 vs 6.1 ± 6.8 days, P < .001) were shorter in the early group than in the late group. The tracheostomy delay time [odds ratio (OR) = 0.908, 95% confidence interval (CI) = 0.832-0.991, P = .031) and procedure type (percutaneous dilatation, OR = 2.489, 95% CI = 1.057-5.864, P = .037) affected successful weaning. Platelet count of >150 × 10/μL (OR = 0.217, 95% CI = 0.051-0.933, P = .043) and procedure type (percutaneous dilatation, OR = 0.252, 95% CI = 0.069-0.912, P = .036) were associated with in-hospital mortality.Shorter tracheostomy delay time is associated with higher weaning success. Percutaneous dilatation tracheostomy is associated with both higher weaning success and lower in-hospital mortality.
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Affiliation(s)
- Hsueh-Ping Tai
- Department of Nursing, Kaohsiung Veterans General Hospital
- Institute of Health Care Management, I-Shou University
| | - David Lin Lee
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Department of Medicine, National Yang-Ming University, Taipei
| | - Chiu-Fan Chen
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Department of Internal Medicine, Taipei Veterans General Hospital, Taitung Branch, Taitung, Taiwan
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