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Nguyen M, Amanian A, Wei M, Prisman E, Mendez-Tellez PA. Predicting Tracheostomy Need on Admission to the Intensive Care Unit-A Multicenter Machine Learning Analysis. Otolaryngol Head Neck Surg 2024. [PMID: 39077854 DOI: 10.1002/ohn.919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 06/12/2024] [Accepted: 07/06/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE It is difficult to predict which mechanically ventilated patients will ultimately require a tracheostomy which further predisposes them to unnecessary spontaneous breathing trials, additional time on the ventilator, increased costs, and further ventilation-related complications such as subglottic stenosis. In this study, we aimed to develop a machine learning tool to predict which patients need a tracheostomy at the onset of admission to the intensive care unit (ICU). STUDY DESIGN Retrospective Cohort Study. SETTING Multicenter Study of 335 Intensive Care Units between 2014 and 2015. METHODS The eICU Collaborative Research Database (eICU-CRD) was utilized to obtain the patient cohort. Inclusion criteria included: (1) Age >18 years and (2) ICU admission requiring mechanical ventilation. The primary outcome of interest included tracheostomy assessed via a binary classification model. Models included logistic regression (LR), random forest (RF), and Extreme Gradient Boosting (XGBoost). RESULTS Of 38,508 invasively mechanically ventilated patients, 1605 patients underwent a tracheostomy. The XGBoost, RF, and LR models had fair performances at an AUROC 0.794, 0.780, and 0.775 respectively. Limiting the XGBoost model to 20 features out of 331, a minimal reduction in performance was observed with an AUROC of 0.778. Using Shapley Additive Explanations, the top features were an admission diagnosis of pneumonia or sepsis and comorbidity of chronic respiratory failure. CONCLUSIONS Our machine learning model accurately predicts the probability that a patient will eventually require a tracheostomy upon ICU admission, and upon prospective validation, we have the potential to institute earlier interventions and reduce the complications of prolonged ventilation.
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Affiliation(s)
| | - Ameen Amanian
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Meihan Wei
- Department of Biomedical Engineering-Whiting School of Engineering, Johns Hopkins University, Baltimore, USA
| | - Eitan Prisman
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Pedro Alejandro Mendez-Tellez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Rose L, Messer B. Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy. Crit Care Clin 2024; 40:409-427. [PMID: 38432703 DOI: 10.1016/j.ccc.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK; Department of Critical Care and Lane Fox Unit, Guy's & St Thomas' NHS Foundation Trust, King's College London, 57 Waterloo Road, London SE1 8WA, UK.
| | - Ben Messer
- Royal Victoria Infirmary, Newcastle-Upon-Tyne NHS Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Villemure-Poliquin N, Costerousse O, Lessard Bonaventure P, Audet N, Lauzier F, Moore L, Zarychanski R, Turgeon AF. Tracheostomy versus prolonged intubation in moderate to severe traumatic brain injury: a multicentre retrospective cohort study. Can J Anaesth 2023; 70:1516-1526. [PMID: 37505417 PMCID: PMC10447593 DOI: 10.1007/s12630-023-02539-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/29/2023] [Accepted: 02/16/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE Tracheostomy is a surgical procedure that is commonly performed in patients admitted to the intensive care unit (ICU). It is frequently required in patients with moderate to severe traumatic brain injury (TBI), a subset of patients with prolonged altered state of consciousness that may require a long period of mechanical respiratory assistance. While many clinicians favour the use of early tracheostomy in TBI patients, the evidence in favour of this practice remains scarce. The aims of our study were to evaluate the potential clinical benefits of tracheostomy versus prolonged endotracheal intubation, as well as whether the timing of the procedure may influence outcome in patients with moderate to severe TBI. METHODS We conducted a retrospective multicentre cohort study based on data from the provincial integrated trauma system of Quebec (Québec Trauma Registry). The study population was selected from adult trauma patients hospitalized between 2013 and 2019. We included patients 16 yr and older with moderate to severe TBI (Glasgow Coma Scale score < 13) who required mechanical ventilation for 96 hr or longer. Our primary outcome was 30-day mortality. Secondary outcomes included hospital and ICU mortality, six-month mortality, duration of mechanical ventilation, ventilator-associated pneumonia, ICU and hospital length of stay as well as orientation of patients upon discharge from the hospital. We used propensity score covariate adjustment. To overcome the effect of immortal time bias, an extended Cox shared frailty model was used to compare mortality between groups. RESULTS From 2013 to 2019, 26,923 patients with TBI were registered in the Québec Trauma Registry. A total of 983 patients who required prolonged endotracheal intubation for 96 hr or more were included in the study, 374 of whom underwent a tracheostomy and 609 of whom remained intubated. We observed a reduction in 30-day mortality (adjusted hazard ratio, 0.33; 95% confidence interval, 0.21 to 0.53) associated with tracheostomy compared with prolonged endotracheal intubation. This effect was also seen in the ICU as well as at six months. Tracheostomy, when compared with prolonged endotracheal intubation, was associated with an increase in the duration of mechanical respiratory assistance without any increase in the length of stay. No effect on mortality was observed when comparing early vs late tracheostomy procedures. An early procedure was associated with a reduction in the duration of mechanical respiratory support as well as hospital and ICU length of stay. CONCLUSION In this multicentre cohort study, tracheostomy was associated with decreased mortality when compared with prolonged endotracheal intubation in patients with moderate to severe TBI. This effect does not appear to be modified by the timing of the procedure. Nevertheless, the generalization and application of these results remains limited by potential residual time-dependent indication bias.
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Affiliation(s)
- Noémie Villemure-Poliquin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Ophthalmology and Otolaryngology - Head and Neck Surgery, Université Laval, Quebec City, QC, Canada
| | - Olivier Costerousse
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
| | - Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Division of Neurosurgery, Department of Surgery, CHU de Québec -Université Laval, Quebec City, QC, Canada
| | - Nathalie Audet
- Department of Ophthalmology and Otolaryngology - Head and Neck Surgery, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Medicine, Université Laval, Quebec City, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Preventive and Social Medicine, Université Laval, Quebec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, of Hematology and of Medical Oncology, Rady Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute of Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada.
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada.
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Rabinstein AA, Cinotti R, Bösel J. Liberation from Mechanical Ventilation and Tracheostomy Practice in Traumatic Brain Injury. Neurocrit Care 2023; 38:439-446. [PMID: 36859490 DOI: 10.1007/s12028-023-01693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
Liberating patients with severe traumatic brain injury (TBI) from mechanical ventilation is often a challenging task. These patients frequently require prolonged ventilation and have persistent alterations in the level and content of consciousness. Questions about their ability to protect their airway are common. Pulmonary complications and copious respiratory secretions are also very prevalent. Thus, it is hardly surprising that rates of extubation failure are high. This is a major problem because extubation failure is associated with a host of poor outcome measures. When the safety of an extubation attempt is uncertain, direct tracheostomy is favored by some, but there is no evidence that this practice leads to better outcomes. Current knowledge is insufficient to reliably predict extubation outcomes in TBI, and practices vary substantially across trauma centers. Yet observational studies provide relevant information that must be weighted when considering the decision to attempt extubation in patients with head injury. This review discusses available evidence on liberation from mechanical ventilation in TBI, proposes priorities for future research, and offers practical advice to guide decisions at the bedside.
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Affiliation(s)
| | - Raphael Cinotti
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France.,Methods in Patient-Centered Outcomes and Health Research, University of Nantes, University of Tours, INSERM, 22 Boulevard Benoni Goulin, 44200, Nantes, France
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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