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

Tracheostomy: update on why, when and how

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Tracheostomy Practice in the Italian Intensive Care Units: A Point-Prevalence Survey

Background and Objectives: A tracheostomy is a frequently performed surgical intervention in intensive care units (ICUs) for patients requiring prolonged mechanical ventilation. This procedure can offer significant benefits, including reduced sedation requirements, improved patient comfort, and enhanced airway management. However, it is also associated with various risks, and the absence of standardized clinical guidelines complicates its implementation. This study aimed to determine the prevalence of tracheostomy among ICU patients, while also evaluating patient characteristics, complication rates, and overall outcomes related to the procedure. Materials and Methods: We conducted an observational, cross-sectional, point-prevalence survey across eight ICUs in Italy. Data were collected over two 24 h periods in March and April 2024, with a focus on ICU characteristics, patient demographics, the details of tracheostomy procedures, and associated complications. Results: Among the 92 patients surveyed in the ICUs, 31 (33.7%) had undergone tracheostomy. The overall prevalence of tracheostomy was found to be 9.1%, translating to a rate of 1.8 per 1000 admission days. The mean age of patients with a tracheostomy was 59.5 years (SD = 13.8), with a notable predominance of male patients (67.7%). Neurological conditions were identified as the most common reason for ICU admission, accounting for 48.4% of cases. Tracheostomy procedures were typically performed after a mean duration of 12.9 days of mechanical ventilation, primarily due to difficulties related to prolonged weaning (64.5%). Both early and late complications were observed, and 19.35% of tracheostomized patients did not survive beyond one month following the procedure. The average length of stay in the ICU for these patients was significantly extended, averaging 43.0 days (SD = 34.3). Conclusions: These findings highlight the critical role of tracheostomy in the management of critically ill patients within Italian ICUs. The high prevalence and notable complication rates emphasize the urgent need for standardized clinical protocols aimed at optimizing patient outcomes and minimizing adverse events. Further research is essential to refine current practices and develop comprehensive guidelines for the management of tracheostomy in critically ill patients.

Clinical management and nursing care for patients with tracheostomy following traumatic brain injury

Tracheostomy is a routine surgical procedure in patients with severe traumatic brain injury, which requires mechanical ventilation to maintain gas exchange and avoid hypoxemia. Inadequate tracheostomy timing, nursing care, and decannulation would lead to a series of complications, such as aggravated pneumonia and prolonged intubation. The effects of early tracheostomy versus late tracheostomy have been explored. And early tracheostomy is more likely associated with shorter hospital stays and fewer complications. But the relevant reports are controversial. A safe and fast tracheostomy decannulation would facilitate the recovery. However, there was a broad variability in the indications and timing of tracheostomy and decannulation. High-quality evidence is subsequently lacking. We conducted this review to address gaps in knowledge regarding the management strategy and nursing protocol in patients with tracheostomy and decannulation following traumatic brain injury. A multidisciplinary tracheostomy team containing nursing care was also discussed to provide the best service to these patients.

Improving Outcomes for Patients With Tracheostomy Through Implementation of AARC Clinical Practice Guidelines

BACKGROUND

The COVID-19 global pandemic dramatically increased our institution's tracheostomy census. Comparing our existing protocols with American Association for Respiratory Care (AARC) January 2021 clinical practice guideline (CPG) relevant to caring for adult patients with tracheostomy in the acute care setting revealed numerous opportunities for improving our care of those patients. We assembled an interdisciplinary tracheostomy team to implement AARC CPG recommendations and manage all patients with tracheostomy in our hospital.

METHODS

We examined the effect our interdisciplinary team approach and implementation of AARC CPG recommendations had on the following metrics: average patient length of stay (LOS); ICU LOS; percentage of ventilator days; percentage of tracheostomy mask days; tracheostomy tube changes; decannulations; average time to decannulation; mortality; 30-d readmissions; and consultations for speech-language pathology (SLP), one-way speaking valves, physical therapy, and occupational therapy.

RESULTS

A total of 203 subjects with tracheostomy were followed in a quality improvement study from June 2019-June 2023 (94 in the pre-intervention group, 109 in the post group). There were significant increases between before and after intervention groups in percentage of decannulations in acutely patients with tracheostomy/not present on admission, non-COVID subjects who survived hospitalization (11.8% vs 33.3%, P = .043), percentage of SLP consults (53.2% vs 89.0%, P < .001), and percentage of one-way speaking valve consults (17.0% vs 32.1%, P = .02).

CONCLUSIONS

Establishment of an interdisciplinary tracheostomy team and implementation of AARC CPG recommendations for care of adult patients with tracheostomy in the acute care setting resulted in positive, statistically significant outcomes.

Tracheostomy tube changes in patients with tracheostomy: A quality improvement project

BACKGROUND

Tracheostomy tube changes are a considerable part of the management of patients with tracheostomy and are necessary for preventing aspiration pneumonia, especially in patients with long-term tracheostomy. The process of tracheostomy tube changes in many patients may not be timely, safe or efficient.

AIM

The objectives were to implement a quality improvement intervention that reduces the incidence of aspiration pneumonia in patients with tracheostomy, improve staff knowledge about tracheostomy tube changes and improve staff adherence to documentation.

METHODS

A pre-post intervention design was used in this quality improvement project. We created a change strategy bundle that included identification of the need for and observation determination of the timing of tube changes timing, change assessments, identification of the person and location, preparation, co-operation and maintenance. A tracheostomy tube change workflow was also created. Then, the intervention was implemented in the clinic after staff training. The incidence of aspiration pneumonia, staff knowledge and staff adherence were compared before and after the intervention.

RESULTS

Two hundred and 20 patients were enrolled (105 in the preintervention group; 115 in the postintervention group) with 88 tracheostomy tube change episodes (23 in the preintervention group; 65 in the postintervention group). Thirty-five staff members completed the training and surveys. The incidence of pneumonia decreased from 43.8% to 27.8% after the intervention (p = .013). The knowledge score of staff increased from 46.57 ± 11.10 to 88.14 ± 6.76, and the implementation rate of the audit increased to 67.32%-100%.

CONCLUSIONS

This quality improvement project regarding tracheostomy changes reduced the incidence of pneumonia, increased staff knowledge about tracheostomy tube changes and improved staff adherence.

RELEVANCE TO CLINICAL PRACTICE

A standardized tracheostomy tube change bundle, education, interprofessional collaboration and culture changes were important to ensure the best outcomes in this quality improvement project. These factors improved the timeliness, efficiency and safety of tracheostomy tube changes.

Timing of Tracheostomy in ICU Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: The ideal timing for tracheostomy in critically ill patients is still debated. This systematic review and meta-analysis examined whether early tracheostomy improves clinical outcomes compared to late tracheostomy or prolonged intubation in critically ill patients on mechanical ventilation. Methods: We conducted a comprehensive search of randomized controlled trials (RCTs) assessing the risk of clinical outcomes in intensive care unit (ICU) patients who underwent early (within 7-10 days of intubation) versus late tracheostomy or prolonged intubation. Databases searched included PubMed, Embase, and the Cochrane Library up to June 2023. The primary outcome evaluated was mortality, while secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), ICU length of stay, and duration of mechanical ventilation. No language restriction was applied. Eligible studies were RCTs comparing early to late tracheostomy or prolonged intubation in critically ill patients that reported on mortality. The risk of bias was evaluated using the Cochrane Risk of Bias Tool for RCTs, and evidence certainty was assessed via the GRADE approach. Results: This systematic review and meta-analysis included 19 RCTs, covering 3586 critically ill patients. Early tracheostomy modestly decreased mortality compared to the control (RR -0.1511 [95% CI: -0.2951 to -0.0070], p = 0.0398). It also reduced ICU length of stay (SMD -0.6237 [95% CI: -0.9526 to -0.2948], p = 0.0002) and the duration of mechanical ventilation compared to late tracheostomy (SMD -0.3887 [95% CI: -0.7726 to -0.0048], p = 0.0472). However, early tracheostomy did not significantly reduce the duration of mechanical ventilation compared to prolonged intubation (SMD -0.1192 [95% CI: -0.2986 to 0.0601], p = 0.1927) or affect VAP incidence (RR -0.0986 [95% CI: -0.2272 to 0.0299], p = 0.1327). Trial sequential analysis (TSA) for each outcome indicated that additional trials are needed for conclusive evidence. Conclusions: Early tracheostomy appears to offer some benefits across all considered clinical outcomes when compared to late tracheostomy and prolonged intubation.

Impact of Tracheostomy Timing Within the National Veterans Affairs Population

OBJECTIVE

There is a lack of a definitive study in the literature comparing early versus late tracheostomy and exploring the impact of tracheostomy timing on patient outcomes. This study may help guide treatment paradigms and contribute to a consensus for optimal tracheostomy timing.

METHODS

A retrospective review was performed comparing early versus late timing of tracheostomy placement and their respective outcomes. The authors used data provided by VA Informatics and Computing Infrastructure (VINCI) to find patients who received a tracheostomy at any VA Medical Center in the United States. There were a total of 25,334 tracheostomies in the database which satisfied our criteria. These occurred between the years 1999 and 2022. Propensity score matching assessed 17,074 tracheostomies, 8537 in either group. The median age of patients in the matched groups was 66 years, and approximately 97.4% of patients were male. Early tracheostomy timing was defined as the placement of the tracheostomy within 10 days of intubation. Outcomes included post-tracheostomy intensive care unit (ICU) days, post-tracheostomy hospital days, successful ventilator weaning, and all-cause mortality.

RESULTS

Early tracheostomy was associated with significantly fewer ICU days and hospital days, and the early group experienced higher rates of successful ventilator weaning. Survival analysis of data within 5 years of tracheostomy showed that early tracheostomy was associated with significantly lower hazard for all-cause mortality.

CONCLUSION

Our results add to the body of evidence that an earlier transition to mechanical ventilation by tracheostomy confers benefits in patient morbidity and mortality as well as resource utilization.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3555-3561, 2024.

Application of speaking valves in adult patients with tracheostomy: a protocol for a systematic review and meta-analysis

INTRODUCTION

Tracheostomy is a common emergency procedure for critically ill patients to secure their airway. The speaking valve is a one-way ventilation valve that is attached to the end of the tracheostomy tube to help the patient remodel subglottic pressure. However, the efficacy and safety of speaking valves in adult patients with tracheostomy remain controversial. The purpose of this protocol is to describe and evaluate the effectiveness, safety and impact on the quality of life of speaking valves in adult patients with tracheostomy.

METHODS AND ANALYSIS

We will search four English databases (PubMed, Embase, Cochrane Library and Web of Science), grey literature websites and reference lists of original studies to screen for studies that might meet the criteria. The two authors will independently screen the literature, extract data and assess the quality and risk of bias of the included studies. The primary outcomes will focus on the patients' swallowing function, vocalisation and quality of life. We will use a fixed effects model or a random effects model based on heterogeneity testing or a descriptive analysis only. The quality of evidence on the effects of interventions will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation.

ETHICS AND DISSEMINATION

This study is based on the literature in the database and does not require the approval of the ethics committee. The results will be disseminated through a peer-reviewed journal and conferences.

PROSPERO REGISTRATION NUMBER

CRD42024502906.

Effect of tracheotomy timing on patients receiving mechanical ventilation: A meta-analysis of randomized controlled trials

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.

Establishment and validation of a predictive model for tracheotomy in critically ill patients and analysis of the impact of different tracheotomy timing on patient prognosis

BACKGROUND

In critically ill patients receiving invasive mechanical ventilation (IMV), it is unable to determine early which patients require tracheotomy and whether early tracheotomy is beneficial.

METHODS

Clinical data of patients who were first admitted to the ICU and underwent invasive ventilation for more than 24 h in the Medical Information Marketplace in Intensive Care (MIMIC)-IV database were retrospectively collected. Patients were categorized into successful extubation and tracheotomy groups according to whether they were subsequently successfully extubated or underwent tracheotomy. The patients were randomly divided into model training set and validation set in a ratio of 7:3. Constructing predictive models and evaluating and validating the models. The tracheotomized patients were divided into the early tracheotomy group (< = 7 days) and the late tracheotomy group (> 7 days), and the prognosis of the two groups was analyzed.

RESULTS

A total of 7 key variables were screened: Glasgow coma scale (GCS) score, pneumonia, traumatic intracerebral hemorrhage, hemorrhagic stroke, left and right pupil responses to light, and parenteral nutrition. The area under the receiver operator characteristic (ROC) curve of the prediction model constructed through these seven variables was 0.897 (95% CI: 0.876-0.919), and 0.896 (95% CI: 0.866-0.926) for the training and validation sets, respectively. Patients in the early tracheotomy group had a shorter length of hospital stay, IMV duration, and sedation duration compared to the late tracheotomy group (p < 0.05), but there was no statistically significant difference in survival outcomes between the two groups.

CONCLUSION

The prediction model constructed and validated based on the MIMIC-IV database can accurately predict the outcome of tracheotomy in critically ill patients. Meanwhile, early tracheotomy in critically ill patients does not improve survival outcomes but has potential advantages in shortening the duration of hospitalization, IMV, and sedation.

Early versus late tracheostomy in people with multiple trauma

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of early tracheostomy compared to late tracheostomy in people with multiple trauma in the intensive care unit.

Tracheostomy is associated with decreased vasoactive-inotropic score in postoperative cardiac surgery patients on prolonged mechanical ventilation

Objective

We sought to quantify the influence that tracheostomy placement has on the hemodynamic stability of postoperative cardiac surgery patients with persistent ventilatory requirements.

Methods

A retrospective, single-center, and observational analysis of postoperative cardiac surgery patients with prolonged mechanical ventilation who underwent tracheostomy placement from 2018 to 2022 was conducted. Patients were excluded if receiving mechanical circulatory support or if they had an unrelated significant complication 3 days surrounding tracheostomy placement. Vasoactive and inotropic requirements were quantified using the Vasoactive-Inotrope Score.

Results

Sixty-one patients were identified, of whom 58 met inclusion criteria. The median vasoactive-inotrope score over the 3 days before tracheostomy compared with 3 days after decreased from 3.35 days (interquartile range, 0-8.79) to 0 days (interquartile range, 0-7.79 days) (P = .027). Graphic representation of this trend demonstrates a clear inflection point at the time of tracheostomy. Also, after tracheostomy placement, fewer patients were on vasoactive/inotropic infusions (67.2% [n = 39] pre vs 24.1% [n = 14] post; P < .001) and sedative infusions (62.1% [n = 36] pre vs 27.6% [n = 16] post; P < .001). The percent of patients on active mechanical ventilation did not differ.

Conclusions

The median vasoactive-inotrope score in cardiac surgery patients with prolonged mechanical ventilation was significantly reduced after tracheostomy placement. There was also a significant reduction in the number of patients on vasoactive/inotropic and sedative infusions 3 days after tracheostomy. These data suggest that tracheostomy has a positive effect on the hemodynamic stability of patients after cardiac surgery and should be considered to facilitate postoperative recovery.

Lessons for the next pandemic: analysis of the timing and outcomes including post-discharge decannulation rates for tracheostomy in severe COVID-19 respiratory failure

PURPOSE

COVID-19 patients with respiratory failure frequently require prolonged ventilatory support that would typically warrant early tracheostomy. There has been significant debate on timing, outcomes, and safety of these procedures. The purpose of this study was to determine the epidemiological, hospital, and post-discharge outcomes of this cohort, based on early (ET) versus late (LT) tracheostomy.

METHODS

Retrospective review (March 2020-January 2021) in a 5-hospital system of ventilated patients who underwent tracheostomy. Demographics, hospital/ICU length of stay (LOS), procedural characteristics, APACHE II scores at ICU admission, stabilization markers, and discharge outcomes were analyzed. Long-term decannulation rates were obtained from long-term acute care facility (LTAC) data.

RESULTS

A total of 97 patients underwent tracheostomy (mean 61 years, 62% male, 64% Hispanic). Despite ET being frequently performed during active COVID infection (85% vs. 64%), there were no differences in complication types or rates versus LT. APACHE II scores at ICU admission were comparable for both groups; however, > 50% of LT patients met PEEP stability at tracheostomy. ET was associated with significantly shorter ICU and hospital LOS, ventilator days, and higher decannulation rates. Of the cohort discharged to an LTAC, 59% were ultimately decannulated, 36% were discharged home, and 41% were discharged to a skilled nursing facility.

CONCLUSIONS

We report the first comprehensive analysis of ET and LT that includes LTAC outcomes and stabilization markers in relation to the tracheostomy. ET was associated with improved clinical outcomes and a short LOS, specifically on days of pre-tracheostomy ventilation and in-hospital decannulation rates.

Optimal Timing of Tracheostomy in the Setting of COVID-19 and Associated Pneumothorax

Introduction At the beginning of the 2020 pandemic, no criteria were in place regarding the timing of tracheostomy placement in intubated COVID-19 patients, nor were there any data pertaining to pneumothorax incidence in this population. This study examines the timing of tracheostomy placement and its correlation with patient outcomes, along with pneumothorax incidence in COVID-19 patients who underwent a tracheostomy.  Methods We performed a multi-institutional retrospective study of intubated COVID-19 patients admitted to intensive care units (ICUs) in North and South Dakota between April 2020 and December 2020. The timing of the tracheostomy was assessed, with primary outcomes being mortality, successful ventilator weaning, discharge to a long-term care facility, and overall length of stay. Patients were grouped by age, gender, ethnicity, and comorbidities. Pre- and post-tracheostomy pneumothorax was extracted from this dataset. Results We identified 85 patients who were intubated with COVID-19 and underwent a tracheostomy. The timing of tracheostomy varied widely, ranging from five to 53 days with an average time to tracheostomy being 17.3 days. Thirty-four of the patients expired, 32 patients were discharged to a long-term care hospital (LTCH), and 11 patients were discharged to an inpatient rehabilitation facility. Only three patients were discharged home. Regression analysis did not reveal statistically significant differences between patients who survived (N = 51) and patients who expired (N = 34) for almost all variables analyzed. Sixteen of the 85 patients were diagnosed with pneumothorax during their hospital stay. Half of these patients were diagnosed after a tracheostomy was placed. Conclusion This study did not demonstrate statistically significant differences in overall mortality or incidence of pneumothorax when it pertains to the timing of placement of tracheostomy. Variation in mortality was identified, in which younger patients were more likely to survive than older patients, a finding that was echoed in other studies. Considering this evidence, we cannot conclude that an association between the timing of tracheostomy and mortality from COVID-19; therefore, tracheostomy in the setting of COVID-19 can be performed at the provider's discretion.

The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a chinese tertiary hospital

OBJECTIVES

The timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

One thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital.

METHODS

Tracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death.

RESULTS

In both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT.

CONCLUSIONS

In a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes.

TRIAL REGISTRATION

ChiCTR2100043905. Registered 05 March 2021. http://www.chictr.org.cn/listbycreater.aspx.

Early versus late tracheostomy in critically ill COVID-19 patients

BACKGROUND

The role of early tracheostomy as an intervention for critically ill COVID-19 patients is unclear. Previous reports have described prolonged intensive care stays and difficulty weaning from mechanical ventilation in critically ill COVID-19 patients, particularly in those developing acute respiratory distress syndrome. Pre-pandemic evidence on the benefits of early tracheostomy is conflicting but suggests shorter hospital stays and lower mortality rates compared to late tracheostomy.

OBJECTIVES

To assess the benefits and harms of early tracheostomy compared to late tracheostomy in critically ill COVID-19 patients.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register, which comprises CENTRAL, PubMed, Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv, as well as Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index) and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions. We conducted the searches on 14 June 2022.

SELECTION CRITERIA

We followed standard Cochrane methodology. We included randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) evaluating early tracheostomy compared to late tracheostomy during SARS-CoV-2 infection in critically ill adults irrespective of gender, ethnicity, or setting.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. To assess risk of bias in included studies, we used the Cochrane RoB 2 tool for RCTs and the ROBINS-I tool for NRSIs. We used the GRADE approach to assess the certainty of evidence for outcomes of our prioritized categories: mortality, clinical status, and intensive care unit (ICU) length of stay. As the timing of tracheostomy was very heterogeneous among the included studies, we applied GRADE only to studies that defined early tracheostomy as 10 days or less, which was chosen according to clinical relevance.

MAIN RESULTS

We included one RCT with 150 participants diagnosed with SARS-CoV-2 infection and 24 NRSIs with 6372 participants diagnosed with SARS-CoV-2 infection. All participants were admitted to the ICU, orally intubated and mechanically ventilated. The RCT was a multicenter, parallel, single-blinded study conducted in Sweden. Of the 24 NRSIs, which were mostly conducted in high- and middle-income countries, eight had a prospective design and 16 a retrospective design. We did not find any ongoing studies. RCT-based evidence We judged risk of bias for the RCT to be of low or some concerns regarding randomization and measurement of the outcome. Early tracheostomy may result in little to no difference in overall mortality (RR 0.82, 95% CI 0.52 to 1.29; RD 67 fewer per 1000, 95% CI 178 fewer to 108 more; 1 study, 150 participants; low-certainty evidence). As an indicator of improvement of clinical status, early tracheostomy may result in little to no difference in duration to liberation from invasive mechanical ventilation (MD 1.50 days fewer, 95%, CI 5.74 days fewer to 2.74 days more; 1 study, 150 participants; low-certainty evidence). As an indicator of worsening clinical status, early tracheostomy may result in little to no difference in the incidence of adverse events of any grade (RR 0.94, 95% CI 0.79 to 1.13; RD 47 fewer per 1000, 95% CI 164 fewer to 102 more; 1 study, 150 participants; low-certainty evidence); little to no difference in the incidence of ventilator-associated pneumonia (RR 1.08, 95% CI 0.23 to 5.20; RD 3 more per 1000, 95% CI 30 fewer to 162 more; 1 study, 150 participants; low-certainty evidence). None of the studies reported need for renal replacement therapy. Early tracheostomy may result in little benefit to no difference in ICU length of stay (MD 0.5 days fewer, 95% CI 5.34 days fewer to 4.34 days more; 1 study, 150 participants; low-certainty evidence). NRSI-based evidence We considered risk of bias for NRSIs to be critical because of possible confounding, study participant enrollment into the studies, intervention classification and potentially systematic errors in the measurement of outcomes. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases overall mortality (RR 1.47, 95% CI 0.43 to 5.00; RD 143 more per 1000, 95% CI 174 less to 1218 more; I2 = 79%; 2 studies, 719 participants) or duration to liberation from mechanical ventilation (MD 1.98 days fewer, 95% CI 0.16 days fewer to 4.12 more; 1 study, 50 participants), because we graded the certainty of evidence as very low. Three NRSIs reported ICU length of stay for 519 patients with early tracheostomy (≤ 10 days) as a median value, which we could not include in the meta-analyses. We are uncertain whether early tracheostomy (≤ 10 days) increases or decreases the ICU length of stay, because we graded the certainty of evidence as very low.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that early tracheostomy may result in little to no difference in overall mortality in critically ill COVID-19 patients requiring prolonged mechanical ventilation compared with late tracheostomy. In terms of clinical improvement, early tracheostomy may result in little to no difference in duration to liberation from mechanical ventilation compared with late tracheostomy. We are not certain about the impact of early tracheostomy on clinical worsening in terms of the incidence of adverse events, need for renal replacement therapy, ventilator-associated pneumonia, or the length of stay in the ICU. Future RCTs should provide additional data on the benefits and harms of early tracheostomy for defined main outcomes of COVID-19 research, as well as of comparable diseases, especially for different population subgroups to reduce clinical heterogeneity, and report a longer observation period. Then it would be possible to draw conclusions regarding which patient groups might benefit from early intervention. Furthermore, validated scoring systems for more accurate predictions of the need for prolonged mechanical ventilation should be developed and used in new RCTs to ensure safer indication and patient safety. High-quality (prospectively registered) NRSIs should be conducted in the future to provide valuable answers to clinical questions. This could enable us to draw more reliable conclusions about the potential benefits and harms of early tracheostomy in critically ill COVID-19 patients.

Early Tracheostomy in Older Trauma Patient Is Associated With Comparable Outcomes to Younger Cohort

INTRODUCTION

Early tracheostomy (ET) is associated with a lower incidence of pneumonia (PNA) and mechanical ventilation duration (MVD) in hospitalized patients with trauma. The purpose of this study is to determine if ET also benefits older adults compared to the younger cohort.

METHODS

Adult hospitalized trauma patients who received a tracheostomy as registered in The American College of Surgeons Trauma Quality Improvement Program from 2013 to 2019 were analyzed. Patients with tracheostomy prior to admission were excluded. Patients were stratified into 2 cohorts consisting of those aged ≥65 and those aged <65. These cohorts were analyzed separately to compare the outcomes of ET (<5 d; ET) versus late tracheostomy (LT) (≥5 d; LT). The primary outcome was MVD. Secondary outcomes were in-hospital mortality, hospital length of stay (HLOS), and PNA. Univariate and multivariate analyses were performed with significance defined as P value < 0.05.

RESULTS

In patients aged <65, ET was performed within a median of 2.3 d (interquartile range, 0.47-3.8) after intubation and a median of 9.9 d (interquartile range, 7.5-13) in the LT group. The ET group's Injury Severity Score was significantly lower with fewer comorbidities. There were no differences in injury severity or comorbidities when comparing the groups. ET was associated with lower MVD (d), PNA, and HLOS on univariate and multivariate analyses in both age cohorts, although the degree of benefit was higher in the less than 65 y cohort [ET versus LT MVD: 5.08 (4.78-5.37), P < 0.001; PNA: 1.45 (1.36-1.54), P < 0.001; HLOS: 5.48 (4.93-6.04), P < 0.001]. Mortality did not differ based on time to tracheostomy.

CONCLUSIONS

ET is associated with lower MVD, PNA, and HLOS in hospitalized patients with trauma regardless of age. Age should not factor into timing for tracheostomy placement.

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

OBJECTIVE

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

DESIGN

Retrospective study of prospectively collected data.

SETTING

Tertiary hospital.

PATIENTS

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

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

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

RESULTS

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

CONCLUSIONS

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

Tracheostomy, Feeding-Tube, and In-Hospital Postoperative Mortality in Children: A Retrospective Cohort Study

BACKGROUND

Neuromuscular/neurologic disease confers increased risk of perioperative mortality in children. Some patients require tracheostomy and/or feeding tubes to ameliorate upper airway obstruction or respiratory failure and reduce aspiration risk. Empiric differences between patients with and without these devices and their association with postoperative mortality have not been previously assessed.

METHODS

This retrospective cohort study using the Pediatric Health Information System measured 3- and 30-day in-hospital postsurgical mortality among children 1 month to 18 years of age with neuromuscular/neurologic disease at 44 US children's hospitals, from April 2016 to October 2018. We summarized differences between patients presenting for surgery with and without these devices using standardized differences. Then, we calculated 3- and 30-day mortality among patients with tracheostomy, feeding tube, both, and neither device, overall and stratified by important exposures, using Fisher exact test to test whether differences were significant.

RESULTS

There were 43,193 eligible patients. Unadjusted 3-day mortality was 1.3% (549/43,193); 30-day mortality was 2.7% (1168/43,193). Most (79.1%) used neither a feeding tube or tracheostomy, 1.2% had tracheostomy only, 15.5% had feeding tube only, and 4.2% used both devices. Compared to children with neither device, children using either or both devices were more likely to have multiple CCCs, dysphagia, chronic pulmonary disease, cerebral palsy, obstructive sleep apnea, or malnutrition, and a prolonged intensive care unit (ICU) stay within the previous year. They were less likely to present for high-risk surgeries (33% vs 57%). Having a feeding tube was associated with decreased 3-day mortality overall compared to having neither device (0.9% vs 1.3%, P = .003), and among children having low-risk surgery, and surgery during urgent or emergent hospitalizations. Having both devices was associated with decreased 3-day mortality among children having low-risk surgery (0.8% vs 1.9%; P = .013), and during urgent or emergent hospitalizations (1.6% vs 2.9%; P = .023). For 30-day mortality, having a feeding tube or both devices was associated with lower mortality when the data were stratified by the number of CCCs.

CONCLUSIONS

Patients requiring tracheostomy, feeding tube, or both are generally sicker than patients without these devices. Despite this, having a feeding tube was associated with lower 3-day mortality overall and lower 30-day mortality when the data were stratified by the number of CCCs. Having both devices was associated with lower 3-day mortality in patients presenting for low-risk surgery, and surgery during urgent or emergent hospitalizations.

Association between tracheostomy and survival in patients with coronavirus disease 2019 who require prolonged mechanical ventilation for more than 14 days: A multicenter cohort study

OBJECTIVE

Tracheostomy is a common procedure with potential prognostic advantages for patients who require prolonged mechanical ventilation (PMV). Early recommendations for patients with coronavirus disease 2019 (COVID-19) suggested delayed or limited tracheostomy considering the risk for viral transmission to clinicians. However, updated guidelines for tracheostomy with appropriate personal protective equipment have revised its indications. This study aimed to evaluate the association between tracheostomy and prognosis in patients with COVID-19 requiring PMV.

METHODS

This was a multicenter, retrospective cohort study using data from the nationwide Japanese Intensive Care PAtient Database. We included adult patients aged ≥16 years who were admitted to the intensive care unit (ICU) due to COVID-19 and who required PMV (for >14 days or until performance of tracheostomy). The primary outcome was hospital mortality, and the association between implementation of tracheostomy and patient prognosis was assessed using weighted Cox proportional hazards regression analysis with inverse probability of treatment weighting (IPTW) using the propensity score to address confounders.

RESULTS

Between January 2020 and February 2021, 453 patients with COVID-19 were observed. Data from 109 patients who required PMV were analyzed: 66 (60.6%) underwent tracheostomy and 38 (34.9%) died. After adjusting for potential confounders using IPTW, tracheostomy implementation was found to significantly reduce hospital mortality (hazard ratio [HR]: 0.316, 95% confidence interval [CI]: 0.163-0.612). Patients who underwent tracheostomy had a similarly decreased ICU and 28-day mortality (HR: 0.269, 95% CI: 0.124-0.581; HR 0.281, 95% CI: 0.094-0.839, respectively). A sensitivity analysis using different definitions of PMV duration consistently showed reduced mortality in patients who underwent tracheostomy.

CONCLUSION

The implementation of tracheostomy was associated with favorable patient prognosis among patients with COVID-19 requiring PMV. Our findings support proactive tracheostomy in critically ill patients with COVID-19 requiring mechanical ventilation for >14 days.

Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers

BACKGROUND

Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults.

METHODS

We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care.

RESULTS

Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]).

CONCLUSION

Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Comparıson of Laryngeal Mask and Endotracheal Tube Usıng Percutaneous Dılatatıonal Tracheostomy

Aim: It was aimed to compare the results of using endotracheal tube and laryngeal mask for airway safety in percutaneous tracheostomy applications. Methods: The results of using ETT and LMA in percutaneous tracheostomy applications in Adıyaman Training and Research Hospital between 2013 and 2018 were analyzed retrospectively. 170 patients were identified. 4 patients were excluded from the study due to missing information. Results: Of the 166 patients included in the study, 76 were female and 90 were male. It was most frequently performed in patients with a diagnosis of cerebrovascular accident. (44%) Tracheostomy was successful in all patients, minor bleeding was detected in 20 patients and a second attempt was detected in 21 patients. The duration of tracheostomy procedure was found to be significantly shorter in the LMA group (p < 0.05). The length of hospital stay was significantly higher in the ETT group than in the LMA group (p < 0.05). Conclusion: It has been determined that the use of LMA in percutaneous dilatational tracheostomy applications shortens the procedure time, increases the success of the procedure and is associated with fewer complications.

If at First You Do Not Succeed: Consideration of Attempts in Patients With Trauma

INTRODUCTION

Failed extubation in critically ill patients is associated with poor outcomes. In critically ill trauma patients who have failed extubation, providers must decide whether to proceed with tracheostomy or attempt extubation again. The aim of this study was to describe the natural history of failed extubation in trauma patients and determine whether tracheostomy or a second attempt at extubation is more appropriate.

METHODS

Trauma patients admitted to our level I trauma center from 2013 to 2019 were identified. Patients who failed extubation, defined as an unplanned reintubation within 48 h of extubation, were included. Patients who immediately underwent tracheostomy were compared with those who had subsequent attempts at extubation. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) length of stay (LOS), ventilator days, and hospital LOS.

RESULTS

The population included 93 patients who failed extubation and met inclusion criteria. A total of 53 patients were ultimately successfully extubated, whereas 40 patients underwent a tracheostomy. There was no statistically significant difference in demographics or injury patterns. Patients who underwent tracheostomy had a longer ICU LOS and more ventilator days. There was no difference in mortality or hospital LOS between the two groups.

CONCLUSIONS

In trauma patients, those who underwent subsequent attempts at extubation did not experience higher rates of mortality than those who received a tracheostomy. Tracheostomy was associated with longer ICU LOS and ventilator days. In certain situations, it is appropriate to consider subsequent attempts at extubation in trauma patients who fail extubation rather than proceeding directly to tracheostomy.

Bleeding Hazard of Percutaneous Tracheostomy in COVID-19 Patients Supported With Venovenous Extracorporeal Membrane Oxygenation: A Case Series

OBJECTIVES

Tracheostomy usually is performed to aid weaning from mechanical ventilation and facilitate rehabilitation and secretion clearance. Little is known about the safety of percutaneous tracheostomy in patients with severe COVID-19 supported on venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to investigate the bleeding risk of bedside percutaneous tracheostomy in patients with COVID-19 infection supported with VV-ECMO.

DESIGN

A Retrospective review of electronic data for routine care of patients on ECMO.

SETTING

Tertiary, university-affiliated national ECMO center.

PARTICIPANTS

Patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support.

INTERVENTIONS

No intervention was conducted during this study.

MEASUREMENTS AND MAIN RESULTS

Electronic medical records of 16 confirmed patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support, including patient demographics, severity of illness, clinical variables, procedural complications, and outcomes, were compared with 16 non-COVID-19 patients. The SPSS statistical software was used for statistical analysis. The demographic data were compared using the chi-square test, and normality assumption was tested using the Shapiro-Wilk test. The indications for tracheostomy in all the patients were prolonged mechanical ventilation and sedation management. None of the patients suffered a life-threatening procedural complication within 48 hours. Moderate-to-severe bleeding was similar in both groups. There was no difference in 30- and 90-days mortality between both groups. As per routine screening results, none of the staff involved contracted COVID-19 infection.

CONCLUSIONS

In this case series, percutaneous tracheostomy during VV-ECMO in patients with COVID-19 appeared to be safe and did not pose additional risks to patients or healthcare workers.

Liberation From Mechanical Ventilation in the Cardiac Intensive Care Unit

The prevalence of respiratory failure is increasing in the contemporary cardiac intensive care unit (CICU) and is associated with a significant increase in morbidity and mortality. For patients that survive their initial respiratory decompensation, liberation from invasive mechanical ventilation (IMV) and the decision to extubate requires careful clinical assessment and planning. Therefore, it is essential for the CICU clinician to know how to assess and manage the various stages of IMV liberation, including ventilator weaning, evaluation of extubation readiness, and provide post-extubation care. In this review, we provide a comprehensive approach to liberation from IMV in the CICU, including cardiopulmonary interactions relative to withdrawal from positive pressure ventilation, evaluation of readiness for and assessment of spontaneous breathing trials, sedation management to optimize extubation, strategies for patients at a high risk for extubation failure, and tracheostomy in the cardiovascular patient.

Timing of tracheostomy and patient outcomes in critically ill patients requiring extracorporeal membrane oxygenation: a single-center retrospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an integral method of life support in critically ill patients with severe cardiopulmonary failure; however, such patients generally require prolonged mechanical ventilation and exhibit high mortality rates. Tracheostomy is commonly performed in patients on mechanical ventilation, and its early implementation has potential advantages for favorable patient outcomes. This study aimed to investigate the association between tracheostomy timing and patient outcomes, including mortality, in patients requiring ECMO.

METHODS

We conducted a single-center retrospective observational study of consecutively admitted patients who were supported by ECMO and underwent tracheostomy during intensive care unit (ICU) admission at a tertiary care center from April 2014 until December 2021. The primary outcome was hospital mortality. Using the quartiles of tracheostomy timing, the patients were classified into four groups for comparison. The association between the quartiles of tracheostomy timing and mortality was explored using multivariable logistic regression models.

RESULTS

Of the 293 patients treated with ECMO, 98 eligible patients were divided into quartiles 1 (≤ 15 days), quartile 2:16-19 days, quartile 3:20-26 days, and 4 (> 26 days). All patients underwent surgical tracheostomy and 35 patients underwent tracheostomy during ECMO. The complications of tracheostomy were comparable between the groups, whereas the duration of ECMO and ICU length of stay increased significantly as the quartiles of tracheostomy timing increased. Patients in quartile 1 had the lowest hospital mortality rate (19.2%), whereas those in quartile 4 had the highest mortality rate (50.0%). Multivariate logistic regression analysis showed a significant association between the increment of the quartiles of tracheostomy timing and hospital mortality (adjusted odds ratio for quartile increment:1.55, 95% confidence interval 1.03-2.35, p for trend = 0.037).

CONCLUSIONS

The timing of tracheostomy in patients requiring ECMO was significantly associated with patient outcomes in a time-dependent manner. Further investigation is warranted to determine the optimal timing of tracheostomy in terms of mortality.

Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey

BACKGROUND

The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized.

METHODS

Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point.

RESULTS

Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients.

CONCLUSIONS

The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.

Comparative evaluation of early versus late tracheostomy for reduction of the length of ICU stay, incidence of nosocomial pneumonias, risk of laryngeal injury and mortality of mechanically ventilated patients at a Tertiary Care Hospital in Western India

Introduction

Tracheostomy is a very common procedure performed in ICU as it offers significant advantages over prolonged endotracheal intubation. It facilitates weaning by decreasing the work of breathing in patients with limited reserve by decreasing the dead space area, decreases the requirement for sedation, and may allow for earlier patient mobilization, feeding, and physical and occupational therapy as compared to prolonged intubation along with lesser oral and oropharyngeal ulcerations, improves pulmonary toileting, and lowers incidence of pulmonary infections. Tracheostomy, however, is not devoid of risks. Complications may include hemorrhage, stoma infections and granulations, pneumothorax, subcutaneous emphysema, tracheal stenosis, tracheomalacia, and rarely death. Hence, performance of tracheostomy should be considerate to outweigh benefit-risk ratio.

Aims and objectives

To evaluate the early versus late tracheostomy for reduction of the length of ICU stay, incidence of nosocomial pneumonias, risk of laryngeal injury and mortality of mechanically ventilated patients.

Materials and methods

We conducted a retrospective study from May, 2019 to April, 2021 of patients being tracheostomized in medical ICU at Civil Hospital, Ahmedabad, who were previously intubated endotracheally and were on mechanical ventilation. The decision to tracheostomize would be taken by physicians in their routine rounds in ICU.

Results

Incidence of endolaryngeal complications like laryngotracheal stenosis, stomal granulations, fistula as well as nosocomial infections have lower incidence in early tracheostomy as compared to with late. Mortality remains same in both the groups as well as hospital and ICU stay.

Open Surgical Tracheostomy in COVID 19 Patients and Their Outcomes During the Second Wave in India: Experience at a Tertiary Referral Centre

Tracheostomy in COVID-19 is a debatable topic, with guidelines and recommendations evolving with every wave. Tracheostomy can help early weaning and potentially increase the availability of ICU beds. The aim of our study was to determine the outcomes of patients undergoing tracheostomy at different timings. This was an ambispective observational descriptive longitudinal study of patients confirmed to have COVID-19 by real- time reverse transcriptase polymerase chain reaction (RT-PCR) admitted in the ICU and needed intubation for mechanical ventilation and underwent tracheostomy at a tertiary referral centre. This study was over a period of two months from May to June 2021. A total of 169 patients were admitted to the ICU for COVID-19 from May to June 2021 out of which 27 patients underwent open surgical tracheostomy. Study included almost equal number of male and female patients. The most frequent comorbidities were hypertension and diabetes. The majority of patients were between 5th and 7th decades of life (59.2%; 16 patients). The common indications for tracheostomy were acute respiratory distress syndrome, failure to wean from ventilation, sedation management, difficult airway, and persistent airway oedema. Five patients (18.5%) underwent tracheostomy on day 8, the maximum number on a single day. The earliest tracheostomy was done on day 3 and the latest on day 17 with variable results. There were 6 survivors out of 27, youngest being a 27-year-old female and oldest a 60-year-old male. Our study showed that there was no association of age, sex of the patients and presence of comorbid conditions with the timing of intubation. Clinical outcome of the patients also was not affected by the any of the socio clinical variables viz. age, sex of the patient, presence of comorbid conditions and timing of intubation. Tracheostomy in COVID-19 is an aerosol generating procedure; strict recommendations and guidelines need to be followed.

Tracheotomy in ventilator-dependent patients with COVID-19: a cross-sectional study of analgesia and sedative requirements

Objective

During March 2020 in the United States, demand for sedatives increased by 91%, that for analgesics rose by 79%, and demand for neuromuscular blockers increased by 105%, all owing to the number of COVID-19 cases requiring invasive mechanical ventilation (MV). We hypothesize that analgesic and sedative requirements decrease following tracheotomy in this patient population.

Methods

In this cross-sectional study, we conducted a retrospective chart review to identify patients with COVID-19 who underwent tracheotomy (T) at an academic medical center between March 2020 and January 2021. We used a paired Student t-test to compare total oral morphine equivalents (OMEs), total lorazepam equivalents, 24-hour average dexmedetomidine dosage in μg/kg/hour, and 24-hour average propofol dosage in μg/kg/minute on days T−1 and T+2 for each patient.

Results

Of 50 patients, 46 required opioids before and after tracheotomy (mean decrease of 49.4 mg OMEs). Eight patients required benzodiazepine infusion (mean decrease of 45.1 mg lorazepam equivalents. Fifteen patients required dexmedetomidine infusion (mean decrease 0.34 μg/kg/hour). Seventeen patients required propofol (mean decrease 20.5 μg/kg/minute).

Conclusions

When appropriate personal protective equipment is available, use of tracheotomy in patients with COVID-19 who require MV may help to conserve medication supplies in times of extreme shortages.

Association of mortality and early tracheostomy in patients with COVID-19: a retrospective analysis

COVID-19 adds to the complexity of optimal timing for tracheostomy. Over the course of this pandemic, and expanded knowledge of the disease, many centers have changed their operating procedures and performed an early tracheostomy. We studied the data on early and delayed tracheostomy regarding patient outcome such as mortality. We performed a retrospective analysis of all tracheostomies at our institution in patients diagnosed with COVID-19 from March 2020 to June 2021. Time from intubation to tracheostomy and mortality of early (≤ 10 days) vs. late (> 10 days) tracheostomy were the primary objectives of this study. We used mixed cox-regression models to calculate the effect of distinct variables on events. We studied 117 tracheostomies. Intubation to tracheostomy shortened significantly (Spearman’s correlation coefficient; rho = − 0.44, p ≤ 0.001) during the course of this pandemic. Early tracheostomy was associated with a significant increase in mortality in uni- and multivariate analysis (Hazard ratio 1.83, 95% CI 1.07–3.17, p = 0.029). The timing of tracheostomy in COVID-19 patients has a potentially critical impact on mortality. The timing of tracheostomy has changed during this pandemic tending to be performed earlier. Future prospective research is necessary to substantiate these results.

Outcomes of prolonged mechanical ventilation and tracheostomy in critically ill elderly patients: a historical cohort study

PURPOSE

With an aging global population, the increased proportion of elderly patients in the intensive care unit (ICU) raises important questions regarding optimal management. Currently, data on tracheostomy and its outcomes in the elderly are limited. We aimed to determine the in-hospital survival of elderly ICU patients following tracheostomy, and describe impacts on discharge disposition and functional outcomes.

METHODS

We conducted a historical cohort study at two academic hospitals in Toronto. All patients aged ≥ 70 yr who received a tracheostomy during their ICU stay between January 2010 and June 2016 were included in a retrospective chart review. Data on patient demographics, frailty, tracheostomy indication, and outcomes were collected.

RESULTS

The study included 270 patients with a mean (standard deviation) age of 81 (6) yr. The majority were admitted to ICU for respiratory failure (147/270, 54%) and received a tracheostomy for prolonged mechanical ventilation (202/270, 75%). Intensive care unit and hospital mortality were 26% (68/270) and 46% (125/270), respectively. Twenty-five percent (67/270) of patients were decannulated during hospital admission, a median [interquartile range (IQR)] of 41 [25-68] days after tracheostomy. Intensive care unit and hospital length of stay were 31 [17-53] and 81 [46-121] days, respectively. At hospital discharge, 6% (17/270) of patients were discharged home, all were frail (median Clinical Frailty Score of 7) and most were tube-fed (101/270, 70%), unable to speak (81/270, 56%), and nonambulatory (98/270, 68%).

CONCLUSIONS

In patients aged ≥ 70 yr, tracheostomy during ICU stay marked a transition toward prolonged chronic critical illness. Nearly half of the patients died during the admission, and although a quarter were successfully decannulated, the majority of survivors were left with severe frailty and functional impairment.

Mortality Risk Factors in Patients Admitted with the Primary Diagnosis of Tracheostomy Complications: An Analysis of 8026 Patients

Background: Tracheostomy is a procedure commonly conducted in patients undergoing emergency admission and requires prolonged mechanical ventilation. In the present study, the aim was to determine the prevalence and risk factors of mortality among emergently admitted patients with tracheostomy complications, during the years 2005−2014. Methods: This was a retrospective cohort study. Demographics and clinical data were obtained from the National Inpatient Sample, 2005−2014, to evaluate elderly (65+ years) and non-elderly adult patients (18−64 years) with tracheostomy complications (ICD-9 code, 519) who underwent emergency admission. A multivariable logistic regression model with backward elimination was used to identify the association between predictors and in-hospital mortality. Results: A total of 4711 non-elderly and 3315 elderly patients were included. Females included 44.5% of the non-elderly patients and 47.6% of the elderly patients. In total, 181 (3.8%) non-elderly patients died, of which 48.1% were female, and 163 (4.9%) elderly patients died, of which 48.5% were female. The mean (SD) age of the non-elderly patients was 50 years and for elderly patients was 74 years. The mean age at the time of death of non-elderly patients was 53 years and for elderly patients was 75 years. The odds ratio (95% confidence interval, p-value) of some of the pertinent risk factors for mortality showed by the final regression model were older age (OR = 1.007, 95% CI: 1.001−1.013, p < 0.02), longer hospital length of stay (OR = 1.008, 95% CI: 1.001−1.016, p < 0.18), cardiac disease (OR = 3.21, 95% CI: 2.48−4.15, p < 0.001), and liver disease (OR = 2.61, 95% CI: 1.73−3.93, p < 0.001). Conclusion: Age, hospital length of stay, and several comorbidities have been shown to be significant risk factors in in-hospital mortality in patients admitted emergently with the primary diagnosis of tracheostomy complications. Each year of age increased the risk of mortality by 0.7% and each additional day in the hospital increased it by 0.8%.

Early Intensive Physical Rehabilitation Combined with a Protocolized Decannulation Process in Tracheostomized Survivors from Severe COVID-19 Pneumonia with Chronic Critical Illness

(1) Background: Intensive care unit (ICU) survivors from severe COVID-19 acute respiratory distress syndrome (CARDS) with chronic critical illness (CCI) may be considered vast resource consumers with a poor prognosis. We hypothesized that a holistic approach combining an early intensive rehabilitation with a protocol of difficult weaning would improve patient outcomes (2) Methods: A single-center retrospective study in a five-bed post-ICU weaning and intensive rehabilitation center with a dedicated fitness room specifically equipped to safely deliver physical activity sessions in frail patients with CCI. (3) Results: Among 502 CARDS patients admitted to the ICU from March 2020 to March 2022, 50 consecutive tracheostomized patients were included in the program. After a median of 39 ICU days, 25 days of rehabilitation were needed to restore patients’ autonomy (ADL, from 0 to 6; p < 0.001), to significantly improve their aerobic capacity (6-min walking test distance, from 0 to 253 m; p < 0.001) and to reduce patients’ vulnerability (frailty score, from 7 to 3; p < 0.001) and hospital anxiety and depression scale (HADS, from 18 to 10; p < 0.001). Forty-eight decannulated patients (96%) were discharged home. (4) Conclusions: A protocolized weaning strategy combined with early intensive rehabilitation in a dedicated specialized center boosted the physical and mental recovery.

TTCOV19: timing of tracheotomy in SARS-CoV-2-infected patients: a multicentre, single-blinded, randomized, controlled trial

BACKGROUND

Critically ill COVID-19 patients may develop acute respiratory distress syndrome and the need for respiratory support, including mechanical ventilation in the intensive care unit. Previous observational studies have suggested early tracheotomy to be advantageous. The aim of this parallel, multicentre, single-blinded, randomized controlled trial was to evaluate the optimal timing of tracheotomy.

METHODS

SARS-CoV-2-infected patients within the Region Västra Götaland of Sweden who needed intubation and mechanical respiratory support were included and randomly assigned to early tracheotomy (≤ 7 days after intubation) or late tracheotomy (≥ 10 days after intubation). The primary objective was to compare the total number of mechanical ventilation days between the groups.

RESULTS

One hundred fifty patients (mean age 65 years, 79% males) were included. Seventy-two patients were assigned to early tracheotomy, and 78 were assigned to late tracheotomy. One hundred two patients (68%) underwent tracheotomy of whom sixty-one underwent tracheotomy according to the protocol. The overall median number of days in mechanical ventilation was 18 (IQR 9; 28), but no significant difference was found between the two treatment regimens in the intention-to-treat analysis (between-group difference: - 1.5 days (95% CI - 5.7 to 2.8); p = 0.5). A significantly reduced number of mechanical ventilation days was found in the early tracheotomy group during the per-protocol analysis (between-group difference: - 8.0 days (95% CI - 13.8 to - 2.27); p = 0.0064). The overall correlation between the timing of tracheotomy and days of mechanical ventilation was significant (Spearman's correlation: 0.39, p < 0.0001). The total death rate during intensive care was 32.7%, but no significant differences were found between the groups regarding survival, complications or adverse events.

CONCLUSIONS

The potential superiority of early tracheotomy when compared to late tracheotomy in critically ill patients with COVID-19 was not confirmed by the present randomized controlled trial but is a strategy that should be considered in selected cases where the need for MV for more than 14 days cannot be ruled out. Trial registration NCT04412356 , registered 05/24/2020.

Tracheostomy decreases continuous analgesia and sedation requirements

BACKGROUND

The goals of sedation in the critically ill surgical patient are to minimize pain, anxiety, and agitation without hindering cardiopulmonary function. One potential benefit of tracheostomy over endotracheal intubation is the reduction of sedation and analgesia, however, there is little data to support this supposition. We hypothesized that patients undergoing tracheostomy would have a rapid reduction in sedation and analgesia following tracheostomy.

METHODS

A retrospective review of tracheostomies performed at a single level 1 trauma center from January 2013- June 2018 was completed. An evaluation of Glasgow Coma Score (GCS), Richmond Agitation-Sedation Score (RASS), and Confusion Assessment Method for the ICU (CAM-ICU) 72 hours pre- to 72 hours post-tracheostomy was performed. The total daily dose of sedation, anxiolytic, and analgesic medications administered were recorded. Mixed-effects models were used to evaluate longitudinal drug does over time (hours).

RESULTS

468 patients included for analysis with a mean age of 58.8 ± 18.3 years. There was a significant decrease in propofol and fentanyl utilization from 24-hours pre to 24-hours post-tracheostomy in both dose and number of patients receiving these continuous intravenous medications. Similarly, total morphine milligram equivalents (MME) use and continuous midazolam significantly decreased from 24-hours pre- to 24-hours post-tracheostomy. By contrast, intermittent enteral quetiapine and methadone administration increased after tracheostomy. Importantly, RASS, GCS, and CAM scoring were also significantly improved as early as 24 hours post-tracheostomy. Total MME use was significantly elevated in patients less than 65 years of age and in male patients pre-tracheostomy compared to female patients. Patients admitted to the MICU had significantly higher MME use compared to those in the SICU pre-tracheostomy.

CONCLUSIONS

Tracheostomy allows for a rapid and significant reduction in intravenous sedation and analgesia medication utilization. Post-tracheostomy sedation can transition to intermittent enteral medications, potentially contributing to the observed improvements in postoperative mental status and agitation.

LEVEL OF EVIDENCE

Level 3, therapeutic.

Association between early tracheostomy and patient outcomes in critically ill patients on mechanical ventilation: a multicenter cohort study

Background

Tracheostomy is commonly performed in critically ill patients because of its clinical advantages over prolonged translaryngeal endotracheal intubation. Early tracheostomy has been demonstrated to reduce the duration of mechanical ventilation and length of stay. However, its association with mortality remains ambiguous. This study aimed to evaluate the association between the timing of tracheostomy and mortality in patients receiving mechanical ventilation.

Methods

We performed a retrospective cohort analysis of adult patients who underwent tracheostomy during their intensive care unit (ICU) admission between April 2015 and March 2019. Patients who underwent tracheostomy before or after 29 days of ICU admission were excluded. Data were collected from the nationwide Japanese Intensive Care Patient Database. The primary outcome was hospital mortality. The timing of tracheostomy was stratified by quartile, and the association between patient outcomes was evaluated using regression analysis.

Results

Among the 85558 patients admitted to 46 ICUs during the study period, 1538 patients were included in the analysis. The quartiles for tracheostomy were as follows: quartile 1, ≤ 6 days; quartile 2, 7–10 days; quartile 3, 11–14 days; and quartile 4, > 14 days. Hospital mortality was significantly higher in quartile 2 (adjusted odds ratio [aOR]: 1.52, 95% confidence interval [CI]: 1.08–2.13), quartile 3 (aOR: 1.82, 95% CI: 1.28–2.59), and quartile 4 (aOR: 2.26, 95% CI: 1.61–3.16) (p for trend < 0.001) than in quartile 1. A similar trend was observed in the subgroup analyses of patients with impaired consciousness (Glasgow Coma Scale score < 8) and respiratory failure (PaO₂:FiO₂ ≤ 300) at ICU admission (p for trend = 0.081 and 0.001, respectively).

Conclusions

This multi-institutional observational study demonstrated that the timing of tracheostomy was significantly and independently associated with hospital mortality in a stepwise manner. Thus, early tracheostomy may be beneficial for patient outcomes, including mortality, and warrants further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00610-x.

Factors associated with prolonged weaning from mechanical ventilation in medical patients

BACKGROUND

Patients who need prolonged mechanical ventilation (MV) have high resource utilization and relatively poor outcomes. The pathophysiologic mechanisms leading to weaning failure in this group may be complex and multifactorial. The aim of this study was to investigate the factors associated with prolonged weaning based on the Weaning Outcome according to a New Definition (WIND) classification.

METHODS

This is a prospective observational study with consecutive adult patients receiving MV for at least two calendar days in medical intensive care units from 1 November 2017 to 30 September 2020. Eligible patients were divided in a non-prolonged weaning group, including short and difficult weaning, and in a prolonged weaning group according to the WIND classification. The risk factors at the time of first separation attempt associated with prolonged weaning were analyzed using a multivariable logistic regression model.

RESULTS

Of the total 915 eligible patients, 172 (18.8%) patients were classified as prolonged weaning. A higher proportion of the prolonged weaning group had previous histories of endotracheal intubation, chronic lung disease, and hematologic malignancies. When compared with the non-prolonged weaning group, the median duration of MV before the first spontaneous breathing trial (SBT) was longer and the proportion of tracheostomized patients was higher in prolonged weaning group. In addition, the prolonged weaning group used higher peak inspiratory pressures and yielded lower PaO₂/FiO₂ ratios at the day of the first SBT compared with the non-prolonged weaning group. In multivariate analyses, the duration of MV before first SBT (adjusted odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.06-1.22, p < 0.001), tracheostomy state (adjusted OR = 1.95, 95% CI = 1.04-3.63, p = 0.036), PaO₂/FiO₂ ratio (adjusted OR = 1.00, 95% CI = 0.99-1.00, p = 0.023), and need for renal replacement therapy (adjusted OR = 2.68, 95% CI = 1.16-6.19, p = 0.021) were independently associated with prolonged weaning. After the exclusion of patients who underwent tracheostomy before the SBTs, similar results were obtained.

CONCLUSION

Longer duration of MV before the first SBT, tracheostomy status, poor oxygenation, and need for renal replacement therapy at the time of first SBT can predict prolonged weaning.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT05134467.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Systematic Review, level III.

The ISPAT project: Implementation of a standardized training program for caregivers of children with tracheostomy

BACKGROUND

Tracheostomy-related morbidity and mortality mainly occur due to decannulation, misplacement, or obstruction of the tube. A standardized training can improve the skills and confidence of the caregivers in tracheostomy care (TC).

OBJECTIVE

Our primary aim was to evaluate the efficiency of standardized training program on the knowledge and skills (changing-suctioning the tracheostomy tube) of the participants regarding TC.

MATERIALS AND METHODS

Sixty-five caregivers of children with tracheostomy were included. First, participants were evaluated with written test about TC and participated in the practical tests. Then, they were asked to participate in a standardized training session, including theoretical and practical parts. Baseline and postintervention assessments were compared through written and practical tests conducted on the same day.

RESULTS

A significant improvement was observed in the written test score after the training. The median number of correct answers of the written test including 23 questions increased 26%, from 12 to 18 (p < .001). The median number of correct steps in tracheostomy tube change (from 9 to 16 correct steps out of 16 steps, 44% increase) and suctioning the tracheostomy tube (from 9 to 17 correct steps out of 18 steps, 44% increase) also improved significantly after the training (p < .001, for both).

CONCLUSION

Theoretical courses and practical hands-on-training (HOT) courses are highly effective in improving the practices in TC. A standardized training program including HOT should be implemented before discharge from the hospital. Still there is a need to assess the impact of the program on tracheostomy-related complications, morbidity, and mortality in the long term.

Percutaneous and Open Tracheostomy in Patients With COVID-19: The Weill Cornell Experience in New York City

OBJECTIVE

Report long-term tracheostomy outcomes in patients with COVID-19.

STUDY DESIGN

Review of prospectively collected data.

METHODS

Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge.

RESULTS

One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037).

CONCLUSION

Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2849-E2856, 2021.

Percutaneous Dilational Tracheostomy at the Epicenter of the SARS-CoV-2 Pandemic: Impact on Critical Care Resource Utilization and Early Outcomes

BACKGROUND

The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity.

METHODS

This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center.

RESULTS

Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period.

CONCLUSION

These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.

Weaning from mechanical ventilation in neurocritical care

In the intensive care unit (ICU), weaning from mechanical ventilation follows a step-by-step process that has been well established in the general ICU population. However, little data is available in brain injury patients, who are often intubated to protect airways and prevent central hypoventilation. In this narrative review, we describe the general principles of weaning and how these principles can be adapted to brain injury patients. We focus on three major issues regarding weaning from mechanic ventilation in brain injury patients: (1) sedation protocol, (2) weaning and extubation protocol and criteria, (3) criteria, timing and technique for tracheostomy.

Impact of Tracheostomy Timing on Outcomes After Cardiovascular Surgery

OBJECTIVES

This study aimed to investigate whether tracheostomy timing in patients undergoing cardiac surgery had an impact on outcomes.

DESIGN

Retrospective, observational study.

SETTING

Single-center university hospital.

PARTICIPANTS

Patients requiring tracheostomy among a total of 961 patients who underwent cardiovascular surgery via a median sternotomy from January 2014 to March 2021.

INTERVENTIONS

Early versus late tracheostomy.

MEASUREMENTS AND MAIN RESULTS

During the study period, tracheostomy was performed in 28 patients (2.9%). According to tracheostomy timing, postoperative day seven was chosen as the cutoff to define early (≤seven days) and late (>seven days) tracheostomy. Patients in the early-tracheostomy group had a significantly shorter ventilation time after tracheostomy compared with the late-tracheostomy group (p = 0.039), and early tracheostomy resulted in a reduction in total ventilation time (p = 0.001). The incidence of pressure ulcers was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group. There was a higher tracheal tube removal rate in the early-tracheostomy group compared with the late-tracheostomy group (p = 0.0007). The one-year survival rate in the early- and late-tracheostomy groups was 65% and 31%, respectively. The long-term mortality rate was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group (p = 0.04).

CONCLUSIONS

Early tracheostomy (<seven days) may provide better clinical outcomes, with lower mortality and morbidity rates, when patients are judged to require at least seven days of ventilation after cardiovascular surgery.

The Royal College of surgeons multidisciplinary guidelines on elective tracheostomy insertion in COVID-19 ventilated patients

BACKGROUND

The current COVID-19 pandemic has placed enormous strain on healthcare systems worldwide. Understanding of COVID-19 is rapidly evolving. Pneumonia associated with COVID-19 may lead to respiratory failure requiring mechanical ventilation. The rise in patients requiring mechanical ventilation may lead to an increase in tracheostomies being performed in patients with COVID-19. Performing tracheostomy in patients with active SARS-CoV-2 infection poses a number of challenges.

METHODS

These guidelines were written following multidisciplinary agreement between Otolaryngology, Head and Neck Surgery, Respiratory Medicine and the Department of Anaesthetics and Critical Care Medicine in the Royal College of Surgeons in Ireland. A literature review was performed and a guideline for elective tracheostomy insertion in patients with COVID-19 proposed.

CONCLUSION

The decision to perform tracheostomy in patients with COVID-19 should be undertaken by senior members of the multidisciplinary team. Steps should be taken to minimise risks to healthcare workers.

Association of Early vs Late Tracheostomy Placement With Pneumonia and Ventilator Days in Critically Ill Patients: A Meta-analysis

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.

Tracheostomy for COVID-19: evolving best practice

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .