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Peng C, Peng L, Yang F, Yu H, Wang P, Cheng C, Zuo W, Li W, Jin Z. Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis. J Cardiothorac Vasc Anesth 2023; 37:2584-2591. [PMID: 36631378 DOI: 10.1053/j.jvca.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Hang Yu
- Emergency Department, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peng Wang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Chao Cheng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Wei Zuo
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China.
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, Shanghai, China.
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Butler EK, Killien EY, Groner JI, Arbabi S, Vavilala MS, Rivara FP. Optimal Timing of Tracheostomy in Injured Adolescents. Pediatr Crit Care Med 2021; 22:629-641. [PMID: 34192728 PMCID: PMC8259766 DOI: 10.1097/pcc.0000000000002681] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the optimal timing of tracheostomy for injured adolescents. DESIGN Retrospective cohort study. SETTING Trauma facilities in the United States. PATIENTS Adolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point. CONCLUSIONS For injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.
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Affiliation(s)
- Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
- Department of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210 USA
| | - Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research and Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Saman Arbabi
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Anesthesiology & Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of General Pediatrics, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
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Surgical airway procedures in emergency surgical patients: Results of what has become a back-up procedure. World J Surg 2021; 45:2683-2693. [PMID: 34023921 PMCID: PMC8322015 DOI: 10.1007/s00268-021-06110-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/11/2022]
Abstract
Background Cricothyroidotomy and surgical tracheostomy are methods to secure airway patency. In emergency surgery, these methods are nowadays mostly reserved for patients unsuited for percutaneous procedures. Detailed description of complications and functional outcomes following both procedures is underreported in current literature. The aim of this study was to evaluate outcomes following cricothyroidotomy and tracheostomy in this presumed complex population. Methods In this retrospective cohort study, adult emergency surgical patients treated with cricothyroidotomy and/or surgical tracheostomy were included. Postoperative complications and functional outcomes in trauma and non-trauma patients were evaluated. Results Forty-one trauma patients and 11 non-trauma emergency surgical patients (mainly after elective onco-abdominal or vascular surgery) were included. Of 52 patients, seven underwent cricothyroidotomy pre-tracheostomy. Mortality was higher in non-trauma patients (p = 0.04) following both procedures. Over half of patients (56%, n = 29) regained unsupported airway patency with a tendency toward increased tracheostomy removal in trauma patients. Among complications, only pneumonia occurred frequently (60%, n = 31), with no relation to patient type. Other complications included local infection (5.8%, n = 4) and wound dehiscence (1.9%, n = 1). Adverse functional outcomes were frequently observed and were mild and self-limiting. Cervical spinal cord injury reduced overall unsupported airway patency (p = 0.01); with high cervical spinal cord injury related to adverse functional outcomes and increased home ventilation need. Conclusions No major procedure-related complications or functional adverse events were encountered following cricothyroidotomy and surgical tracheostomy, even though only complex patients were included. Only mild, self-limiting functional problems occurred, especially in trauma patients with cervical injury who underwent early tracheostomy by longitudinal incision. This information can aid clinicians in making tailor-made decisions for individual patients.
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Kang BH, Cho J, Lee JCJ, Jung K. Early Versus Late Tracheostomy in Trauma Patients: A Propensity-Matched Cohort Study of 5 Years’ Data at a Single Institution in Korea. World J Surg 2018; 42:1742-1747. [DOI: 10.1007/s00268-018-4474-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Adly A, Youssef TA, El-Begermy MM, Younis HM. Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review. Eur Arch Otorhinolaryngol 2017; 275:679-690. [PMID: 29255970 DOI: 10.1007/s00405-017-4838-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/01/2017] [Indexed: 02/07/2023]
Abstract
The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.
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Affiliation(s)
- Ahmed Adly
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
| | - Tamer Ali Youssef
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt.
| | - Marwa M El-Begermy
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
| | - Hussein M Younis
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
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Cai SQ, Hu JW, Liu D, Bai XJ, Xie J, Chen JJ, Yang F, Liu T. The influence of tracheostomy timing on outcomes in trauma patients: A meta-analysis. Injury 2017; 48:866-873. [PMID: 28284468 DOI: 10.1016/j.injury.2017.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aims to assess the influence of tracheostomy timing on outcomes among trauma patients, including mortality, medical resource utility and incidence of pneumonia. METHOD A systematic review of the literature was conducted by internet search. Data were extracted from selected studies and analyzed using Stata to compare outcomes in trauma patients with early tracheostomy (ET) or late tracheostomy (LT)/prolonged intubation (PI). RESULT 20 studies met our inclusion criteria with 3305 patients in ET group and 4446 patients in LT/PI group. Pooled data revealed that mortality was not lower in trauma patients with ET compared to those with LT/IP. However, ET was found to be associated with a significantly reduced length of ICU and hospital stay, shorter MV duration and lower risk of pneumonia. CONCLUSION Evidence of this meta-analysis supports the dimorphism in some clinical outcomes of trauma patients with different tracheostomy timing. Additional well-designed randomized controlled trials (RCTs) are needed to confirm it in future.
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Affiliation(s)
- Shi-Qi Cai
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jun-Wu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Dong Liu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Xiang-Jun Bai
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jia-Jun Chen
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Fan Yang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Tao Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
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