1
|
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.
Collapse
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
| |
Collapse
|
2
|
Velamuri SR, Ali Y, Lanfranco J, Gupta P, Hill DM. Inhalation Injury, Respiratory Failure, and Ventilator Support in Acute Burn Care. Clin Plast Surg 2024; 51:221-232. [PMID: 38429045 DOI: 10.1016/j.cps.2023.11.001] [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] [Indexed: 03/03/2024]
Abstract
Sustaining an inhalation injury increases the risk of severe complications and mortality. Current evidential support to guide treatment of the injury or subsequent complications is lacking, as studies either exclude inhalation injury or design limit inferences that can be made. Conventional ventilator modes are most commonly used, but there is no consensus on optimal strategies. Settings should be customized to patient tolerance and response. Data for pharmacotherapy adjunctive treatments are limited.
Collapse
Affiliation(s)
- Sai R Velamuri
- Department of Surgery, College of Medicine, University of Tennessee, Health Science Center, Memphis, TN 38103, USA.
| | - Yasmin Ali
- Department of Surgery, College of Medicine, University of Tennessee Health Science Center, 910 Madison Avenue, 2nd floor Suite 217, Memphis, TN 38103, USA
| | - Julio Lanfranco
- Division of Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 Court Avenue Room H316B, Memphis, TN 38103, USA
| | - Pooja Gupta
- Pulmonary and Critical Care, University of Tennessee Health Science Center, 965 court avenue, Room H316B, Memphis, TN 38103, USA
| | - David M Hill
- Department of Pharmacy, Regional One Health, University of Tennessee, 80 madison avenue, Memphis TN 38103, USA
| |
Collapse
|
3
|
Zheng M, Wandell GM, Maxin AJ, Gomez-Castillo LA, Giliberto JP, Bhatt NK. Sociodemographic Disparities in Tracheostomy Timing and Outcomes. Laryngoscope 2024; 134:582-587. [PMID: 37584408 DOI: 10.1002/lary.30872] [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: 03/01/2023] [Revised: 05/30/2023] [Accepted: 06/25/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE Tracheostomies are commonly performed in critically ill patients requiring prolonged mechanical ventilation. Although early tracheostomy has been associated with improved outcomes, the reasons for delayed tracheostomy are complex. We examined the impact of sociodemographic factors on tracheostomy timing and outcomes. METHODS Medical records were retrospectively reviewed of ventilator-dependent adult patients who underwent tracheostomy from 2021 to 2022. Tracheostomy timing was defined as routine (<21 days) versus late (21 days or more). Sociodemographic variables were compared between cohorts using univariate and multivariate models. Secondary outcomes included hospital length of stay (LOS), decannulation, tracheostomy-related complications, and inhospital mortality. RESULTS One hundred forty-two patients underwent tracheostomy after initial intubation: 74.7% routine (n = 106) and 25.4% late (n = 36). In a multivariate model adjusted for age, race, surgical service, tracheostomy technique, and time between consultation and surgery, non-English speaking patients and women were more likely to receive a late tracheostomy compared with English speaking patients and men, respectively (odds ratio [OR] 3.18, 95% confidence interval [CI] 1.03, 9.81, p < 0.05), (OR 3.15, 95% CI 1.18, 8.41, p < 0.05). Late tracheostomy was associated with longer median hospital LOS (62 vs. 52 days, p < 0.05). Tracheostomy timing did not significantly impact mortality, decannulation or tracheostomy-related complications. CONCLUSION Despite an association between earlier tracheostomy and shorter LOS, non-English speaking patients and female patients are more likely to receive a late tracheostomy. Standardized protocols for tracheostomy timing may address bias in the referral and execution of tracheostomy and reduce unnecessary hospital days. LEVEL OF EVIDENCE 4 Laryngoscope, 134:582-587, 2024.
Collapse
Affiliation(s)
- Melissa Zheng
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Grace M Wandell
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Anthony J Maxin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
- School of Medicine, Creighton University, Omaha, Nebraska, U.S.A
| | - Luis A Gomez-Castillo
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - John P Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Neel K Bhatt
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| |
Collapse
|
4
|
Galicia KE, Mehta A, Kowalske KJ, Gibran NS, Stewart BT, McMullen K, Wolf SE, Ryan CM, Kubasiak J, Schneider JC. Preliminary Exploration of Long-Term Patient Outcomes After Tracheostomy in Burns: A Burn Model System Study. J Surg Res 2023; 291:221-230. [PMID: 37454428 PMCID: PMC10528102 DOI: 10.1016/j.jss.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/02/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Upper airway management is crucial to burn care. Endotracheal intubation is often performed in the setting of inhalation injury, burns of the face and neck, or large burns requiring significant resuscitation. Tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term, patient-reported outcomes in burn patients with and without tracheostomy. MATERIALS AND METHODS Data from the Burn Model System Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcomes, collected at 6-, 12-, and 24-mo follow-up, were analyzed: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life, Community Integration Questionnaire, Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure, employment status, and days to return to work. Regression models and propensity-matched analyses were used to assess the associations between tracheostomy and each outcome. RESULTS Of 714 patients included in this study, 5.5% received a tracheostomy. Mixed model regression analyses demonstrated that only VR-12 Physical Component Summary scores at 24-mo follow-up were significantly worse among those requiring tracheostomy. Tracheostomy was not associated with VR-12 Mental Component Summary, Satisfaction with Life, Community Integration Questionnaire, or Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure scores. Likewise, tracheostomy was not found to be independently associated with employment status or days to return to work. CONCLUSIONS This preliminary exploration suggests that physical and psychosocial recovery, as well as the ability to regain employment, are no worse in burn patients requiring tracheostomy. Future investigations of larger scale are still needed to assess center- and provider-level influences, as well as the influences of various hallmarks of injury severity. Nonetheless, this work should better inform goals of care discussions with patients and families regarding the use of tracheostomy in burn injury.
Collapse
Affiliation(s)
- Kevin E Galicia
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois.
| | - Anupama Mehta
- Division of Trauma, Burn, and Surgical Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Karen J Kowalske
- Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nicole S Gibran
- Department of Surgery, The University of Washington, Seattle, Washington
| | - Barclay T Stewart
- Department of Surgery, The University of Washington, Seattle, Washington
| | - Kara McMullen
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Steven E Wolf
- Division of Burn and Trauma Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Charlestown, Massachusetts
| |
Collapse
|
5
|
Impact of Early Tracheostomy Versus Late or No Tracheostomy in Nonneurologically Injured Adult Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:310-318. [PMID: 36661455 DOI: 10.1097/ccm.0000000000005699] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The optimal timing of tracheostomy in nonneurologically injured mechanically ventilated critically ill adult patients is uncertain. We conducted a systematic review of randomized controlled trials to evaluate the effect of early versus late tracheostomy or prolonged intubation in this population. DATA SOURCES We searched MEDLINE, Embase, CENTRAL, CINAHL, and Web of science databases for randomized controlled trials comparing early tracheostomy (<10 d of intubation) with late tracheostomy or prolonged intubation in adults. DATA SELECTION We selected trials comparing early tracheostomy (defined as being performed less than 10 d after intubation) with late tracheostomy (performed on or after the 10th day of intubation) or prolonged intubation and no tracheostomy in nonneurologically injured patients. The primary outcome was overall mortality. Secondary outcomes included ventilator-associated pneumonia, duration of mechanical ventilation, ICU, and hospital length of stay. DATA EXTRACTION Two reviewers screened citations, extracted data, assessed the risk of bias, and classification of Grading of Recommendations, Assessment, Development, and Evaluation independently. DATA SYNTHESIS Our search strategy yielded 8,275 citations, from which nine trials (n = 2,457) were included. We did not observe an effect on the overall mortality of early tracheostomy compared with late tracheostomy or prolonged intubation (risk ratio, 0.91, 95% CI, 0.82-1.01; I2 = 18%). Our results were consistent in all subgroup analyses. No differences were observed in ICU and hospital length of stay, duration of mechanical ventilation, incidence of ventilator-acquired pneumonia, and complications. Our trial sequential analysis showed that our primary analysis on mortality was likely underpowered. CONCLUSION In our systematic review, we observed that early tracheostomy, as compared with late tracheostomy or prolonged intubation, was not associated with a reduction in overall mortality. However, we cannot exclude a clinically relevant reduction in mortality considering the level of certainty of the evidence. A well-designed trial is needed to answer this important clinical question.
Collapse
|
6
|
Quinn L, Veenith T, Bion J, Hemming K, Whitehouse T, Lilford R. Bayesian analysis of a systematic review of early versus late tracheostomy in ICU patients. Br J Anaesth 2022; 129:693-702. [PMID: 36163077 PMCID: PMC9642836 DOI: 10.1016/j.bja.2022.08.012] [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] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 08/02/2022] [Accepted: 08/15/2022] [Indexed: 12/01/2022] Open
Abstract
Background A recent systematic review and meta-analysis of RCTs of early vs late tracheostomy in mechanically ventilated patients suggest that early tracheostomy reduces the duration of ICU stay and mechanical ventilation, but does not reduce short-term mortality or ventilator-associated pneumonia (VAP). Meta-analysis of randomised trials is typically performed using a frequentist approach, and although reporting confidence intervals, interpretation is usually based on statistical significance. To provide a robust basis for clinical decision-making, we completed the search used from the previous review and analysed the data using Bayesian methods to estimate posterior probabilities of the effect of early tracheostomy on clinical outcomes. Methods The search was completed for RCTS comparing early vs late tracheostomy in the databases PubMed, EMBASE, and Cochrane library in June 2022. Effect estimates and 95% confidence intervals were calculated for the outcomes short-term mortality, VAP, duration of ICU stay, and mechanical ventilation. A Bayesian meta-analysis was performed with uninformative priors. Risk ratios (RRs) and standardised mean differences (SMDs) with 95% credible intervals were reported alongside posterior probabilities for any benefit (RR<1; SMD<0), a small benefit (number needed to treat, 200; SMD<–0.5), or modest benefit (number needed to treat, 100; SMD<–1). Results Nineteen RCTs with 3508 patients were included. Comparing patients with early vs late tracheostomy, the posterior probabilities for any benefit, small benefit, and modest benefit, respectively, were: 99%, 99%, and 99% for short-term mortality; 94%, 78%, and 51% for VAP; 97%, 43%, and 1% for duration of mechanical ventilation; and 97%, 75%, and 27% and for length of ICU stay. Conclusions Bayesian meta-analysis suggests a high probability that early tracheostomy compared with delayed tracheostomy has at least some benefit across all clinical outcomes considered.
Collapse
Affiliation(s)
- Laura Quinn
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK.
| | - Tonny Veenith
- Department of Critical Care and Anaesthesia, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Julian Bion
- Intensive Care Medicine, University of Birmingham, Birmingham, UK
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tony Whitehouse
- Department of Critical Care and Anaesthesia, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| |
Collapse
|
7
|
Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS Clinical Practice Guideline 2021. J Intensive Care 2022; 10:32. [PMID: 35799288 PMCID: PMC9263056 DOI: 10.1186/s40560-022-00615-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/10/2022] [Indexed: 12/16/2022] Open
Abstract
Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00615-6.
Collapse
Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Urayasu Hospital, Juntendo University, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Tokai, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kyoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Kameda Medical Center Department of Infectious Diseases, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | | |
Collapse
|
8
|
Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, Egi M, Hashimoto S, Shime N, Saito O, Matsumoto S, Nango E, Okada Y, Hayashi K, Sakuraya M, Nakajima M, Okamori S, Miura S, Fukuda T, Ishihara T, Kamo T, Yatabe T, Norisue Y, Aoki Y, Iizuka Y, Kondo Y, Narita C, Kawakami D, Okano H, Takeshita J, Anan K, Okazaki SR, Taito S, Hayashi T, Mayumi T, Terayama T, Kubota Y, Abe Y, Iwasaki Y, Kishihara Y, Kataoka J, Nishimura T, Yonekura H, Ando K, Yoshida T, Masuyama T, Sanui M. ARDS clinical practice guideline 2021. Respir Investig 2022; 60:446-495. [PMID: 35753956 DOI: 10.1016/j.resinv.2022.05.003] [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: 04/19/2022] [Revised: 05/07/2022] [Accepted: 05/13/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.
Collapse
Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Aomori, Japan.
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Kazuya Ichikado
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenji Tsushima
- International University of Health and Welfare, Tokyo, Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Hyogo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Osamu Saito
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shotaro Matsumoto
- Division of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Eishu Nango
- Department of Family Medicine, Seibo International Catholic Hospital, Tokyo, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenichiro Hayashi
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Mikio Nakajima
- Emergency and Critical Care Center, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Satoshi Okamori
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Tetsuro Kamo
- Department of Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomoaki Yatabe
- Department of Anesthesiology, Nishichita General Hospital, Aichi, Japan
| | | | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University, Urayasu Hospital, Chiba, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Kawakami
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Hiromu Okano
- Department of Critical Care and Emergency Medicine, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Takuya Hayashi
- Pediatric Emergency and Critical Care Center, Saitama Children's Medical Center, Saitama, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Saitama, Japan
| | - Yoshifumi Kubota
- Department of Infectious Diseases, Kameda Medical Center, Chiba, Japan
| | - Yoshinobu Abe
- Division of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | - Yudai Iwasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yuki Kishihara
- Department of Emergency Medicine, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Jun Kataoka
- Department of Critical Care Medicine, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yonekura
- Department of Anesthesiology and Pain Medicine, Fujita Health University Bantane Hospital, Aichi, Japan
| | - Koichi Ando
- Division of Respiratory Medicine and Allergology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Tomoyuki Masuyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| |
Collapse
|
9
|
Sasaki J, Matsushima A, Ikeda H, Inoue Y, Katahira J, Kishibe M, Kimura C, Sato Y, Takuma K, Tanaka K, Hayashi M, Matsumura H, Yasuda H, Yoshimura Y, Aoki H, Ishizaki Y, Isono N, Ueda T, Umezawa K, Osuka A, Ogura T, Kaita Y, Kawai K, Kawamoto K, Kimura M, Kubo T, Kurihara T, Kurokawa M, Kobayashi S, Saitoh D, Shichinohe R, Shibusawa T, Suzuki Y, Soejima K, Hashimoto I, Fujiwara O, Matsuura H, Miida K, Miyazaki M, Murao N, Morikawa W, Yamada S. Japanese Society for Burn Injuries (JSBI) Clinical Practice Guidelines for Management of Burn Care (3rd Edition). Acute Med Surg 2022; 9:e739. [PMID: 35493773 PMCID: PMC9045063 DOI: 10.1002/ams2.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 01/28/2023] Open
|
10
|
Outcomes following traumatic inhalational airway injury - Predictors of mortality and effect of procedural intervention. Injury 2021; 52:3320-3326. [PMID: 34565616 DOI: 10.1016/j.injury.2021.09.013] [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: 05/28/2021] [Revised: 07/19/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Study outcomes, predictors of mortality, and effects of procedural interventions on patients following traumatic inhalational airway injury. STUDY Design: Retrospective study. SETTING National Trauma Data Bank METHODS: Patients over the age of eighteen admitted between 2008 and 2016 to NTDB-participating sites were included. In-hospital mortality and length of stay were the primary outcomes. RESULTS The final study cohort included 13,351 patients. History of active smoking was negatively associated with in-house mortality with an OR of 0.33 (0.25-0.44). History of alcohol use, and presence of significant medical co-morbidities were positively associated with in-house mortality with OR of 5.28 (4.32-6.46) 2.74 (19.4-3.86) respectively. There was little to no association between procedural interventions and in-house mortality. Intubation, laryngobronchoscopy, and tracheostomy had OR of 0.90 (0.67-1.20), 1.02 (0.79-1.30), and 0.94 (0.58-1.51), respectively. However, procedural intervention did affect both the median hospital and ICU lengths of stay of patients. Median hospital and ICU length of stay were shorter for patients receiving endotracheal intubation. Median hospital length of stay was longer for patients undergoing bronchoscopy and laryngoscopy, but median ICU length of stay was shorter for patients undergoing bronchoscopy and laryngoscopy. Patients receiving a tracheostomy have both significantly increased median hospital and ICU lengths of stay. CONCLUSIONS Active smoking was associated with decreased odds of in-hospital mortality, while presence of pre-existing medical comorbidities and history of alcohol use disorder was associated with increased odds of in-hospital mortality. Procedural intervention had little to no association with in-hospital mortality but did affect overall hospital and ICU LOS.
Collapse
|
11
|
Smailes S, Spoors C, da Costa FM, Martin N, Barnes D. Early tracheostomy and active exercise programmes in adult intensive care patients with severe burns. Burns 2021; 48:1599-1605. [PMID: 34955297 DOI: 10.1016/j.burns.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/23/2021] [Accepted: 10/11/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Tracheostomy is a strategy often employed in patients requiring prolonged intubation in ICU settings. Evidence suggests that earlier tracheostomy and early active exercise are associated with better patient centered outcomes. Severe burn patients often require prolonged ventilatory support due to their critical condition, complex sedation management and multiple operating room visits. It is still unclear the optimal timing for tracheostomy in this population. METHODS We conducted a service evaluation where we compared Early Tracheostomy (≤10 days) with Late Tracheostomy (>10 days) in 41 severely burned patients that required prolonged respiratory support. RESULTS Early Tracheostomy cohort was associated with fewer days of mechanical ventilation (16 vs 33, p = 0.001), shorter hospital length of stay (65 vs 88 days, p = 0.018), earlier first day of active exercise (day 8 vs day 25, p < 0.0001) and higher Functional Assessment for Burns scores upon discharge (32 vs 28, p = 0.016). CONCLUSION Early tracheostomy in patients with severe burns is associated with earlier active exercise, fewer days of ventilation, shorter length of hospital stay and better physical functional independence upon discharge from hospital.
Collapse
Affiliation(s)
- Sarah Smailes
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom.
| | - Catherine Spoors
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom
| | - Filipe Marques da Costa
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom
| | - Niall Martin
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom; Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Queen Mary University of London, United Kingdom
| | - David Barnes
- St Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, Essex CM1 7ET, United Kingdom
| |
Collapse
|
12
|
Chorath K, Hoang A, Rajasekaran K, Moreira A. Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients: A Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:450-459. [PMID: 33704354 DOI: 10.1001/jamaoto.2021.0025] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance The timing of tracheostomy placement in adult patients undergoing critical care remains unestablished. Previous meta-analyses have reported mixed findings regarding early vs late tracheostomy placement for ventilator-associated pneumonia (VAP), ventilator days, mortality, and length of intensive care unit (ICU) hospitalization. Objective To compare the association of early (≤7 days) vs late tracheotomy with VAP and ventilator days in critically ill adults. Data Sources A search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, references of relevant articles, previous meta-analyses, and gray literature from inception to March 31, 2020, was performed. Study Selection Randomized clinical trials comparing early and late tracheotomy with any of our primary outcomes, VAP or ventilator days, were included. Data Extraction and Synthesis Two independent reviewers conducted all stages of the review. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Pooled odds ratios (ORs) or the mean difference (MD) with 95% CIs were calculated using a random-effects model. Main Outcomes and Measures Primary outcomes included VAP and duration of mechanical ventilation. Intensive care unit days and mortality (within the first 30 days of hospitalization) constituted secondary outcomes. Results Seventeen unique trials with a cumulative 3145 patients (mean [SD] age range, 32.9 [12.7] to 67.9 [17.6] years) were included in this review. Individuals undergoing early tracheotomy had a decrease in the occurrence of VAP (OR, 0.59 [95% CI, 0.35-0.99]; 1894 patients) and experienced more ventilator-free days (MD, 1.74 [95% CI, 0.48-3.00] days; 1243 patients). Early tracheotomy also resulted in fewer ICU days (MD, -6.25 [95% CI, -11.22 to -1.28] days; 2042 patients). Mortality was reported for 2445 patients and was comparable between groups (OR, 0.66 [95% CI, 0.38-1.15]). Conclusions and Relevance Compared with late tracheotomy, early intervention was associated with lower VAP rates and shorter durations of mechanical ventilation and ICU stay, but not with reduced short-term, all-cause mortality. These findings have substantial clinical implications and may result in practice changes regarding the timing of tracheotomy in severely ill adults requiring mechanical ventilation.
Collapse
Affiliation(s)
- Kevin Chorath
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia
| | - Ansel Hoang
- Division of Neonatology, Department of Pediatrics, University of Texas Health-San Antonio
| | | | - Alvaro Moreira
- Division of Neonatology, Department of Pediatrics, University of Texas Health-San Antonio
| |
Collapse
|
13
|
Su CL, Chang GH, Tsai IJ, Hsu CY, Wang IK, Chang CC. Factors Impacting Survival in Patients With Major Burn-Induced Acute Kidney Injury Postrenal Replacement Therapy: A Nationwide Study With 15 Years Follow-Up in Taiwan. Ann Plast Surg 2021; 86:S23-S29. [PMID: 33346544 DOI: 10.1097/sap.0000000000002649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Major burn-induced acute kidney injury (AKI) causes extremely high mortality, even though renal replacement therapy (RRT) was thought of as the most efficient treatment. There was scanty research for investigating the characteristic of burn-AKI-RRT patients during intensive care. This study aims to investigate the factors impacting the survival outcomes in those burn-AKI-RRT cases. METHODS Using the Taiwan National Health Insurance Research Database and its affiliated database, the Registry for Catastrophic Illness Patients, we defined a cohort composed of 171 patients encountering major burn-induced AKI and receiving RRT during burn care for a 15-year observation period. Demographic characteristic, comorbidities, total body surface area (TBSA), major procedures, and complications were analyzed to explore the factors affecting the survival outcomes during acute burn care and 1 year after discharge. RESULTS Patients who underwent tracheostomy and skin grafting had higher survival rates during acute burn care (tracheostomy: mortality vs survival, 15.7% vs 30.2%; P = 0.0257; skin grafting: mortality vs survival, 57.4% vs 76.2%; P = 0.0134). Multivariate regression analysis showed that tracheostomy group significantly presented with lower mortality risk by 65% (odds ratio [OR], 0.35; P = 0.0372), and subgroup analysis of delaminating follow-up duration showed that patients with tracheostomy had higher overall survival by 22% (90-day postburn mortality: nontracheostomy vs tracheostomy, 58.3% vs 36.3%; adjusted hazards ratio, 0.39; 95% confidence interval, 0.22-0.69; P = 0.0011), especially during postburn first 30 days (adjusted hazards ratio, 0.15; 95% confidence interval, 0.05-0.49; P = 0.0016). Total body surface area did not significantly affect survival; however, mortality risk was significantly higher in those with a larger TBSA (TBSA, ≥80%; OR, 6.48; P = 0.0022; TBSA, 60-79%; OR, 3.12; P = 0.0518; TBSA, 40-59%; OR, 1.88; P = 0.2402; TBSA, 30-39% as reference). CONCLUSIONS For patients with major burn-induced AKI receiving RRT, tracheostomy and skin grafting may improve survival in the cases living through acute burn stage.
Collapse
Affiliation(s)
- Chun-Lin Su
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou
| | - Geng-He Chang
- Department of Otolaryngology, Chang Gung Memorial Hospital at Chiayi
| | | | | | | | | |
Collapse
|
14
|
Deng H, Fang Q, Chen K, Zhang X. Early versus late tracheotomy in ICU patients: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e24329. [PMID: 33546065 PMCID: PMC7837817 DOI: 10.1097/md.0000000000024329] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 12/19/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed to quantitatively analyze the available randomized controlled trials (RCTs) and investigate whether early tracheotomy can improve clinical endpoints compared with late tracheotomy in critically ill patients undergoing mechanical ventilation. METHODS The electronic databases of PubMed, Embase, and the Cochrane library were systematically searched in August 2019. The investigated outcomes were calculated using relative risks (RRs) and standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) through the random-effects model for categories and continuous data, respectively. RESULTS The electronic searches yielded 2289 records, including 15 RCTs comprising a total of 3003 patients and found to be relevant for the final quantitative analysis. The summary RRs that indicated early versus late tracheotomy were not associated with the risk of short-term mortality (RR: 0.87; 95% CI: 0.74-1.03; P = .114) and ventilator-associated pneumonia (RR: 0.90; 95% CI: 0.78-1.04; P = .156). Moreover, early tracheotomy was associated with shorter intensive care unit (ICU) stay (SMD: -1.81; 95% CI: -2.64 to -0.99; P < .001) and mechanical ventilation duration (SMD: -1.17; 95% CI: -2.10 to -0.24; P = .014). Finally, no significant difference was observed between early and late tracheotomy for hospital stay (SMD: -0.42; 95% CI: -1.36-0.52; P = .377). CONCLUSIONS The present meta-analysis suggests that early tracheotomy can reduce the length of ICU stay and mechanical ventilation duration, but the timing of the tracheotomy was not associated with the short-term clinical endpoints in critically ill patients undergoing mechanical ventilation.
Collapse
Affiliation(s)
- Hongsheng Deng
- Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Intensive Care Unit, Affiliated Jinhua hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Qiang Fang
- Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
| | - Kun Chen
- Intensive Care Unit, Affiliated Jinhua hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Xiaoling Zhang
- Intensive Care Unit, Affiliated Jinhua hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| |
Collapse
|
15
|
Janik S, Grasl S, Yildiz E, Besser G, Kliman J, Hacker P, Frommlet F, Fochtmann-Frana A, Erovic BM. A new nomogram to predict the need for tracheostomy in burned patients. Eur Arch Otorhinolaryngol 2020; 278:3479-3488. [PMID: 33346855 PMCID: PMC8328908 DOI: 10.1007/s00405-020-06541-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Stefan Janik
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University Vienna, Vienna, Austria
| | - Stefan Grasl
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University Vienna, Vienna, Austria
| | - Erdem Yildiz
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University Vienna, Vienna, Austria
| | - Gerold Besser
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University Vienna, Vienna, Austria
| | - Jonathan Kliman
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University Vienna, Vienna, Austria
| | - Philipp Hacker
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University Vienna, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Alexandra Fochtmann-Frana
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University Vienna, Vienna, Austria
| | - Boban M Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital Vienna, Hans-Sachs Gasse 10-12, Vienna, Austria.
| |
Collapse
|
16
|
Duke GJ, Moran JL, Santamaria JD, Roodenburg O. Safety of the endotracheal tube for prolonged mechanical ventilation. J Crit Care 2020; 61:144-151. [PMID: 33161243 DOI: 10.1016/j.jcrc.2020.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 11/26/2022]
Abstract
RATIONALE The endotracheal tube (ETT) is the most common route for invasive mechanical ventilation (MV) yet controversy attends its long-term safety. OBJECTIVE Assess the safety of ETT compared with tracheostomy tube (TT) for MV support in the intensive care unit (ICU). METHODS Retrospective analysis of five year national dataset of 128,977 adults (age > 15-years) admitted for MV therapy with tracheostomy tube (TT; n = 4772) or without (ETT; n = 124,204), excluding those with neurological diagnoses or likely to require a surgical airway (n = 27,466), in 93 public health service ICUs across Australia, between July 2013-June 2018. MEASUREMENTS Hospital survival (including liberation from MV) for ETT Group compared with TT Group using a probit regression model adjusted for confounding using fixed, endogenous and non-random treatment assignment covariates, and their interactions; analysed and plotted as marginal effects by duration of MV. RESULTS Median duration of MV was 2 (IQR =1-4) days, predominantly via ETT (124,205; 96.3%), and 21,620 (16.7%) died. Temporal trend for ETT increased (OR = 1.06 per year, 95%CI =1.03-1.10) compared to TT, even for prolonged (>3 weeks) MV (38.1%). Higher risk-adjusted mortality was associated with longer duration of MV and after 9 days of MV with retention of ETT compared with TT - average (mortality) treatment effect 12.6% (95%CI =10.7-14.5). The latter was not significant after 30 days of MV. CONCLUSIONS The safety of ETT compared with TT beyond short-term MV (≤9-days) is uncertain and requires prospective evaluation with additional data.
Collapse
Affiliation(s)
- Graeme J Duke
- Department of Intensive Care Medicine, Eastern Health, Box Hill, Australia; Monash University, Clayton, Australia.
| | - John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital (Melbourne), Fitzroy, Australia
| | - Owen Roodenburg
- Department of Intensive Care Medicine, Eastern Health, Box Hill, Australia; Monash University, Clayton, Australia
| |
Collapse
|
17
|
Nam IC, Shin YS, Jeong WJ, Park MW, Park SY, Song CM, Lee YC, Jeon JH, Lee J, Kang CH, Park IS, Kim K, Sun DI. Guidelines for Tracheostomy From the Korean Bronchoesophagological Society. Clin Exp Otorhinolaryngol 2020; 13:361-375. [PMID: 32717774 PMCID: PMC7669309 DOI: 10.21053/ceo.2020.00353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/19/2020] [Indexed: 12/17/2022] Open
Abstract
The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.
Collapse
Affiliation(s)
| | - Inn-Chul Nam
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Seob Shin
- Department of Otolaryngology-Head and Neck Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Woo Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Myeon Song
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Young Chan Lee
- Department of Otolaryngology-Head and Neck Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Hyun Jeon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Il Sun
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
18
|
Aggarwal A, Chittoria RK, Chavan V, Reddy CL, Gupta S, Mohan PB, Pathan I, Shijina K. Prophylactic Tracheostomy for Inhalational Burns. World J Plast Surg 2020; 9:10-13. [PMID: 32190585 PMCID: PMC7068194 DOI: 10.29252/wjps.9.1.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Various studies have reported different conclusions over the safety and benefits of early tracheostomy in burns. Our study aimed to assess the role of prophylactic tracheostomy in treatment and improvement of outcomes in inhalational burns in India. METHODS In a retrospective descriptive analysis of burns admitted over 1 year in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Tertiary Burns Center in India, patients with thermal burns of TBSA less than 60% and those with indirect evidence of airway burns were enrolled and divided into two groups who underwent prophylactic tracheostomy vs. patients for whom prophylactic tracheostomy was not done. Mortality was the final point and primary variable measurement. RESULTS Totally, 10 patients with inhalational burns were admitted. Out of the 4 patients for whom prophylactic tracheostomy was undertaken, three patients survived, while one died. Out of the 6 patients for which prophylactic tracheostomy were not performed, 4 patients died; while 2 survived. The average percentage of burns TBSA in the prophylactic tracheostomy group was 34%. Average age of patients in the prophylactic tracheostomy group was 31.3 years. The average percentage burns TBSA in the group, where prophylactic tracheostomy was not carried out was 42%. Average age of patients in the prophylactic tracheostomy group was 36.2 years. CONCLUSION Our study is a pilot study to investigate the possibility and a way to improve outcomes in patients with inhalational injuries. Larger trials may be needed to facilitate or disprove the same.
Collapse
Affiliation(s)
- Abhinav Aggarwal
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Ravi Kumar Chittoria
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Vinayak Chavan
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Chirra Likhitha Reddy
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Saurabh Gupta
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Padmalakshmi Bharathi Mohan
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Imran Pathan
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - K Shijina
- Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| |
Collapse
|
19
|
Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Zirpe K, Srinivasan S, Mohamed Z, Gupta KV, Wanchoo J, Chakrabortty N, Gurav S. Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020; 24:S31-S42. [PMID: 32205955 PMCID: PMC7085814 DOI: 10.5005/jp-journals-10071-g23184] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs. MATERIALS AND METHODS All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation. RESULTS After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity. CONCLUSION This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients. HOW TO CITE THIS ARTICLE Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31-S42.
Collapse
Affiliation(s)
- Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India, , e-mail:
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, , e-mail:
| | - Dhruva Choudhry
- Department of Pulmonary & Critical Care Medicine, University of Health Sciences Rohtak, Haryana, India, , e-mail:
| | - Deepak Govil
- Department of Critical Care, Institute of Critical Care & Anesthesiology, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | | | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India, , e-mail:
| | - Zubair Mohamed
- Department of Organ Transplant Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India, , e-mail:
| | - Kv Venkatesha Gupta
- Department of Critical Care Medicine, Manipal Hospitals, Bengaluru, Karnataka, India, , e-mail:
| | - Jaya Wanchoo
- Department of Neuroanaesthesia and Critical Care, Institute of Neurosciences, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Nilanchal Chakrabortty
- Department of Neurointensive Care, Institute of Neurosciences, Kolkata, West Bengal, India, , e-mail:
| | - Sushma Gurav
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| |
Collapse
|
20
|
Reid A, Ha JF. Inhalational injury and the larynx: A review. Burns 2019; 45:1266-1274. [DOI: 10.1016/j.burns.2018.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 09/01/2018] [Accepted: 10/31/2018] [Indexed: 12/13/2022]
|
21
|
Abstract
Surgeons are often asked to perform tracheostomies and percutaneous endoscopic gastrostomies for a wide variety of patients. As consultants, surgeons are tasked with honoring the relationship between the referring provider and the patient while also assessing whether the consult is appropriate given the patient's prognosis and goals of care. This article discusses the most common conditions for which these procedures are requested and reviews the evidence supporting either the placement or avoidance of these tubes in each condition. It provides a framework for surgeons to use when discussing these procedures in the context of goals of care.
Collapse
|
22
|
Wang R, Pan C, Wang X, Xu F, Jiang S, Li M. The impact of tracheotomy timing in critically ill patients undergoing mechanical ventilation: A meta-analysis of randomized controlled clinical trials with trial sequential analysis. Heart Lung 2018; 48:46-54. [PMID: 30336945 DOI: 10.1016/j.hrtlng.2018.09.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The optimal timing of tracheotomy in critically ill ventilated patients remains controversial. OBJECTIVES The objective of this meta-analysis was to assess tracheotomy timing for critically ill ventilated patients and determine the outcomes' reliability. METHODS We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials. RESULTS Compared with late tracheotomy, early tracheotomy presented a lower incidence of ventilator-associated pneumonia (VAP), shorter duration of mechanical ventilation (MV), and shorter intensive care unit (ICU) stay. However, trial sequential analysis (TSA), a kind of cumulative meta-analysis, indicated that the evidence was unreliable and inconclusive. CONCLUSIONS The Findings suggest that early tracheotomy seems to be associated with a lower incidence of VAP, shorter duration of MV, shorter duration of sedation, and shorter ICU stay. However, the apparent benefits revealed in traditional meta-analysis contrast with the post-TSA results. More fully powered, randomized controlled trials focused on the outcomes of tracheotomy are highly warranted.
Collapse
Affiliation(s)
- Ruohui Wang
- Department of ICU, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Changkun Pan
- Department of ICU, Jiamusi Tumour Hospital, Jiamusi, China
| | - Xiaokun Wang
- Department of neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Xu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuang Jiang
- Department of ICU, Jiamusi Hospital of Chinese Medicine, Jiamusi, China.
| | - Ming Li
- Department of ICU, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.
| |
Collapse
|
23
|
Tracheostomy and mortality in patients with severe burns: A nationwide observational study. Burns 2018; 44:1954-1961. [PMID: 29980328 DOI: 10.1016/j.burns.2018.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/27/2018] [Accepted: 06/15/2018] [Indexed: 11/22/2022]
Abstract
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.
Collapse
|
24
|
Hashimoto S, Sanui M, Egi M, Ohshimo S, Shiotsuka J, Seo R, Tanaka R, Tanaka Y, Norisue Y, Hayashi Y, Nango E. The clinical practice guideline for the management of ARDS in Japan. J Intensive Care 2017; 5:50. [PMID: 28770093 PMCID: PMC5526253 DOI: 10.1186/s40560-017-0222-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/19/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Japanese Society of Respiratory Care Medicine and the Japanese Society of Intensive Care Medicine provide here a clinical practice guideline for the management of adult patients with ARDS in the ICU. METHOD The guideline was developed applying the GRADE system for performing robust systematic reviews with plausible recommendations. The guideline consists of 13 clinical questions mainly regarding ventilator settings and drug therapies (the last question includes 11 medications that are not approved for clinical use in Japan). RESULTS The recommendations for adult patients with ARDS include: we suggest against early tracheostomy (GRADE 2C), we suggest using NPPV for early respiratory management (GRADE 2C), we recommend the use of low tidal volumes at 6-8 mL/kg (GRADE 1B), we suggest setting the plateau pressure at 30cmH20 or less (GRADE2B), we suggest using PEEP within the range of plateau pressures less than or equal to 30cmH2O, without compromising hemodynamics (Grade 2B), and using higher PEEP levels in patients with moderate to severe ARDS (Grade 2B), we suggest using protocolized methods for liberation from mechanical ventilation (Grade 2D), we suggest prone positioning especially in patients with moderate to severe respiratory dysfunction (GRADE 2C), we suggest against the use of high frequency oscillation (GRADE 2C), we suggest the use of neuromuscular blocking agents in patients requiring mechanical ventilation under certain circumstances (GRADE 2B), we suggest fluid restriction in the management of ARDS (GRADE 2A), we do not suggest the use of neutrophil elastase inhibitors (GRADE 2D), we suggest the administration of steroids, equivalent to methylprednisolone 1-2mg/kg/ day (GRADE 2A), and we do not recommend other medications for the treatment of adult patients with ARDS (GRADE1B; inhaled/intravenous β2 stimulants, prostaglandin E1, activated protein C, ketoconazole, and lisofylline, GRADE 1C; inhaled nitric oxide, GRADE 1D; surfactant, GRADE 2B; granulocyte macrophage colony-stimulating factor, N-acetylcysteine, GRADE 2C; Statin.). CONCLUSIONS This article was translated from the Japanese version originally published as the ARDS clinical practice guidelines 2016 by the committee of ARDS clinical practice guideline (Tokyo, 2016, 293p, available from http://www.jsicm.org/ARDSGL/ARDSGL2016.pdf). The original article, written for Japanese healthcare providers, provides points of view that are different from those in other countries.
Collapse
Affiliation(s)
- Satoru Hashimoto
- Department of Anesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Moritoki Egi
- Department of anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Hiroshima University, Hiroshima, Japan
| | - Junji Shiotsuka
- Division of Critical Care Medicine, Okinawa Chubu Hospital, Okinawa, Japan
| | - Ryutaro Seo
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryoma Tanaka
- Pulmonary & Critical Care Medicine, LDS Hospital, Salt Lake City, USA
| | - Yu Tanaka
- Department of Anesthesiology, Nara Medical University, Nara, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Medical Center, Tokyo, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Eishu Nango
- Department of General Medicine, Tokyo kita Social Insurance Hospital, Tokyo, Japan
| |
Collapse
|
25
|
Raimondi N, Vial MR, Calleja J, Quintero A, Cortés Alban A, Celis E, Pacheco C, Ugarte S, Añón JM, Hernández G, Vidal E, Chiappero G, Ríos F, Castilleja F, Matos A, Rodriguez E, Antoniazzi P, Teles JM, Dueñas C, Sinclair J, Martínez L, Von der Osten I, Vergara J, Jiménez E, Arroyo M, Rodriguez C, Torres J, Fernandez-Bussy S, Nates JL. Evidence-based guides in tracheostomy use in critical patients. Med Intensiva 2017; 41:94-115. [PMID: 28188061 DOI: 10.1016/j.medin.2016.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 11/20/2016] [Accepted: 12/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.
Collapse
Affiliation(s)
- N Raimondi
- Hospital Municipal Juan A. Fernández, Universidad de Buenos Aires, Argentina
| | - M R Vial
- MD Anderson Cancer Center, The University of Texas, Texas, United States; Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - J Calleja
- Hospital Zambrano Hellion, Instituto Tecnológico de Monterrey, Monterrey, Nuevo León, México
| | - A Quintero
- Instituto Medico de Alta Tecnología, Universidad del Sinú, Montería, Colombia
| | - A Cortés Alban
- Clínica Mayor de Temuco, Hospital de Nueva Imperial, Universidad Mayor de Temuco, Temuco, Chile
| | - E Celis
- Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Colombia
| | - C Pacheco
- Hospital Universitario de Caracas, Caracas, Venezuela
| | - S Ugarte
- Hospital del Salvador, Clínica Indisa, Universidad de Chile, Santiago, Chile
| | - J M Añón
- Hospital Universitario la Paz -Carlos III. IdiPaz, Madrid, España
| | - G Hernández
- Complejo Hospitalario de Toledo, Toledo, España
| | - E Vidal
- Hospital Ángeles Lomas, Hospital Español de México, Ciudad de México, México
| | - G Chiappero
- Hospital Juan A. Fernández CABA, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - F Ríos
- Hospital Nacional Alejandro Posadas, Sanatorio Las Lomas, San Isidro, Buenos Aires, Argentina
| | - F Castilleja
- Hospital Zambrano Hellion, Instituto Tecnológico de Monterrey, Monterrey, Nuevo León, México
| | - A Matos
- Complejo Hospitalario Caja de Seguro Social, Panamá
| | - E Rodriguez
- Complejo Hospitalario Caja de Seguro Social, Panamá
| | - P Antoniazzi
- Hospital Santa Casa, Ribeirao Preto, Sao Paulo, Brazil
| | - J M Teles
- Hospital de Urgências de Goiânia, Goiás, Brazil
| | - C Dueñas
- Gestión Salud, Santa Cruz de Bocagrande, Universidad de Cartagena, Cartagena, Colombia
| | - J Sinclair
- Hospital Punta Pacífica, Johns Hopkins Medicine, Universidad de Panamá, Ciudad de Panamá, Panamá
| | - L Martínez
- Hospital Policlínica Metropolitana, Caracas, Venezuela
| | - I Von der Osten
- Hospital Central "Miguel Pérez Carreño" IVSS, Universidad Central de Venezuela, Caracas, Venezuela
| | - J Vergara
- Hospital Luis Vernaza, Universidad de Especialidades Espíritu Santo "UEES", Guayaquil, Ecuador
| | - E Jiménez
- Baylor Scott & White Health, Texas A&M Health Science Center College of Medicine, Temple, Texas, Estados Unidos
| | - M Arroyo
- Clínica Santa Sofía, Caracas, Venezuela
| | - C Rodriguez
- Instituto Medico de Alta Tecnología, Universidad del Sinú, Montería, Colombia
| | - J Torres
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - S Fernandez-Bussy
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile; Division of Pulmonary, Critical Care & Sleep Medicine, University of Florida, Gainesville, Florida, Estados Unidos
| | - J L Nates
- MD Anderson Cancer Center, The University of Texas, Texas, United States.
| |
Collapse
|
26
|
Raimondi N, Vial MR, Calleja J, Quintero A, Cortés A, Celis E, Pacheco C, Ugarte S, Añón JM, Hernández G, Vidal E, Chiappero G, Ríos F, Castilleja F, Matos A, Rodriguez E, Antoniazzi P, Teles JM, Dueñas C, Sinclair J, Martínez L, von der Osten I, Vergara J, Jiménez E, Arroyo M, Rodríguez C, Torres J, Fernandez-Bussy S, Nates JL. Evidence-based guidelines for the use of tracheostomy in critically ill patients. J Crit Care 2016; 38:304-318. [PMID: 28103536 DOI: 10.1016/j.jcrc.2016.10.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To provide evidence-based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS A taskforce composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified, of which 226 publications were chosen. The taskforce generated a total of 19 recommendations, 10 positive (1B, 3; 2C, 3; 2D, 4) and 9 negative (1B, 8; 2C, 1). A recommendation was not possible in 6 questions. CONCLUSIONS Percutaneous techniques are associated with a lower risk of infections compared with surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.
Collapse
Affiliation(s)
- Néstor Raimondi
- Hospital Municipal Juan A. Fernández, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Macarena R Vial
- MD Anderson Cancer Center, The University of Texas, Houston, TX, USA; Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - José Calleja
- Hospital Zambrano Hellion, Instituto Tecnológico de Monterrey, Monterrey, México
| | - Agamenón Quintero
- Instituto Médico de Alta Tecnología, Universidad del Sinú, Montería, Córdoba, Colombia
| | - Albán Cortés
- Clínica Mayor de Temuco, Hospital de Nueva Imperial, Universidad Mayor de Temuco, Temuco, Chile
| | - Edgar Celis
- Hospital Universitario Fundación Santa Fé de Bogotá, Bogotá, Colombia
| | - Clara Pacheco
- Hospital Universitario de Caracas, Caracas, Venezuela
| | - Sebastián Ugarte
- Hospital del Salvador, Clínica Indisa, Universidad de Chile, Santiago, Chile
| | - José M Añón
- Hospital Universitario La Paz-Carlos III. IdiPaz, Madrid, Spain
| | | | - Erick Vidal
- Hospital Ángeles Lomas, Hospital Español de México, Ciudad de México, México
| | - Guillermo Chiappero
- Hospital Juan A. Fernández CABA, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Ríos
- Hospital Nacional Alejandro Posadas, Sanatorio Las Lomas, San Isidro, Buenos Aires, Argentina
| | - Fernando Castilleja
- Hospital Zambrano Hellion, Instituto Tecnológico de Monterrey, Monterrey, México
| | - Alfredo Matos
- Complejo Hospitalario Caja de Seguro Social, Ciudad de Panamá, Panamá
| | - Enith Rodriguez
- Complejo Hospitalario Caja de Seguro Social, Ciudad de Panamá, Panamá
| | - Paulo Antoniazzi
- Hospital Santa Casa de Ribeirão Preto, Centro Universitário Barao de Maua, São Paulo, Brazil
| | | | - Carmelo Dueñas
- Gestión Salud, Santa Cruz de Bocagrande, Universidad de Cartagena, Cartagena, Colombia
| | - Jorge Sinclair
- Hospital Punta Pacífica, Johns Hopkins Medicine, Universidad de Panamá, Ciudad de Panamá, Panamá
| | | | - Ingrid von der Osten
- Hospital Central "Miguel Pérez Carreño" IVSS, Universidad Central de Venezuela, Caracas, Venezuela
| | - José Vergara
- Hospital Luis Vernaza, Universidad de Especialidades Espíritu Santo "UEES,", Guayaquil, Ecuador
| | - Edgar Jiménez
- Baylor Scott & White Health, Texas A&M Health Science Center College of Medicine, Temple, TX, USA
| | | | - Camilo Rodríguez
- Instituto Médico de Alta Tecnología, Universidad del Sinú, Montería, Córdoba, Colombia
| | - Javier Torres
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Sebastián Fernandez-Bussy
- Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile; Division of Pulmonary, Critical Care & Sleep Medicine, University of Florida, Gainesville, FL
| | - Joseph L Nates
- MD Anderson Cancer Center, The University of Texas, Houston, TX, USA.
| | | |
Collapse
|
27
|
Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2016; 26:14-25. [DOI: 10.1007/s12028-016-0297-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
|
28
|
Longworth A, Veitch D, Gudibande S, Whitehouse T, Snelson C, Veenith T. Tracheostomy in special groups of critically ill patients: Who, when, and where? Indian J Crit Care Med 2016; 20:280-4. [PMID: 27275076 PMCID: PMC4876649 DOI: 10.4103/0972-5229.182202] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Tracheostomy is one of the most common procedures undertaken in critically ill patients. It offers many theoretical advantages over translaryngeal intubation. Recent evidence in a heterogeneous group of critically ill patients, however, has not demonstrated a benefit for tracheostomy, in terms of mortality, length of stay in Intensive Care Unit (ICU), or incidence of ventilator-associated pneumonia. It may be a beneficial intervention in articular subsets of ICU patients. In this article, we will focus on the evidence for the timing of tracheostomy and its effect on various subgroups of patients in critical care.
Collapse
Affiliation(s)
- Aisling Longworth
- Department of Critical Care Medicine, Intensive Care Unit, University College Hospital, London, UK
| | - David Veitch
- Department of Critical Care Medicine, Intensive Care Unit, University College Hospital, London, UK
| | - Sandeep Gudibande
- Department of Critical Care Medicine, Critical Care Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tony Whitehouse
- Department of Critical Care Medicine, Critical Care Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust, Birmingham, UK
| | - Catherine Snelson
- Department of Critical Care Medicine, Critical Care Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tonny Veenith
- Department of Critical Care Medicine, Critical Care Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust, Birmingham, UK; Department of Medicine, Division of Anaesthesia, University of Cambridge, Cambridge, UK
| |
Collapse
|
29
|
Chung KK, Rhie RY, Lundy JB, Cartotto R, Henderson E, Pressman MA, Joe VC, Aden JK, Driscoll IR, Faucher LD, McDermid RC, Mlcak RP, Hickerson WL, Jeng JC. A Survey of Mechanical Ventilator Practices Across Burn Centers in North America. J Burn Care Res 2016; 37:e131-9. [PMID: 26135527 PMCID: PMC5312724 DOI: 10.1097/bcr.0000000000000270] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The χ, Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.
Collapse
Affiliation(s)
- Kevin K. Chung
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Ryan Y. Rhie
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Jonathan B. Lundy
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Robert Cartotto
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Elizabeth Henderson
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Melissa A. Pressman
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Victor C. Joe
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - James K. Aden
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Ian R. Driscoll
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Lee D. Faucher
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Robert C. McDermid
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - Ronald P. Mlcak
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - William L. Hickerson
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| | - James C. Jeng
- From the United States Army Institute of Surgical Research, Fort Sam Houston, Texas; Uniformed Services University of the Health Sciences, Bethesda, Maryland; Sunnybrook Health Sciences Centre, Toronto, Canada; Massachusetts General Hospital, Boston; Arizona Burn Center, Phoenix; University of California Irvine Regional Burn Center, Orange; University of Wisconsin Hospital, Madison; University of Alberta, Edmonton, Canada; Shriners Hospital for Children, Galveston, Texas; Memphis Burn Center, Memphis, Tennessee; and Mount Sinai Beth Israel Medical Center, New York, New York
| |
Collapse
|
30
|
Voineskos SH, Coroneos CJ, Ziolkowski NI, Kaur MN, Banfield L, Meade MO, Thoma A, Chung KC, Bhandari M. A Systematic Review of Surgical Randomized Controlled Trials. Plast Reconstr Surg 2016; 137:696-706. [DOI: 10.1097/01.prs.0000475766.83901.5b] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
31
|
Hosokawa K, Nishimura M, Egi M, Vincent JL. Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:424. [PMID: 26635016 PMCID: PMC4669624 DOI: 10.1186/s13054-015-1138-8] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/17/2015] [Indexed: 01/23/2023]
Abstract
Introduction The optimal timing of tracheotomy in critically ill patients remains a topic of debate. We performed a systematic review to clarify the potential benefits of early versus late tracheotomy. Methods We searched PubMed and CENTRAL for randomized controlled trials that compared outcomes in patients managed with early and late tracheotomy. A random-effects meta-analysis, combining data from three a priori-defined categories of timing of tracheotomy (within 4 versus after 10 days, within 4 versus after 5 days, within 10 versus after 10 days), was performed to estimate the weighted mean difference (WMD) or odds ratio (OR). Results Of the 142 studies identified in the search, 12, including a total of 2,689 patients, met the inclusion criteria. The tracheotomy rate was significantly higher with early than with late tracheotomy (87 % versus 53 %, OR 16.1 (5.7-45.7); p <0.01). Early tracheotomy was associated with more ventilator-free days (WMD 2.12 (0.94, 3.30), p <0.01), a shorter ICU stay (WMD -5.14 (-9.99, -0.28), p = 0.04), a shorter duration of sedation (WMD -5.07 (-10.03, -0.10), p <0.05) and reduced long-term mortality (OR 0.83 (0.69-0.99), p = 0.04) than late tracheotomy. Conclusions This updated meta-analysis reveals that early tracheotomy is associated with higher tracheotomy rates and better outcomes, including more ventilator-free days, shorter ICU stays, less sedation, and reduced long-term mortality, compared to late tracheotomy. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1138-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Koji Hosokawa
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Masaji Nishimura
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan.
| | - Moritoki Egi
- Department Intensive Care, Kobe University Hospital, Kobe-city, Hyogo, Japan.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| |
Collapse
|
32
|
The Intensive Care Management of the Adult Burns Patient. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0129-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
33
|
Bice T, Nelson JE, Carson SS. To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill. Semin Respir Crit Care Med 2015; 36:851-8. [PMID: 26595045 DOI: 10.1055/s-0035-1564872] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging.
Collapse
Affiliation(s)
- Thomas Bice
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Shannon S Carson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
34
|
Fire disaster caused by LPG tanker explosion at Lice in Diyarbakır (Turkey): July 21, 2014. Burns 2015; 41:1347-52. [DOI: 10.1016/j.burns.2015.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 01/21/2015] [Accepted: 02/02/2015] [Indexed: 11/18/2022]
|
35
|
Mourelo M, Galeiras R, Pértega S, Freire D, López E, Broullón J, Campos E. Tracheostomy in the management of patients with thermal injuries. Indian J Crit Care Med 2015; 19:449-55. [PMID: 26321803 PMCID: PMC4548413 DOI: 10.4103/0972-5229.162460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: To assess the use and clinical impact of tracheostomy in burn patients. Summary Background Data: The role of tracheostomy in the management of burn patients is controversial, with only a few recent studies conducted in this population. Methods: Retrospective study of all adult burn patients who underwent a tracheostomy in a Burns Unit between 1995 and 2013. These were compared with a control group (1:1) who underwent orotracheal intubation. Hospital records were reviewed to obtain demographic and clinical information, including those related to respiratory support and tracheostomy. The McNemar's Chi-square and Signed-Rank Tests were used to study differences in morbimortality between both groups. Results: A total of n = 20 patients underwent tracheostomy (0.9% of admissions, 56.0 ± 19.5 years, 60.0% women). The most common indication was long-term ventilation (75%), 24.6 ± 19.7 days after admission. Thirteen patients were successfully decannulated with a fatal complication observed in one case. Patients in the tracheostomy group were found to require longer-term mechanical ventilation (43.2 vs. 20.4 days; P = 0.004), with no differences in respiratory infection rates (30.0% vs. 31.6%; P = 0.687) or mortality (30.0% vs. 42.1%; P = 0.500). Ventilator weaning times (15.7 vs. 3.3 days; P = 0.001) and hospital stays (99.1 vs. 53.1 days; P = 0.030) were longer in the tracheostomy group, with no differences in duration of sedation. Conclusions: Tracheostomy may be a safe procedure in burn patients and is not associated with higher rates of mortality or respiratory infection. Tracheostomy patients showed longer mechanical ventilation times and higher morbidity, probably not attributable to tracheostomy.
Collapse
Affiliation(s)
- Mónica Mourelo
- Department of Critical Care, University Hospital of A Coruna, A Coruña, Spain
| | - Rita Galeiras
- Department of Critical Care, University Hospital of A Coruna, A Coruña, Spain
| | - Sonia Pértega
- Department of Clinical Epidemiology and Biostatistics, University Hospital of A Coruna, A Coruña, Spain
| | - David Freire
- Department of Critical Care, University Hospital of A Coruna, A Coruña, Spain
| | - Eugenia López
- Department of Plastic Surgery, Burn Unit, University Hospital of A Coruna, A Coruña, Spain
| | - Javier Broullón
- Department of Health Information Technology, University Hospital of A Coruna, A Coruña, Spain
| | - Eva Campos
- Department of Plastic Surgery, Burn Unit, University Hospital of A Coruna, A Coruña, Spain
| |
Collapse
|
36
|
Patel SA, Plowman EK, Halum S, Merati AL, Sardesai MG. Late tracheotomy is associated with higher morbidity and mortality in mechanically ventilated patients. Laryngoscope 2015; 125:2134-8. [PMID: 26152892 DOI: 10.1002/lary.25322] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 03/16/2015] [Accepted: 03/18/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine whether the timing of tracheotomy placement impacts ventilation weaning status and mortality. STUDY DESIGN Multi-institution retrospective cohort study. METHODS Demographic data, procedural details, and clinical outcomes were recorded for patients undergoing tracheotomy for prolonged mechanical ventilation across eight sites. The study group was divided into two groups: those undergoing tracheotomy within 14 days of initiation of mechanical ventilation and those undergoing tracheotomy at or after 14 days. Groups were compared for primary outcome measures of mortality and ability to wean from mechanical ventilation within the study period. RESULTS Of the 539 patients intubated for ventilator dependence with complete data available, 280 (51.9%) underwent tracheotomy within 14 days. Patients who underwent late tracheotomy were 1.72 times more likely to remain ventilator dependent during the follow-up period (95% confidence interval [CI]: 1.12-2.66), and had a 40% increased risk of death (odds ratio: 1.4, 95% CI: 0.96-1.99). CONCLUSIONS In this multicenter retrospective review of tracheotomy outcomes, late tracheotomy placement (>14 days) was associated with increased mortality and prolonged ventilator dependence. Standardized multidisciplinary management protocols for prolonged mechanical ventilation are recommended, and future work should confirm these results in a prospective manner. LEVEL OF EVIDENCE 4.
Collapse
Affiliation(s)
- Sapna A Patel
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | | | - Stacey Halum
- Department of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, U.S.A
| | - Albert L Merati
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Maya G Sardesai
- Department of Otolaryngology-Head & Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| |
Collapse
|
37
|
Meng L, Wang C, Li J, Zhang J. Early vs late tracheostomy in critically ill patients: a systematic review and meta-analysis. CLINICAL RESPIRATORY JOURNAL 2015; 10:684-692. [PMID: 25763477 DOI: 10.1111/crj.12286] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 02/28/2015] [Indexed: 12/26/2022]
Affiliation(s)
- Liang Meng
- Intensive Care Unit of Vascular Surgery Department; Xuanwu Hospital; Capital Medical University; Beijing China
| | - Chunmei Wang
- Intensive Care Unit of Vascular Surgery Department; Xuanwu Hospital; Capital Medical University; Beijing China
| | - Jianxin Li
- Intensive Care Unit of Vascular Surgery Department; Xuanwu Hospital; Capital Medical University; Beijing China
| | - Jian Zhang
- Intensive Care Unit of Vascular Surgery Department; Xuanwu Hospital; Capital Medical University; Beijing China
| |
Collapse
|
38
|
Keenan JE, Gulack BC, Nussbaum DP, Green CL, Vaslef SN, Shapiro ML, Scarborough JE. Optimal timing of tracheostomy after trauma without associated head injury. J Surg Res 2015; 198:475-81. [PMID: 25976854 DOI: 10.1016/j.jss.2015.03.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/19/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Controversy exists over optimal timing of tracheostomy in patients with respiratory failure after blunt trauma. The study aimed to determine whether the timing of tracheostomy affects mortality in this population. METHODS The 2008-2011 National Trauma Data Bank was queried to identify blunt trauma patients without concomitant head injury who required tracheostomy for respiratory failure between hospital days 4 and 21. Restricted cubic spline analysis was performed to evaluate the relationship between tracheostomy timing and the odds of inhospital mortality. The cohort was stratified based on this analysis. Unadjusted characteristics and outcomes were compared. Multivariable logistic regression was used to evaluate the effect of tracheostomy timing on mortality after adjustment for age, gender, race, payor status, level of trauma center, injury severity score, presentation Glasgow coma scale, and thoracic and abdominal abbreviated injury score. RESULTS There were 9662 patients included in the study. Restricted cubic spline analysis demonstrated a nonlinear relationship between timing of tracheostomy and mortality, with higher odds of mortality occurring with tracheostomy placement within 10 d of admission compared with later time points. The cohort was therefore stratified into early and delayed tracheostomy groups relative to this time point. The resulting groups contained 5402 (55.9%) and 4260 (44.1%) patients, respectively. After multivariable adjustment, the delayed tracheostomy group continued to have significantly reduced odds of mortality (Adjusted odds ratio, 0.82, 95% confidence interval, 0.71-0.95, C-statistic, 0.700). CONCLUSIONS Among non-head injured blunt trauma patients with prolonged respiratory failure, tracheostomy placement within 10 d of admission may result in increased mortality compared with later time points.
Collapse
Affiliation(s)
- Jeffrey E Keenan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Cindy L Green
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Steven N Vaslef
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark L Shapiro
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John E Scarborough
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| |
Collapse
|
39
|
Choix et gestion des différents types de canules de trachéotomie en réanimation. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1037-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
40
|
Abstract
OBJECTIVES Tracheostomy is a common procedure in the ICU when prolonged mechanical ventilation is expected. Although adult data show morbidity and mortality benefits over translaryngeal intubation, there is no consensus on optimal timing. In the pediatric population, there is sparse data regarding morbidities associated with duration of ventilation prior to tracheostomy. Our objective was to associate timing of tracheostomy with clinical outcomes in PICU patients. DESIGN This is a retrospective cohort study of patients undergoing tracheostomy. Patient factors and duration of ventilation prior to tracheostomy were collected on each patient. Morbidities such as ventilator-associated pneumonia, central catheter-associated bloodstream infection, and cardiopulmonary arrests were examined both pre- and posttracheostomy. ICU and total hospital length of stay as well as mortality were recorded. For data analysis regarding tracheostomy timing, patients were stratified into early and late groups using a cutoff of 14 days. SETTING The PICUs and cardiac ICUs in a quaternary-care children's hospital. PATIENTS All patients undergoing tracheostomy over a 3-year period. MEASUREMENTS AND MAIN RESULTS Seventy-three patients were analyzed with a median of 22 days of ventilation prior to tracheostomy. Patient factors associated with longer pretracheostomy ventilation included congenital heart disease and vasoactive drug use. Clinical events associated with longer pretracheostomy ventilation included bloodstream infection, ventilator-associated pneumonia, and cardiac arrest. Age, congenital heart disease, vasoactive drug use, bloodstream infection, and ventilator-associated pneumonia each independently increased pretracheostomy ventilator days. Median ICU length of stay after tracheostomy was 18 days. For each pretracheostomy ventilator day, ICU length of stay increased by 0.5 days and hospital length of stay increased by 1.9 days. For patients undergoing early tracheostomy, ICU and total hospital lengths of stay were 4 days and 4 weeks shorter, respectively. CONCLUSIONS Analysis of our results suggests that a longer duration of ventilation prior to tracheostomy is associated with increased ICU morbidities and length of stay. Early tracheostomy may have significant benefits without adversely affecting mortality.
Collapse
|
41
|
Siempos II, Ntaidou TK, Filippidis FT, Choi AMK. Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2015; 3:150-158. [DOI: 10.1016/s2213-2600(15)00007-7] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
42
|
Andriolo BNG, Andriolo RB, Saconato H, Atallah ÁN, Valente O. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev 2015; 1:CD007271. [PMID: 25581416 PMCID: PMC6517297 DOI: 10.1002/14651858.cd007271.pub3] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Brenda NG Andriolo
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Regis B Andriolo
- Universidade do Estado do ParáDepartment of Public HealthTravessa Perebebuí, 2623BelémParáBrazil66087‐670
| | - Humberto Saconato
- Santa Casa de Campo MourãoDepartment of MedicineBR 158 Saída para Peabiru, 2761Campo MourãoCampo MourãoBrazil87309‐650
| | - Álvaro N Atallah
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Orsine Valente
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeBrazilian Cochrane CentreRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | | |
Collapse
|
43
|
Szakmany T, Russell P, Wilkes AR, Hall JE. Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials. Br J Anaesth 2014; 114:396-405. [PMID: 25534400 DOI: 10.1093/bja/aeu440] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Early tracheostomy may decrease the duration of mechanical ventilation, sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes, but the evidence is conflicting. METHODS Systematic review and meta-analysis of randomized trials in patients allocated to tracheostomy within 10 days of start of mechanical ventilation was compared with placement of tracheostomy after 10 days if still required. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register, and Google Scholar were searched for eligible trials. The co-primary outcomes were mortality within 60 days, and duration of mechanical ventilation, sedation, and intensive care unit stay. Secondary outcomes were the number of tracheostomy procedures performed, and incidence of ventilator-associated pneumonia (VAP). Outcomes are described as relative risk or weighted mean difference with 95% confidence intervals. RESULTS Of note, 4482 publications were identified and 14 trials enrolling 2406 patients were included. Tracheostomy within 10 days was not associated with any difference in mortality [risk ratio (RR): 0.93 (0.83-1.05)]. There were no differences in duration of mechanical ventilation [-0.19 days (-1.13-0.75)], intensive care stay [-0.83 days (-2.05-0.40)], or incidence of VAP. However, duration of sedation was reduced in the early tracheostomy groups [-2.78 days (-3.68 to -1.88)]. More tracheostomies were performed in patients randomly assigned to receive early tracheostomy [RR: 2.53 (1.18-5.40)]. CONCLUSION We found no evidence that early (within 10 days) tracheostomy reduced mortality, duration of mechanical ventilation, intensive care stay, or VAP. Early tracheostomy leads to more procedures and a shorter duration of sedation.
Collapse
Affiliation(s)
- T Szakmany
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK Cwm Taf UHB, Royal Glamorgan Hospital, Llantrisant, UK
| | - P Russell
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK
| | - A R Wilkes
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK
| | - J E Hall
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK
| |
Collapse
|
44
|
Liu CC, Livingstone D, Dixon E, Dort JC. Early versus Late Tracheostomy. Otolaryngol Head Neck Surg 2014; 152:219-27. [DOI: 10.1177/0194599814561606] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To investigate whether early tracheostomy leads to improved outcomes compared with late tracheostomy. Data Sources Ovid MEDLINE (including PubMed), Embase, and the Cochrane Central Register of Controlled Trials. Review Methods A systematic search was performed of the above-mentioned databases according to PRISMA guidelines. Data were collected on the following outcomes of interest: hospital mortality, intensive care unit length of stay, length of mechanical ventilation, incidence of pneumonia, laryngotracheal injury, and sedation use. Analysis was performed using the RevMan 5 software (Cochrane Collaboration, Oxford, England). Results Eleven studies were included for analysis. There was a significant decrease in the intensive care unit length of stay in the early tracheostomy group (weighted mean difference, −9.13 days; 95% confidence interval [CI], −17.55 to −0.70; P = .03). There was no significant difference in hospital mortality (relative risk, 0.84; 95% CI, 0.67 to 1.04; P = .11). A pooled analysis was not performed for the incidence of pneumonia or length of mechanical ventilation, secondary to considerable heterogeneity among the studies. None of the studies reporting laryngotracheal outcomes found a significant difference between the early and late tracheostomy groups, whereas all 3 studies reporting sedation use found a significant decrease in the early tracheostomy group. Conclusion Early tracheostomy performed within 7 days of intubation was associated with a decrease in intensive care unit length of stay. No difference was found in hospital mortality. Insufficient data currently exist to make conclusions about the effect of early tracheostomy on the incidence of pneumonia, length of mechanical ventilation, laryngotracheal injury, or sedation use.
Collapse
Affiliation(s)
- C. Carrie Liu
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Alberta, Canada
| | - Devon Livingstone
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Alberta, Canada
| | - Elijah Dixon
- Division of General Surgery, Department of Surgery, University of Calgary, Alberta, Canada
| | - Joseph C. Dort
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Calgary, Alberta, Canada
- Ohlson Research Initiative, University of Calgary, Alberta, Canada
| |
Collapse
|
45
|
Diaz-Prieto A, Mateu A, Gorriz M, Ortiga B, Truchero C, Sampietro N, Ferrer MJ, Mañez R. A randomized clinical trial for the timing of tracheotomy in critically ill patients: factors precluding inclusion in a single center study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:585. [PMID: 25358451 PMCID: PMC4234827 DOI: 10.1186/s13054-014-0585-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 10/09/2014] [Indexed: 11/16/2022]
Abstract
Introduction We investigated the potential benefits of early tracheotomy performed before day eight of mechanical ventilation (MV) compared with late tracheotomy (from day 14 if it still indicated) in reducing mortality, days of MV, days of sedation and ICU length of stay (LOS). Methods Randomized controlled trial (RCT) including all-consecutive ICU admitted patients requiring seven or more days of MV. Between days five to seven of MV, before randomization, the attending physician (AP) was consulted about the expected duration of MV and acceptance of tracheotomy according to randomization. Only accepted patients received tracheotomy as result of randomization. An intention to treat analysis was performed including patients accepted for the AP and those rejected without exclusion criteria. Results A total of 489 patients were included in the RCT. Of 245 patients randomized to the early group, the procedure was performed for 167 patients (68.2%) whereas in the 244 patients randomized to the late group was performed for 135 patients (55.3%) (P <0.004). Mortality at day 90 was similar in both groups (25.7% versus 29.9%), but duration of sedation was shorter in the early tracheotomy group median 11 days (range 2 to 92) days compared to 14 days (range 0 to 79) in the late group (P <0.02). The AP accepted the protocol of randomization in 205 cases (42%), 101 were included in early group and 104 in the late group. In these subgroup of patients (per-protocol analysis) no differences existed in mortality at day 90 between the two groups, but the early group had more ventilator-free days, less duration of sedation and less LOS, than the late group. Conclusions This study shows that early tracheotomy reduces the days of sedation in patients undergoing MV, but was underpowered to prove any other benefit. In those patients selected by their attending physicians as potential candidates for a tracheotomy, an early procedure can lessen the days of MV, the days of sedation and LOS. However, the imprecision of physicians to select patients who will require prolonged MV challenges the potential benefits of early tracheotomy. Trial registration Controlled-Trials.com ISRCTN22208087. Registered 27 March 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0585-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Antonio Diaz-Prieto
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| | - Antoni Mateu
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| | - Maite Gorriz
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| | - Berta Ortiga
- Departament de Gerencia, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| | - Consol Truchero
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| | - Neus Sampietro
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| | - María Jesus Ferrer
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| | - Rafael Mañez
- Servei de Medicina Intensiva, Hospital Universitari de Bellvitge, C/Feixa Llarga, Hospitalet de Llobregat, Barcelona, 08907, Spain.
| |
Collapse
|
46
|
Liu X, Wang HC, Xing YW, He YL, Zhang ZF, Wang T. The effect of early and late tracheotomy on outcomes in patients: a systematic review and cumulative meta-analysis. Otolaryngol Head Neck Surg 2014; 151:916-22. [PMID: 25305270 DOI: 10.1177/0194599814552415] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To compare the effect of early tracheotomy (ET) and late tracheotomy (LT) on ventilator-associated pneumonia (VAP) incidence and short-term mortality in critically ill patients who received mechanical ventilation. DATA SOURCES We searched databases of PubMed, Embase, and others for randomized controlled trials (RCTs) that compared ET (≤ 8 days after admission to the intensive care unit, initiation of translaryngeal intubation, or initiation of mechanical ventilation) with LT (≥ 6 days) in critically ill patients. REVIEW METHODS The overall odds ratio (OR) was estimated by traditional meta-analysis. In addition, cumulative meta-analysis was conducted by adding 1 study at a time in the order of year of publication. RESULTS A total of 11 RCTs involving 1436 patients (708 in the ET group and 728 in the LT group) were included in this analysis. Early tracheotomy could significantly reduce the short-term mortality (OR = 0.74; 95% confidence interval [CI] [0.58, 0.95]) but did not reduce the VAP incidence (OR = 0.70; 95% CI [0.47, 1.04]). The cumulative meta-analysis showed that evidence of the benefit of ET on VAP incidence was unstable over time. In contrast, the difference in short-term mortality was stable from the first appearance during the cumulative meta-analysis. CONCLUSION Early tracheotomy could improve short-term mortality but did not alter VAP incidence. Many factors may be responsible for the unstable results during cumulative meta-analysis, and further study is still needed to explore the optimal timing of tracheotomy.
Collapse
Affiliation(s)
- Xiao Liu
- Department of Infectious Diseases, Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hong-Chao Wang
- Department of General Surgery, Maternal and Child Health Hospital of Pinggu District, Beijing, China
| | - Ya-Wei Xing
- Department of Infectious Diseases, Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan-Ling He
- Department of Infectious Diseases, Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ze-Feng Zhang
- Department of Thoracic Surgery, Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tao Wang
- Department of Thoracic Surgery, Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
47
|
Siempos II, Ntaidou TK, Filippidis FT, Choi AMK. RETRACTED: Effect of early versus late or no tracheostomy on mortality of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. THE LANCET. RESPIRATORY MEDICINE 2014:S2213-2600(14)70125-0. [PMID: 24981963 DOI: 10.1016/s2213-2600(14)70125-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delay of tracheostomy for roughly 2 weeks after translaryngeal intubation of critically ill patients is the presently recommended practice and is supported by findings from large trials. However, these trials were suboptimally powered to detect small but clinically important effects on mortality. We aimed to assess the mortality benefit of early versus late or no tracheostomy in critically ill patients who need mechanical ventilation. METHODS We systematically searched PubMed, CINAHL, Embase, Web of Science, DOAJ, the Cochrane Library, references of relevant articles, scientific conference proceedings, and grey literature up to Aug 31, 2013, to identify randomised controlled trials comparing early tracheostomy (done within 1 week after translaryngeal intubation) with late (done any time after the first week of mechanical ventilation) or no tracheostomy and reporting on mortality or incidence of pneumonia in critically ill patients under mechanical ventilation. Our primary outcomes were all-cause mortality during the stay in the intensive-care unit and incidence of ventilator-associated pneumonia. We calculated pooled odds ratios (OR), pooled risk ratios (RR), and 95% CIs with a random-effects model. All but complications analyses were done on an intention-to-treat basis. FINDINGS Analyses of 13 trials (2434 patients, 800 deaths) showed that all-cause mortality in the intensive-care unit was significantly lower in patients assigned to the early versus the late or no tracheostomy group (OR 0·72, 95% CI 0·53-0·98; p=0·04). This finding represents an 18% reduction in the relative risk of death, translating to a 5% absolute improvement in survival (from 65% to 70%). This result persisted when we considered only trials with a low risk of bias (663 deaths; OR 0·68, 95% CI 0·49-0·95; p=0·02; eight trials with 1934 patients). There was no evidence of a difference between the compared groups for 1-year mortality (788 deaths; RR 0·93, 95% CI 0·85-1·02; p=0·14; three trials with 1529 patients). INTERPRETATION The synthesised evidence suggests that early tracheostomy is associated with lower mortality in the intensive-care unit than late or no tracheostomy; a finding that might question the present practice of delaying tracheostomy beyond the first week after translaryngeal intubation in mechanically ventilated patients. However, the scarcity of a beneficial effect on long-term mortality and the potential complications associated with tracheostomy need careful consideration; thus, further studies focusing on long-term outcomes are warranted. FUNDING None.
Collapse
Affiliation(s)
- Ilias I Siempos
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece; Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medical College, New York, NY, USA.
| | - Theodora K Ntaidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece
| | | | - Augustine M K Choi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York-Presbyterian Hospital-Weill Cornell Medical Center, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
48
|
Huang H, Li Y, Ariani F, Chen X, Lin J. Timing of tracheostomy in critically ill patients: a meta-analysis. PLoS One 2014; 9:e92981. [PMID: 24667875 PMCID: PMC3965497 DOI: 10.1371/journal.pone.0092981] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/27/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To compare important outcomes between early tracheostomy (ET) and late tracheostomy (LT) or prolonged intubation (PI) for critically ill patients receiving long-term ventilation during their treatment. METHOD We performed computerized searches for relevant articles on PubMed, EMBASE, and the Cochrane register of controlled trials (up to July 2013). We contacted international experts and manufacturers. We included in the study randomized controlled trials (RCTs) that compared ET (performed within 10 days after initiation of laryngeal intubation) and LT (after 10 days of laryngeal intubation) or PI in critically ill adult patients admitted to intensive care units (ICUs). Two investigators evaluated the articles; divergent opinions were resolved by consensus. RESULTS A meta-analysis was evaluated from nine randomized clinical trials with 2,072 participants. Compared to LT/PI, ET did not significantly reduce short-term mortality [relative risks (RR) = 0.91; 95% confidence intervals (CIs) = 0.81-1.03; p = 0.14] or long-term mortality (RR = 0.90; 95% CI = 0.76-1.08; p = 0.27). Additionally, ET was not associated with a markedly reduced length of ICU stay [weighted mean difference (WMD) = -4.41 days; 95% CI = -13.44-4.63 days; p = 0.34], ventilator-associated pneumonia (VAP) (RR = 0.88; 95% CI = 0.71-1.10; p = 0.27) or duration of mechanical ventilation (MV) (WMD = - 2.91 days; 95% CI = -7.21-1.40 days; p = 0.19). CONCLUSION Among the patients requiring prolonged MV, ET showed no significant difference in clinical outcomes compared to that of the LT/PI group. But more rigorously designed and adequately powered RCTs are required to confirm it in future.
Collapse
Affiliation(s)
- Huibin Huang
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Ying Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Felinda Ariani
- Department of Pulmonary Medicine, Huadong Hospital, Shanghai Medical School of Fudan University, Shanghai, China
| | - Xiaoli Chen
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jiandong Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- * E-mail:
| |
Collapse
|
49
|
Breckenridge SJ, Chlan L, Savik K. Impact of tracheostomy placement on anxiety in mechanically ventilated adult ICU patients. Heart Lung 2014; 43:392-8. [PMID: 24559754 DOI: 10.1016/j.hrtlng.2014.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Revised: 01/10/2014] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine if self-reported anxiety levels decreased after tracheostomy placement in a sample of mechanically ventilated intensive care unit patients. BACKGROUND There is limited research regarding the impact of a tracheostomy on patients' anxiety. Elevated anxiety delays healing and contributes to long-term mental health complications. METHODS This was a secondary analysis of data from a large clinical trial conducted in urban Minnesota. Fifty-one of 116 patients received a tracheostomy. Anxiety scores were obtained daily using the Visual Analog Scale-Anxiety. Mixed model analysis was used to compare anxiety ratings pre- and post-tracheostomy. RESULTS There was no significant decrease in anxiety following tracheostomy after controlling for time and gender (all p > .16). Age was the only variable to impact anxiety levels: anxiety scores increased as age increased (p = .02). CONCLUSIONS Prospective studies are needed to more accurately assess the impact of tracheostomy placement on patient anxiety and salient outcomes.
Collapse
Affiliation(s)
| | - Linda Chlan
- Symptom Management Research, College of Nursing, Ohio State University, 398 Newton Hall, 1585 Neil Avenue, Columbus, OH 43210, USA
| | - Kay Savik
- School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN 55455, USA
| |
Collapse
|
50
|
Effect of timing of tracheotomy on clinical outcomes: an update meta-analysis including 11 trials. ACTA ACUST UNITED AC 2013; 28:159-66. [PMID: 24074618 DOI: 10.1016/s1001-9294(13)60042-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To estimate the relative effect of early vs. late tracheotomy on clinical end-points in unselected intensive care unit (ICU) patients undergoing mechanical ventilation. METHODS We searched electronic databases (up to February 27, 2013) for both randomized control trials and observational studies satisfying the predefined inclusion criteria. RESULTS We retrieved 11 reports of studies including a total of 13 705 patients. Early tracheotomy was associated with significant reductions in mortality [33.3% vs. 36.3%; relative risk (RR); 0.92; 95% confidence interval (CI): 0.88, 0.97; I(2): 29%], length of ICU stay (mean difference: -6.55 days; 95% CI: -8.19, -4.90; I(2): 98%) and duration of mechanical ventilation (mean difference: -6.53 days; 95% CI: -11.43, -1.63; I(2): 100%). However, as compared with late tracheotomy, early tracheotomy did not reduce the incidence of hospital pneumonia (21.9% vs. 21.0%, RR: 0.85; 95% CI: 0.68, 1.06; I(2): 67%). CONCLUSIONS Early tracheotomy can reduce length of ICU stay, duration of mechanical ventilation and mortality but has no influence on hospital pneumonia when compared with late tracheotomy. Once the decision has been made about tracheotomy, clinical physicians should not hesitate to perform the procedure.
Collapse
|