Tracheotomy application and timing

Tracheostomy: update on why, when and how

PURPOSE OF REVIEW

The aim of this review is to summarize available data, including the most recent ones, to help develop the best possible strategy regarding the use of tracheostomy in ICU patients requiring prolonged mechanical ventilation or who experience loss of airway-protecting mechanisms.

RECENT FINDINGS

Tracheostomy facilitates the weaning process by reducing the patient's work of breathing and increasing comfort. It thus allows for a reduction in sedation levels. It also helps with secretions clearance, facilitates disconnection from the ventilator, and enables earlier phonation, oral intake, and mobilization. Despite these advantages, tracheostomy does not reduce mortality and is associated with both early and late complications, particularly tracheal stenosis. The timing of tracheostomy remains a subject of debate, and only a personalized approach that considers each patient's specific characteristics can help find the best possible compromise between avoiding unnecessary delays and minimizing the risks of performing a needless invasive procedure. In the absence of contraindications, the percutaneous single dilator technique under fibroscopic guidance should be the first choice, but only if the team is properly trained.

SUMMARY

A step-by-step individualized approach based on the available evidence allows identifying the best strategy regarding the use of tracheostomy in ICU patients.

Early tracheostomy after cardiac surgery improves intermediate- and long-term survival

OBJECTIVE

Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study's second aim was to assess the incidence of both superficial and deep sternal wound infections.

DESIGN

Retrospective study of prospectively collected data.

SETTING

Tertiary hospital.

PATIENTS

Patients were divided into 3 groups, according to the timing of tracheostomy; early (4-10 days); intermediate (11-20 days) and late (≥21 days).

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection.

RESULTS

During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014-1.036)] and timing of tracheostomy [0.315 (0.159-0.757)] had significant impacts on mortality.

CONCLUSIONS

This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4-10 days of mechanical ventilation) is associated with better intermediate- and long-term survival.

Multiparametric CT-based assessment of pretracheal anatomical relationships for safe tracheotomy: A long-forgotten issue revisited

OBJECTIVES

To assess the anatomical relationships and variations in the pretracheal space and to guide tracheotomy procedures in a safe manner with image-based evidence.

MATERIALS AND METHODS

A retrospective study was conducted on unirradiated patients requiring elective tracheotomies. Preoperative contrast-enhanced CT (CECT)/CT venography (CTV) was applied for an anatomical evaluation of the pretracheal region. Vascular morphologies were compared for three vessels: the anterior jugular vein (AJV), the innominate artery (IA) and the inferior thyroid vascular plexus (ITVP). The relationships between the thyroid isthmus and the 2nd-4th tracheal rings were also analyzed.

RESULTS

A total of 120 patients were identified, most of whom (n = 110, 91.7%) had head and neck squamous cell carcinomas. Patients with recognizable AJVs (n = 118) were divided into 3 groups: single-branch (n = 11, 9.2%), double-branch (n = 105, 87.5%), and multibranch (n = 2, 1.7%). In addition, IAs were categorized as low-bifurcation (n = 51, 42.5%), high-bifurcation (n = 40, 33.3%), platform (n = 27, 22.5%) and variant types (n = 2, 1.7%). Within the platform types, high-lying IAs (n = 15, 8.3%) might have interfered with the standard tracheal incisions due to possible IA-tracheal overlay. This interference was also related to the height of intraoperative tracheal incisions (r_n = 0.364, P = 0.001). Within ITVPs, independent-trunk types were found in 71 cases (59.2%), while common-trunk types were found in 45 (37.5%). In addition, a low thyroid isthmus (suprasternal-isthmus distance <3 cm) was found in 83 cases (69.2%).

CONCLUSIONS

CT image-based evidence can prepare junior practitioners with important pretracheal anatomical information, thereby facilitating safer tracheotomy procedures. Our results shed light on vascular relationships for emergent tracheotomy.

Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis

BACKGROUND

Patients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes.

METHODS

Six databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale.

RESULTS

Seventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale.

CONCLUSION

Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes.

LEVEL OF EVIDENCE

Systematic Review, level III.

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.

The Lost Airway

Management of the unanticipated difficult airway is one of the most relevant and challenging crisis management scenarios encountered in clinical anesthesia practice. Several guidelines and approaches have been developed to assist clinicians in navigating this high-acuity scenario. In the most serious cases, the clinician may encounter a failed airway that results from failure to ventilate an anesthetized patient via facemask or supraglottic airway or intubate the patient with an endotracheal tube. This dreaded cannot intubate, cannot oxygenate situation necessitates emergency invasive access. This article reviews the incidence, management, and complications of the failed airway and training issues related to its management.

Is Timing of Tracheotomy a Factor Influencing the Clinical Course in COVID-19 Patients?

The timing of tracheotomy is a complex decision that requires understanding of the relative risks and benefits as compared with prolonging intubation. The role of tracheotomy during the COVID-19 pandemic remains to be determined. There is no evidence that early tracheostomy improves patient's clinical course and it is not impact on the natural history of these patients. In our opinion, the tracheotomy should be proposed in stable COVID-19 patients after 18th days after orotracheal intubation when the viral load is finished. Only in the case of patients with difficult of intubation do we perform earlier tracheotomies.

Early tracheostomy in acute heart failure exacerbation

BACKGROUND

The optimal timing for tracheostomy among patients with acute heart failure (AHF) exacerbation has been controversial, despite multiple studies assessing the utility of early tracheostomy. Our objective was to assess the trend of utilization and outcomes of early tracheostomy among patients with AHF exacerbation in the United States.

METHODS AND RESULTS

A retrospective cohort study using the National Inpatient Sample from 2005 to 2014 was conducted. Among those who were admitted with AHF exacerbation (n = 1,390,356), 0.26% of patients underwent tracheostomy (n = 2,571), and among them, 19.4% received early tracheostomy (n = 496). There was no significant shift in the percentage of early tracheostomy from 2008 to 2014. We used propensity score matching to compare the clinical and economic outcomes between the early tracheostomy group and late tracheostomy group. In-hospital mortality did not show any difference between the two groups (13.97% in early group vs. 18.04% in late group; p =0.163). The median total hospital cost ($53,466), total hospital length of stay (19 days), and length of stay after intubation (16 days) in the early tracheostomy group were significantly lower than in the late tracheostomy group ($73,680; 26 days; 23 days, respectively).

CONCLUSION

Early tracheostomy showed economic benefit with lower hospital costs and shorter length of stay, without a difference in in-hospital mortality compared to late tracheostomy.

Best practices for emergency surgical airway: A systematic review

Objective

In the case of an emergency surgical airway, current guidelines state that surgical cricothyrotomy is preferable to tracheotomy. However, complications associated with emergency cricothyrotomy may be more frequent and severe. We systematically reviewed the English literature on emergency surgical airway to elicit best practices.

Methods

PubMed, Embase, MEDLINE, and the Cochrane Library were searched from inception to January 2019 for studies reporting emergency cricothyrotomy and tracheotomy outcomes. All English-language retrospective analyses, systematic reviews, and meta-analyses were included. Case reports were excluded, as well as studies with pediatric, nonhuman, or nonliving subjects.

Results

We identified 783 articles, and 20 met inclusion criteria. Thirteen evaluated emergency cricothyrotomy and included 1,219 patients (mean age = 39.8 years); 4 evaluated emergency tracheotomy and included 342 patients (mean age = 46.0 years); 2 evaluated both procedures. The rate of complications with both cricothyrotomy and tracheotomy was comparable. The most frequent early complications were failure to obtain an airway (1.6%) and hemorrhage (5.6%) for cricothyrotomy and tracheotomy, respectively. Airway stenosis was the most common long-term complication, occurring at low rates in both procedures (0.22-7.0%).

Conclusions

Complications associated with emergency cricothyrotomy may not occur as frequently as presumed. Tracheotomy is an effective means of securing the airway in an emergent setting, with similar risk for intraoperative and postoperative complications compared to cricothyrotomy. Ultimately, management should depend on clinician experience and patient characteristics.

Level of Evidence

IV.

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

BACKGROUND

Tracheostomy is often performed in patients with severe burns who are undergoing prolonged mechanical ventilation. However, the appropriate timing of tracheostomy and its effect on mortality remain unknown. The aim of this study was to determine whether tracheostomy can reduce mortality in patients with severe burns.

METHODS

Using the Japanese Diagnosis Procedure Combination database from April 2010 to March 2014, we extracted data on adult patients with severe burns (burn index score of ≥15) who started mechanical ventilation within 3days of admission. We estimated the hazard ratio for 28-day in-hospital mortality associated with tracheotomy performed from day 5 to 28. We adjusted for baseline and time-dependent confounders using inverse probability of treatment weighting methods and fitted a marginal structural Cox proportional hazard model.

RESULTS

We identified 680 eligible patients (94 in the tracheostomy group, 2289 person-days; 586 in the non-tracheostomy group, 11,197 person-days). Patients who underwent a tracheostomy had worse prognostic factors for mortality. After adjustment for these factors, the hazard ratio for 28-day mortality associated with tracheostomy compared with non-tracheostomy was 0.73 (95% confidence interval, 0.39-1.34).

CONCLUSIONS

There was no significant association between 28-day in-hospital mortality and early tracheostomy in adult patients with severe burns.

Early versus late tracheostomy for critically ill patients

BACKGROUND

Long-term mechanical ventilation is the most common situation for which tracheostomy is indicated for patients in intensive care units (ICUs). 'Early' and 'late' tracheostomies are two categories of the timing of tracheostomy. Evidence on the advantages attributed to early versus late tracheostomy is somewhat conflicting but includes shorter hospital stays and lower mortality rates.

OBJECTIVES

To evaluate the effectiveness and safety of early (≤ 10 days after tracheal intubation) versus late tracheostomy (> 10 days after tracheal intubation) in critically ill adults predicted to be on prolonged mechanical ventilation with different clinical conditions.

SEARCH METHODS

This is an update of a review last published in 2012 (Issue 3, The Cochrane Library) with previous searches run in December 2010. In this version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); MEDLINE (via PubMed) (1966 to August 2013); EMBASE (via Ovid) (1974 to August 2013); LILACS (1986 to August 2013); PEDro (Physiotherapy Evidence Database) at www.pedro.fhs.usyd.edu.au (1999 to August 2013) and CINAHL (1982 to August 2013). We reran the search in October 2014 and will deal with any studies of interest when we update the review.

SELECTION CRITERIA

We included all randomized and quasi-randomized controlled trials (RCTs or QRCTs) comparing early tracheostomy (two to 10 days after intubation) against late tracheostomy (> 10 days after intubation) for critically ill adult patients expected to be on prolonged mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and conducted a quality assessment. Meta-analyses with random-effects models were conducted for mortality, time spent on mechanical ventilation and time spent in the ICU.

MAIN RESULTS

We included eight RCTs (N = 1977 participants). At the longest follow-up time available in these studies, evidence of moderate quality from seven RCTs (n = 1903) showed lower mortality rates in the early as compared with the late tracheostomy group (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70 to 0.98; P value 0.03; number needed to treat for an additional beneficial outcome (NNTB) ≅ 11). Divergent results were reported on the time spent on mechanical ventilation and no differences were noted for pneumonia, but the probability of discharge from the ICU was higher at day 28 in the early tracheostomy group (RR 1.29, 95% CI 1.08 to 1.55; P value 0.006; NNTB ≅ 8).

AUTHORS' CONCLUSIONS

The whole findings of this systematic review are no more than suggestive of the superiority of early over late tracheostomy because no information of high quality is available for specific subgroups with particular characteristics.

A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score

Background

Tracheostomy is one of the most common surgical procedures performed in critical care patient management; more specifically, ventilation through tracheal cannula allows removal of the endotracheal tube (ETT). Available literature about tracheostomy care and decannulation is mainly represented by expert opinions and no certain knowledge arises from it.

Methods

In lack of statistical requirements, a systematic and critical review of literature regarding tracheostomy tube removal was performed in order to assess predictor factors of successful decannulation and to propose a predictive score. We combined 3 terms and a literature search has been performed using the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE via Ovid SP; EMBASE via Ovid SP; EBSCO. Abstracts were independently reviewed: for those studies fitting the inclusion criteria on the basis of the title and abstract, full-text was achieved. We included studies published from January 1, 1995 until March 31, 2014; any sort of review and expert opinion has been excluded by our survey. English language restriction was applied. Ten studies have been considered eligible for inclusion in the review and were analysed further.

Results

Cough effectiveness and ability to tolerate tracheostomy tube capping are the most considered parameters in clinical practice; other parameters are taken into different consideration by many authors in order to proceed to decannulation. Among them, we distinguished between objective quantitative parameters and semi-quantitative parameters more dependent from clinician’s opinion. We then built a score (the Quantitative semi Quantitative score: QsQ score) based on selected parameters coming from literature.

Conclusions

On our knowledge, this review provides the first proposal of decannulation score system based on current literature that is hypothetical and requires to be validated in daily practice. The key point of our proposal is to give a higher value to the objective parameters coming from literature compared to less quantifiable clinical ones.

Early versus late tracheostomy for critically ill patients

BACKGROUND

Long-term mechanical ventilation is the most common situation where tracheostomy is indicated for patients in intensive care units (ICU). 'Early' and 'late' tracheostomies are two categories of the timing of tracheostomy. The evidence on the advantages attributed to early over late tracheostomy is somewhat conflicting but includes shorter hospital stays and lower mortality rates.

OBJECTIVES

To evaluate the effectiveness and safety of early (≤ 10 days after intubation) versus late tracheostomy (> 10 days after intubation) in critically ill adult patients predicted to be on prolonged mechanical ventilation and with different clinical conditions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 12); MEDLINE (via PubMed) (1966 to December 2010); EMBASE (via Ovid) (from 1974 to December 2010); LILACS (1986 to December 2010); PEDro (Physiotherapy Evidence Database) at www.pedro.fhs.usyd.edu.au (1999 to December 2010) and CINAHL (1982 to December 2010).

SELECTION CRITERIA

We included all randomized or quasi-randomized controlled trials which compared early tracheostomy (two to10 days after intubation) against late tracheostomy (> 10 days after intubation) for critically ill adult patients expected to be on prolonged mechanical ventilation. There was no language restriction.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and conducted a quality assessment. Meta-analyses using the random-effects model were conducted for mortality and pneumonia.

MAIN RESULTS

We included four studies, with a high risk of bias, in which a total of 673 patients were randomized to either early or late tracheostomy. We could not pool data in a meta-analysis because of clinical, methodological and statistical heterogeneity between the included studies. There is no strong evidence for real differences between early and late tracheostomy in the primary outcome of mortality. In one study a statistically significant result favouring early tracheostomy was observed in the outcome measuring time spent on ventilatory support (mean difference (MD) -9.80 days, 95% CI -11.48 to -8.12, P < 0.001).

AUTHORS' CONCLUSIONS

Updated evidence is of low quality, and potential differences between early and late tracheostomy need to be better investigated by means of randomized controlled trials. At present there is no specific information about any subgroup or individual characteristics potentially associated with better outcomes with either early or late tracheostomy.

[Invasive mechanical ventilation in COPD and asthma]

COPD and asthmatic patients use a substantial proportion of mechanical ventilation in the ICU, and their overall mortality with ventilatory support can be significant. From the pathophysiological standpoint, they have increased airway resistance, pulmonary hyperinflation, and high pulmonary dead space, leading to increased work of breathing. If ventilatory demand exceeds work output of the respiratory muscles, acute respiratory failure follows. The main goal of mechanical ventilation in this kind of patients is to improve pulmonary gas exchange and to allow for sufficient rest of compromised respiratory muscles to recover from the fatigued state. The current evidence supports the use of noninvasive positive-pressure ventilation for these patients (especially in COPD), but invasive ventilation also is required frequently in patients who have more severe disease. The physician must be cautious to avoid complications related to mechanical ventilation during ventilatory support. One major cause of the morbidity and mortality arising during mechanical ventilation in these patients is excessive dynamic pulmonary hyperinflation (DH) with intrinsic positive end-expiratory pressure (intrinsic PEEP or auto-PEEP). The purpose of this article is to provide a concise update of the most relevant aspects for the optimal ventilatory management in these patients.

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

OBJECTIVE

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

DESIGN

Review of a prospectively collected database.

SETTING

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

PARTICIPANTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Tracheostomy in the critically ill: indications, timing and techniques

PURPOSE OF REVIEW

Tracheostomy is one of the most common procedures performed in the intensive care unit. Indications, risks, benefits, timing and technique of the procedure, however, remain controversial. The decision of when and how to perform a tracheostomy is often subjective, but must be individualized to the patient. The following review gives an update on recent literature related to tracheostomy in the critically ill.

RECENT FINDINGS

Surprisingly, few data are available on the current practice of tracheostomy in the intensive care unit setting. Very few trials address this issue in a prospective, randomized fashion (randomized controlled trial). Most reports include small numbers representing a heterogeneous population, describing contrary results and precluding any definite conclusions. Evidence seems to suggest that early tracheostomy, however, might be preferable in selected patients.

SUMMARY

Due to increased experience and advanced techniques, percutaneous tracheostomy has become a popular, relatively safe procedure in the intensive care unit. The question of appropriate timing, however, has not been definitely answered with a randomized controlled trial. Instead, a number of retrospective studies and a single prospective study have shed some light on this issue. Most reports favor the performance of tracheostomy within 10 days of respiratory failure.

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

OBJECTIVE

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

DESIGN, SETTING, AND PATIENTS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Clinical review: percutaneous dilatational tracheostomy

As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside. It is now considered a viable alternative to (ST) in the intensive care unit. Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT.

Predictive factors for tracheostomy in neurocritical care patients with spontaneous supratentorial hemorrhage

BACKGROUND

Up to 30% of patients with supratentorial intracerebral hemorrhage (ICH) require mechanical ventilation during the course of treatment. For these patients, tracheostomy is necessary in cases of protracted weaning. As only limited data exist about predictors for a tracheostomy in patients with ICH, the aim of this study was to investigate the frequency of tracheostomy and clinical findings that increase the risk for a tracheostomy in patients with supratentorial hemorrhage.

METHODS

A total of 392 patients with supratentorial ICH were analyzed. The parameters age, gender, chronic obstructive pulmonary disease (COPD), Glasgow Coma Scale on admission, ganglionic or non-ganglionic localization, presence of ventricular hemorrhage, hydrocephalus, hematoma volume, and hematoma evacuation were investigated. The effects on the end-point tracheostomy were analyzed using multivariate regression analyses.

RESULTS

The overall need for tracheostomy was 9.9% (16.3% in patients with ganglionic hemorrhage versus 2.8% in patients with non-ganglionic hemorrhages). 31% of the ventilated patients required tracheostomy. The risk for tracheostomy was increased eightfold in patients who developed hydrocephalus. The presence of ventricular blood, in general, showed no significant impact on the need for tracheostomy, whereas hemorrhage extending into the third and fourth ventricles in conjunction with hydrocephalus increased the risk for tracheostomy. The hematoma volume correlated positively with the risk for tracheostomy.

CONCLUSIONS

Our study demonstrates that approximately 10% of patients with ICH require tracheostomy during the course of their disease. Presence of COPD, hematoma volume, ganglionic location of the hematoma, and the development of hydrocephalus are predisposing factors for tracheostomy.

Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients*

OBJECTIVE

To assess the impact of tracheotomy on sedative administration, sedation level, and autonomy of mechanically-ventilated intensive care unit (ICU) patients.

DESIGN, SETTING, AND PATIENTS

In this observational study, the charts of all consecutive patients undergoing mechanical ventilation requiring tracheotomy over a 14-month period in our 18-bed tertiary care ICU were reviewed retrospectively. Patients' sedation levels (according to the Riker's 7-level sedation-agitation score) and intravenous (fentanyl and midazolam) and oral (clorazepate and haloperidol) sedative administration were measured daily during the 7 days before and after tracheotomy. We also recorded patients for whom chair positioning and oral alimentation became possible in the days following tracheotomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Tracheotomy was performed on 72 (23.1%) of the 312 patients undergoing mechanical ventilation for > or = 48 hrs. After tracheotomy, median (25th, 75th percentiles) fentanyl and midazolam administration decreased from 866 (191, 1672) to 71 (3, 426) microg/(patient.day) and from 44 (16, 128) to 7 (1, 42) mg/(patient.day) (p < .001), respectively. Concomitant median time spent heavily sedated decreased from 7 (3, 17) to 1 (0, 6) hrs/day (p < .001), with no increase in agitation time. During the 7 days following tracheotomy, partial oral alimentation became possible for 35 patients (48.6%) and out-of-bed positioning became possible for 16 patients (22.2%).

CONCLUSION

On the basis of these observations, we conclude that tracheotomized mechanically ventilated ICU patients required less intravenous sedative administration, spent less time heavily sedated, and achieved more autonomy earlier.

Impact of neck length on the safety of percutaneous and surgical tracheotomy: a prospective, randomized study

OBJECTIVE

To investigate a correlation between neck length and the incidence of complications after both percutaneous and surgical tracheotomy (ST) and to compare the relative safety of the two procedures at our institution.

STUDY DESIGN

Prospective, randomized study of patients undergoing tracheotomy at a tertiary care center.

METHODS

Forty-three patients evaluated for tracheotomy at our institution between the years 2003 and 2004 were enrolled in the study and were randomly assigned to receive either an ST or a percutaneous dilatational tracheotomy (PDT). All patients underwent standardized measurement of the cricosternal distance (CSD) in the neutral and extended positions before the procedure. Demographic and procedural variables were recorded, and the occurrence of postoperative complications was followed for 1 week.

RESULTS

PDT was performed in 29 patients and ST in 14 patients. The mean CSD of 2.7 cm increased to 3.7 cm after extension with a shoulder roll. PDT required less time (mean 8 vs. 23 minutes) and resulted in less blood loss compared with ST. A trend toward a higher incidence of complications with PDT (40%) compared with ST (7%) and in the first half of our series (learning curve) was noted. This, however, did not reach statistical significance. There was no correlation between the incidence of complications and neck length as determined by the CSD in either group of patients.

CONCLUSIONS

We failed to demonstrate a correlation between CSD and tracheotomy related complications. Patients with short necks may be at no higher risk during either a PDT or ST. Experience, awareness of complications, and a dedicated team approach are necessary for the safe performance of PDT.

Early tracheostomy versus late tracheostomy in the surgical intensive care unit

BACKGROUND

This study's purpose was to determine if early tracheostomy (ET) of severely injured patients reduces days of ventilatory support, the frequency of ventilator-associated pneumonia (VAP), and surgical intensive care unit (SICU) length of stay (LOS).

METHODS

This 2-year retrospective review included 185 SICU patients with acute injuries requiring mechanical ventilation and tracheostomy. ET was defined as 7 days or less, and late tracheostomy (LT) as more than 7 days.

RESULTS

The incidence of VAP was significantly higher in the LT group, relative to the ET group (42.3% vs. 27.2%, respectively; P <.05). Acute Physiology and Chronic Health Evaluation II scores, hospital and SICU LOS, and the number of ventilator days were significantly higher in the LT group.

CONCLUSIONS

In patients who required prolonged mechanical ventilation, there was significant decreased incidence of VAP, less ventilator time, and lower ICU LOS when tracheostomy was performed within 7 days after admission to the SICU.

Routine Chest X-ray after Percutaneous Tracheostomy is Unnecessary

Percutaneous tracheostomy (PT) is an increasingly common procedure in the management of critically ill patients. Current practice for both open and percutaneous tracheostomies is a post-procedure chest X-ray to rule out potentially life-threatening complications such as a pneumothorax or tube malposition. Our study evaluated the utility of chest X-ray after PT. A retrospective chart review was conducted for patients undergoing PT at Kern Medical Center between January 1999 and December 2003. Charts were reviewed for age, sex, and clinical outcome as well as the radiologist's interpretation of the postprocedure chest X-ray. A total of 73 procedures were completed in 47 men and 26 women. The majority of the tracheostomies were in trauma patients who needed prolonged ventilatory support. There were no complications identified on postprocedure chest X-ray. A single patient was converted to an open procedure secondary to bleeding. We conclude that routine chest X-ray after PT is unnecessary.

La trachéotomie

INTRODUCTION

Tracheotomy was initially described as a means to relieve acute upper airway obstruction. Indications for its use have changed and developed over time.

STATE OF THE ART

During the 1960's, tracheotomy was promoted as a treatment for ventilator-dependent patients but the complications reported in the 1970's and early 1980's both reduced its accepted indications and led to it being proposed later. During the last 20 years advances in intensive care medicine and a reduction in the rate of complications associated with the procedure have encouraged intensivists again to propose tracheotomy at an earlier stage.

PERSPECTIVES

Over the last 10 years, a new technique, percutaneous dilatational tracheotomy has gained widespread acceptance because of its simplicity of execution, its low cost and the low rate of postoperative complications that has been observed.

CONCLUSIONS

Although the ideal time to perform a tracheotomy has not yet been established, the benefits of this approach compared to prolonged laryngeal intubation, the low morbidity associated with modern surgical tracheotomy and the development of percutaneous techniques support the use of this procedure in the management of patients requiring prolonged ventilatory support.