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Merola R, Iacovazzo C, Troise S, Marra A, Formichella A, Servillo G, Vargas M. Timing of Tracheostomy in ICU Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Life (Basel) 2024; 14:1165. [PMID: 39337948 PMCID: PMC11433256 DOI: 10.3390/life14091165] [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: 08/16/2024] [Revised: 09/05/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
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.
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Affiliation(s)
- Raffaele Merola
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (C.I.); (A.M.); (A.F.); (G.S.); (M.V.)
| | - Carmine Iacovazzo
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (C.I.); (A.M.); (A.F.); (G.S.); (M.V.)
| | - Stefania Troise
- Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy;
| | - Annachiara Marra
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (C.I.); (A.M.); (A.F.); (G.S.); (M.V.)
| | - Antonella Formichella
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (C.I.); (A.M.); (A.F.); (G.S.); (M.V.)
| | - Giuseppe Servillo
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (C.I.); (A.M.); (A.F.); (G.S.); (M.V.)
| | - Maria Vargas
- Anesthesia and Intensive Care Medicine, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, 80131 Naples, Italy; (C.I.); (A.M.); (A.F.); (G.S.); (M.V.)
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Blackwell T, Alvi S, Curran NR, Germanwala A. Impact of Tracheostomy Timing Within the National Veterans Affairs Population. Laryngoscope 2024; 134:3555-3561. [PMID: 38501701 DOI: 10.1002/lary.31397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/25/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
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.
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Affiliation(s)
- Thomas Blackwell
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Suffia Alvi
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | | | - Arpita Germanwala
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
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Han R, Gao X, Gao Y, Zhang J, Ma X, Wang H, Ji Z. Effect of tracheotomy timing on patients receiving mechanical ventilation: A meta-analysis of randomized controlled trials. PLoS One 2024; 19:e0307267. [PMID: 39042629 PMCID: PMC11265711 DOI: 10.1371/journal.pone.0307267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 07/01/2024] [Indexed: 07/25/2024] Open
Abstract
PURPOSE We assessed the effects of tracheostomy timing (early vs. late) on outcomes among adult patients receiving mechanical ventilation. METHODS PubMed, Embase, Web of Science and Cochrane Library were searched to identify relevant RCTs of tracheotomy timing on patients receiving mechanical ventilation. Two reviewers independently screened the literature, extracted data. Outcomes in patients with early tracheostomy and late tracheostomy groups were compared and analyzed. Meta-analysis was performed using Stata14.0 and RevMan 5.4 software. This study is registered with PROSPERO (CRD42022360319). RESULTS Twenty-one RCTs were included in this Meta-analysis. The Meta-analysis indicated that early tracheotomy could significantly shorten the duration of mechanical ventilation (MD: -2.77; 95% CI -5.10~ -0.44; P = 0.02) and the length of ICU stay (MD: -6.36; 95% CI -9.84~ -2.88; P = 0.0003), but it did not significantly alter the all-cause mortality (RR 0.86; 95% CI 0.73~1.00; P = 0.06), the incidence of pneumonia (RR 0.86; 95% CI 0.74~1.01; P = 0.06), and length of hospital stay (MD: -3.24; 95% CI -7.99~ 1.52; P = 0.18). CONCLUSION In patients requiring mechanical ventilation, the tracheostomy performed at an earlier stage may shorten the duration of mechanical ventilation and the length of ICU stay but cannot significantly decrease the all-cause mortality and incidence of pneumonia.
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Affiliation(s)
- Rongrong Han
- Department of Otolaryngology, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Xiang Gao
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Yongtao Gao
- Urology Department I, Weifang Hospital of traditional Chinese Medicine, Weifang, Shan dong Province, China
| | - Jihong Zhang
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Xiaoyan Ma
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Haibo Wang
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
| | - Zhixin Ji
- Department of Critical Care Medicine, Weifang People’s Hospital, Weifang, Shan dong Province, China
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Papaioannou M, Vagiana E, Kotoulas SC, Sileli M, Manika K, Tsantos A, Kapravelos N. Tracheostomy-related data from an intensive care unit for two consecutive years before the COVID-19 pandemic. World J Methodol 2024; 14:91868. [PMID: 38983661 PMCID: PMC11229867 DOI: 10.5662/wjm.v14.i2.91868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/24/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Tracheostomy is commonly used in intensive care unit (ICU) patients who are expected to be on long-term mechanical ventilation or suffer from emergency upper airway obstruction. However, some studies have conflicting findings regarding the optimal technique and its timing and benefits. AIM To provide evidence of practice, characteristics, and outcome concerning tracheostomy in an ICU of a tertiary care hospital. METHODS This was a retrospective cohort study including adult critical care patients in a single ICU for two consecutive years. Patients' demographic characteristics, severity of illness (APACHE II score), level of consciousness [Glasgow Coma Scale (GCS)], comorbidities, timing and type of tracheostomy procedure performed and outcome were recorded. We defined late as tracheostomy placement after 8 days or no tracheotomy. RESULTS Data of 660 patients were analyzed (median age of 60 years), median APACHE II score of 19 and median GCS score of 12 at admission. Tracheostomy was performed in 115 patients, of whom 63 had early and 52 late procedures. Early tracheostomy was mainly executed in case of altered level of consciousness and severe critical illness polyneuromyopathy, however there were no significant statistical results (47.6% vs 36.5%, P = 0.23) and (23.8% vs 19.2%, P = 0.55) respectively. Regarding the method selected, early surgical tracheostomy (ST) was conducted in patients with maxillofacial injuries (50.0% vs 0.0%, P = 0.033), whereas late surgical tracheostomy was selected for patients with goiter (44.4% vs 0.0% P = 0.033). Patients with early tracheostomy spent significantly fewer days on mechanical ventilation (15.3 ± 8.5 vs 22.8 ± 9.6, P < 0.001) and in ICU in general (18.8 ± 9.1 vs 25.4 ± 11.5, P < 0.001). Percutaneous dilatation tracheostomy (PDT) vs ST was preferable in older critical care patients in the case of Central Nervous System underlying cause of admission (62.5% vs 26.3%, P = 0.004). ST was the method of choice in compromised airway (31.6%, vs 7.3% P = 0.008). A large proportion of patients (88/115) with tracheostomy managed to wean from mechanical ventilation and were transferred out of the ICU (100% vs 17.4%, P < 0.001). CONCLUSION PDT was performed more frequently in our cohort. This technique did not affect mechanical ventilation days, ventilator-associated pneumonia (VAP), ICU length of stay, or survival. No complications were observed in the percutaneous or surgical tracheostomy groups. Patients undergoing early tracheostomy benefited in terms of mechanical ventilation days and ICU length of stay but not of discharge status, presence of VAP, or survival.
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Affiliation(s)
- Maria Papaioannou
- 1st Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Evdoxia Vagiana
- 2nd Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | | | - Maria Sileli
- 2nd Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Katerina Manika
- Department of Pulmonary, Medical School, Aristotle University of Thessaloniki, G. Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Alexandros Tsantos
- 2nd Department of Internal Medicine, General Hospital of Thessaloniki “Ippokration”, Thessaloniki 54642, Greece
| | - Nikolaos Kapravelos
- 2nd Intensive Care Unit, G Papanikolaou General Hospital, Exohi, Thessaloniki 57010, Greece
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Tekin P, Bulut A. Tracheostomy Timing in Unselected Critically Ill Patients with Prolonged Intubation: A Prospective Cohort Study. J Clin Med 2024; 13:2729. [PMID: 38792271 PMCID: PMC11121849 DOI: 10.3390/jcm13102729] [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: 04/07/2024] [Revised: 04/24/2024] [Accepted: 05/04/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Tracheostomy procedures are performed in the intensive care unit (ICU) for prolonged intubation, unsuccessful weaning and infection prevention through either percutaneous or surgical techniques. This study aimed to outline the impact of tracheostomy timing in the ICU on mortality, need for mechanical ventilation, and complications. Methods: Patients were included in the study on the day of tracheostomy. Demographic information, tracheostomy timing, technique, complications, sedation requirement and need for mechanical ventilation at discharge were recorded by an anesthesiologist, including the pre-tracheostomy period. Results: Tracheostomy was performed on 33 patients during the first 14 days of intubation and on 54 patients on the 15th day and beyond. There was no significant difference between the tracheostomy timing and mortality, sedation requirement, or weaning from the ventilator. We observed that patients who underwent tracheostomy with the surgical technique experienced more complications, but there was no significant difference. Tracheostomy performed after the 14th day was shown to be associated with prolonged hospital stay. Conclusions: Early tracheostomy does not have any influence on the need for mechanical ventilation, sedation and mortality. The optimal timing for tracheostomy is still controversial. We are of the opinion that randomized controlled trials involving patient groups with similar survival expectations are needed.
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Affiliation(s)
| | - Azime Bulut
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Giresun University, 28100 Giresun, Türkiye;
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Patel D, Devivo A, Leibner E, Shittu A, Govindarajulu U, Tandon P, Lee D, Owen R, Fernandez-Ranvier G, Hiensch R, Marin M, Kohli-Seth R, Bassily-Marcus A. The COVID-19 Tracheostomy Experience at a Large Academic Medical Center in New York during the First Year. J Clin Med 2024; 13:2130. [PMID: 38610895 PMCID: PMC11012500 DOI: 10.3390/jcm13072130] [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: 02/21/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Background: New York City was the epicenter of the initial surge of the COVID-19 pandemic in the United States. Tracheostomy is a critical procedure in the care of patients with COVID-19. We hypothesized that early tracheostomy would decrease the length of time on sedation, time on mechanical ventilation, intensive care unit length of stay, and mortality. Methods: A retrospective analysis of outcomes for all patients with COVID-19 who underwent tracheostomy during the first year of the COVID-19 pandemic at the Mount Sinai Hospital in New York City, New York. All adult intensive care units at the Mount Sinai Hospital, New York. Patients/subjects: 888 patients admitted to intensive care with COVID-19. Results: All patients admitted to the intensive care unit with COVID-19 (888) from 1 March 2020 to 1 March 2021 were analyzed and separated further into those intubated (544) and those requiring tracheostomy (177). Of those receiving tracheostomy, outcomes were analyzed for early (≤12 days) or late (>12 days) tracheostomy. Demographics, medical history, laboratory values, type of oxygen and ventilatory support, and clinical outcomes were recorded and analyzed. Conclusions: Early tracheostomy resulted in reduced duration of mechanical ventilation, reduced hospital length of stay, and reduced intensive care unit length of stay in patients admitted to the intensive care unit with COVID-19. There was no effect on overall mortality.
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Affiliation(s)
- Dhruv Patel
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Anthony Devivo
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Evan Leibner
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Atinuke Shittu
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
| | - Usha Govindarajulu
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Pranai Tandon
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David Lee
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Randall Owen
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | | | - Robert Hiensch
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Michael Marin
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Adel Bassily-Marcus
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Szafran A, Dahms K, Ansems K, Skoetz N, Monsef I, Breuer T, Benstoem C. Early versus late tracheostomy in critically ill COVID-19 patients. Cochrane Database Syst Rev 2023; 11:CD015532. [PMID: 37982427 PMCID: PMC10658650 DOI: 10.1002/14651858.cd015532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
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.
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Affiliation(s)
- Agnieszka Szafran
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Karolina Dahms
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Kelly Ansems
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Breuer
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Carina Benstoem
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Tavares WM, Araujo de França S, Paiva WS, Teixeira MJ. Early tracheostomy versus late tracheostomy in severe traumatic brain injury or stroke: A systematic review and meta-analysis. Aust Crit Care 2023; 36:1110-1116. [PMID: 36775675 DOI: 10.1016/j.aucc.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVES We aim to ascertain whether the benefit of early tracheostomy can be found in patients with severe traumatic brain injury (TBI) and stroke and if the benefit will remain considering distinct pathologies. DATA SOURCES Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, a search through Lilacs, PubMed, and Cochrane databases was conducted. REVIEW METHODS Included studies were those written in English, French, Spanish, or Portuguese, with a formulated question, which compared outcomes between early and late trach (minimum of two outcomes), such as intensive care unit (ICU) length of stay (LOS), duration of mechanical ventilation (MV), hospital LOS, mortality rates, or ventilator-associated pneumonia (VAP). Likewise, patients presented exclusively with head injury or stroke had minimum hospital stay follow-up, and as for severe TBI patients, they presented Glasgow Coma Scale ≤8 at admission. Evaluated outcomes were the risk ratio (RR) of VAP, risk difference (RD) of mortality, and mean difference (MD) of the duration of MV, ICU LOS, and hospital LOS. RESULTS The early and late tracheostomy cohorts were composed of 6211 and 8140 patients, respectively. The meta-analysis demonstrated that the early tracheostomy cohort had a lower risk for VAP (RR: 0.73 [95% confidence interval {CI}, 0.66, 0.81] p < 0.00001), shorter duration of MV (MD: -4.40 days [95% CI, -8.28, -0.53] p = 0.03), and shorter ICU (MD: -6.93 days [95% CI, -8.75, -5.11] p < 0.00001) and hospital LOS (MD: -7.05 days [95% CI, -8.27, -5.84] p < 0.00001). The mortality rate did not demonstrate a statistical difference. CONCLUSION Early tracheostomy could optimise patient outcomes by patients' risk for VAP and decreasing MV durationand ICU and hospital LOS.
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Affiliation(s)
- Wagner Malago Tavares
- Department of Research of IPSPAC, Instituto Paulista de Saúde para Alta Complexidade, 215 - Al. Terracota, Room 407, Cerâmica, São Caetano do Sul, SP, 09531-190, Brazil; Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar Avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil
| | - Sabrina Araujo de França
- Department of Research of IPSPAC, Instituto Paulista de Saúde para Alta Complexidade, 215 - Al. Terracota, Room 407, Cerâmica, São Caetano do Sul, SP, 09531-190, Brazil.
| | - Wellingson Silva Paiva
- Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar Avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil
| | - Manoel Jacobsen Teixeira
- Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar Avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil
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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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Morris CAD, Donaldson RE. Mechanical ventilation in snake envenomation of dogs and cats. Front Vet Sci 2023; 10:1071257. [PMID: 37065246 PMCID: PMC10090310 DOI: 10.3389/fvets.2023.1071257] [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: 10/16/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06-40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76-84%) with 33 h (19.5-58 h) median duration of mechanical ventilation and 140 h (84-196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.
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Affiliation(s)
- Cameron A. D. Morris
- Critical Care Department, Queensland Veterinary Specialists, Brisbane, QLD, Australia
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11
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Mc Mahon A, Griffin S, Gorman E, Lennon A, Kielthy S, Flannery A, Cherian BS, Josy M, Marsh B. Patient-Centred Outcomes Following Tracheostomy in Critical Care. J Intensive Care Med 2023:8850666231160669. [PMID: 36883211 PMCID: PMC10374991 DOI: 10.1177/08850666231160669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Around 20% of intensive care unit (ICU) patients undergo tracheostomy insertion and expect high-quality care concentrating on patient-centered outcomes including communication, oral intake, and mobilization. The majority of data has focused on timing, mortality, and resource utilization, with a paucity of information on quality of life following tracheostomy. METHODS Single center retrospective study including all patients requiring tracheostomy from 2017 to 2019. Information collected on demographics, severity of illness, ICU and hospital length of stay (LOS), ICU and hospital mortality, discharge disposition, sedation, time to vocalization, swallow and mobilization. Outcomes were compared for early versus late tracheostomy (early = <day 10) and age category (≤ 65 vs ≥ 66 years). RESULTS In total, 304 patients were included and 71% male, median age 59, APACHE II score 17. Median ICU and hospital LOS 16 and 56 days, respectively. ICU and hospital mortality 9.9% and 22.4%. Median time to tracheostomy 8 days, 8.55% open. Following tracheostomy, median days of sedation was 0, time to noninvasive ventilation (NIV) 1 day (94% of patients achieving this), ventilator-free breathing (VFB) 5 days (72%), speaking valve 7 days (60%), dynamic sitting 5 days (64%), and swallow assessment 16 days (73%). Early tracheostomy was associated with shorter ICU LOS (13 vs 26 days, P < .0001), reduced sedation (6 vs 12 days, P < .0001), faster transition to level 2 care (6 vs 10 days, P < .003), NIV (1 vs 2 days, P < .003), and VFB (4 vs 7 days, P < .005). Older patients received less sedation, had higher APACHE II scores and mortality (36.1%) and 18.5% were discharged home. Median time to VFB was 6 days (63.9%), speaking valve 7 days (64.7%), swallow assessment 20.5 days (66.7%), and dynamic sitting 5 days (62.2%). CONCLUSION Patient-centered outcomes are a worthy goal to consider when selecting patients for tracheostomy in addition to mortality or timing alone, including in older patients.
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Affiliation(s)
- A Mc Mahon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - S Griffin
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Emma Gorman
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aoife Lennon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Stephen Kielthy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Andrea Flannery
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Bindu Sam Cherian
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Minu Josy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - B Marsh
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
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12
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Menon R, Vasani SS, Widdicombe NJ, Lipman J. Laryngeal injury following endotracheal intubation: Have you considered reflux? Anaesth Intensive Care 2023; 51:14-19. [PMID: 36168788 DOI: 10.1177/0310057x221102472] [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: 01/17/2023]
Abstract
Laryngotracheal injury is an increasingly common complication of intubation and mechanical ventilation, with an estimated 87% of intubated and ventilated patients developing a laryngotracheal injury often preventing their rehabilitation from acute illness. Laryngotracheal injuries encompass a diverse set of pathologies including inflammation and oedema in addition to vocal cord ulceration and paralysis, granuloma, stenosis, and scarring. The existing literature has identified several factors including intubation duration, endotracheal tube size, type and cuff pressures, and technical factors including the skill and experience of the endoscopist. Despite these associations, a key aspect in the sequelae of laryngotracheal injuries is due to reflux and is not clearly related to iatrogenic and mechanical factors.Laryngopharyngeal reflux is a type of reflux that contaminates the upper aerodigestive tract. The combination of patient positioning and continuous nasogastric tube feeding act to affect the upper aerodigestive tract with acidic and non-acidic refluxate that causes direct and indirect mucosal injury impeding healing.Despite laryngopharyngeal reflux being an established and recognised causative factor of upper aerodigestive tract inflammatory pathology and laryngotracheal injury, it is very understudied in critical care. Further, there is yet to be an agreed pathway to assess, manage and prevent laryngotracheal injury in intubated and ventilated patients. The incidence of laryngopharyngeal reflux in the intubated and mechanically ventilated patient in the intensive care unit is currently unknown. Prospective studies may allow us to understand further potential mechanisms of upper aerodigestive tract injury due to laryngopharyngeal reflux and herald the development of preventative and management strategies of laryngopharyngeal reflux-mediated upper aerodigestive tract injury in critically ill patients.
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Affiliation(s)
- Rahul Menon
- Department of Otorhinolaryngology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Sarju S Vasani
- Department of Otorhinolaryngology, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Neil J Widdicombe
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women's Hospital, Herston, Australia
- The University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Australia
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, Nimes, France
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Open Surgical Tracheostomy in COVID 19 Patients and Their Outcomes During the Second Wave in India: Experience at a Tertiary Referral Centre. Indian J Otolaryngol Head Neck Surg 2022:1-5. [PMID: 36406803 PMCID: PMC9649005 DOI: 10.1007/s12070-022-03276-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 10/31/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Battaglini D, Premraj L, White N, Sutt AL, Robba C, Cho SM, Di Giacinto I, Bressan F, Sorbello M, Cuthbertson BH, Bassi GL, Suen J, Fraser JF, Pelosi P. Tracheostomy outcomes in critically ill patients with COVID-19: a systematic review, meta-analysis, and meta-regression. Br J Anaesth 2022; 129:679-692. [PMID: 36182551 PMCID: PMC9345907 DOI: 10.1016/j.bja.2022.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/12/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND We performed a systematic review of mechanically ventilated patients with COVID-19, which analysed the effect of tracheostomy timing and technique (surgical vs percutaneous) on mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), decannulation from tracheostomy, duration of mechanical ventilation, and complications. METHODS Four databases were screened between January 1, 2020 and January 10, 2022 (PubMed, Embase, Scopus, and Cochrane). Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Population or Problem, Intervention or exposure, Comparison, and Outcome (PICO) guidelines. Meta-analysis and meta-regression for main outcomes were performed. RESULTS The search yielded 9024 potentially relevant studies, of which 47 (n=5268 patients) were included. High levels of between-study heterogeneity were observed across study outcomes. The pooled mean tracheostomy timing was 16.5 days (95% confidence interval [CI]: 14.7-18.4; I2=99.6%). Pooled mortality was 22.1% (95% CI: 18.7-25.5; I2=89.0%). Meta-regression did not show significant associations between mortality and tracheostomy timing, mechanical ventilation duration, time to decannulation, and tracheostomy technique. Pooled mean estimates for ICU and hospital LOS were 29.6 (95% CI: 24.0-35.2; I2=98.6%) and 38.8 (95% CI: 32.1-45.6; I2=95.7%) days, both associated with mechanical ventilation duration (coefficient 0.8 [95% CI: 0.2-1.4], P=0.02 and 0.9 [95% CI: 0.4-1.4], P=0.01, respectively) but not tracheostomy timing. Data were insufficient to assess tracheostomy technique on LOS. Duration of mechanical ventilation was 23.4 days (95% CI: 19.2-27.7; I2=99.3%), not associated with tracheostomy timing. Data were insufficient to assess the effect of tracheostomy technique on mechanical ventilation duration. Time to decannulation was 23.8 days (95% CI: 19.7-27.8; I2=98.7%), not influenced by tracheostomy timing or technique. The most common complications were stoma infection, ulcers or necrosis, and bleeding. CONCLUSIONS In patients with COVID-19 requiring tracheostomy, the timing and technique of tracheostomy did not clearly impact on patient outcomes. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42021272220.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Medicine, University of Barcelona, Barcelona, Spain.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Nicole White
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ida Di Giacinto
- Unit of Anesthesia and Intensive Care, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Filippo Bressan
- Anesthesia and Intensive Care, Anestesia e Rianimazione Ospedale Santo Stefano di Prato, Prato, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico San Marco University Hospital, Catania, Italy
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University Department of Anaesthesiology in Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; Critical Care Medicine, UnitingCare Health, Brisbane, QLD, Australia
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; Critical Care Medicine, UnitingCare Health, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia; Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Queensland University of Technology, Brisbane, QLD, Australia; Critical Care Medicine, UnitingCare Health, Brisbane, QLD, Australia
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Zhang B, Li GK, Wang YR, Wu F, Shi SQ, Hang X, Feng QL, Li Y, Wan XY. Prediction of factors influencing the timing and prognosis of early tracheostomy in patients with multiple rib fractures: A propensity score matching analysis. Front Surg 2022; 9:944971. [PMID: 36211272 PMCID: PMC9537817 DOI: 10.3389/fsurg.2022.944971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the factors affecting the timing and prognosis of early tracheostomy in multiple rib fracture patients. Methods A retrospective case-control study was used to analyze the clinical data of 222 patients with multiple rib fractures who underwent tracheotomy in the Affiliated Hospital of Yangzhou University from February 2015 to October 2021. According to the time from tracheal intubation to tracheostomy after admission, the patients were divided into two groups: the early tracheostomy group (within 7 days after tracheal intubation, ET) and late tracheostomy group (after the 7th day, LT). Propensity score matching (PSM) was used to eliminate the differences in baseline characteristics Logistic regression was used to predict the independent risk factors for early tracheostomy. Kaplan–Meier and Cox survival analyses were used to analyze the influencing factors of the 28-day survival. Results According to the propensity score matching analysis, a total of 174 patients were finally included in the study. Among them, there were 87 patients in the ET group and 87 patients in the LT group. After propensity score matching, Number of total rib fractures (NTRF) (P < 0.001), Acute respiratory distress syndrome (ARDS) (P < 0.001) and Volume of pulmonary contusion(VPC) (P < 0.000) in the ET group were higher than those in the LT group. Univariate analysis showed that the patients who underwent ET had a higher survival rate than those who underwent LT (P = 0.021). Pearson's analysis showed that there was a significant correlation between NTRF and VPC (r = 0.369, P = 0.001). A receiver operating characteristic(ROC)curve analysis showed that the areas under the curves were 0.832 and 0.804. The best cutoff-value values of the VPC and NTRF were 23.9 and 8.5, respectively. The Cox survival analysis showed that the timing of tracheostomy (HR = 2.51 95% CI, 1.12–5.57, P = 0.004) and age (HR = 1.53 95% CI, 1.00–2.05, P = 0.042) of the patients had a significant impact on the 28-day survival of patients with multiple rib fractures. In addition, The Kaplan–Meier survival analysis showed that the 28-day survival of patients in the ET group was significantly better than that of the LT group, P = 0.01. Conclusions NTRF, ADRS and VPC are independent risk factors for the timing and prognosis of early tracheotomy. A VPC ≥ 23.9% and/or an NTRF ≥ 8.5 could be used as predictors of ET in patients with multiple rib fractures. Predicting the timing of early tracheostomy also need prediction models in the future.
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Affiliation(s)
- Bing Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gong-Ke Li
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yu-Rong Wang
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Fei Wu
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Su-Qin Shi
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Xin Hang
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qin-Ling Feng
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yong Li
- Department of Critical Care Medicine, affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Xian-Yao Wan
- Department of Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
- Correspondence: Xian-Yao Wan Yong Li
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Arias-Rivera S, Jam-Gatell R, Nuvials-Casals X, Vázquez-Calatayud M. [Update of the recommendations of the Pneumonia Zero project]. ENFERMERIA INTENSIVA 2022; 33:S17-S30. [PMID: 35911624 PMCID: PMC9326456 DOI: 10.1016/j.enfi.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial. Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales). Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos. Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.
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Affiliation(s)
- S Arias-Rivera
- Investigación de enfermería. Hospital Universitario de Getafe, Getafe. CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España
| | - R Jam-Gatell
- Área de críticos. Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - X Nuvials-Casals
- Área de Desarrollo Profesional e investigación de Enfermería, Clínica Universidad de Navarra. Universidad de Navarra. IdisNA, Instituto de Investigación Sanitaria de Navarra, Navarra, España
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17
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Kristinsdottir EA, Sigvaldason K, Karason S, Jonasdottir RJ, Bodvarsdottir R, Olafsson O, Tryggvason G, Gudbjartsson T, Sigurdsson MI. Utilization and outcomes of tracheostomies in the intensive care unit in Iceland in 2007-2020: A descriptive study. Acta Anaesthesiol Scand 2022; 66:996-1002. [PMID: 35704855 DOI: 10.1111/aas.14105] [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: 03/25/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tracheostomies are commonly utilized in ICU patients due to prolonged mechanical ventilation, upper airway obstruction, or surgery in the face/neck region. However, practices regarding the timing of placement and utilization vary. This study provides a nationwide overview of tracheostomy utilization and outcomes in the ICU over a 14-year period. METHODS A retrospective study including all patients that received a tracheostomy during their ICU stay in Iceland between 2007 and 2020. Data were retrieved from hospital records on admission cause, comorbidities, indication for tracheostomy insertion, duration of mechanical ventilation before and after tracheostomy placement, extubation attempts, complications, length of ICU and hospital stay and survival. Descriptive statistics were provided, and survival analysis was performed using Cox regression. RESULTS A total of 336 patients (median age 64 years, 33% females) received a tracheostomy during the study period. The most common indication for tracheostomy insertion was respiratory failure, followed by neurological disorders. The median duration of mechanical ventilation prior to tracheostomy insertion was 9 days and at least one extubation had been attempted in 35% of the cases. Percutaneous tracheostomies were 32%. The overall rate of complications was 25% and the most common short-term complication was bleeding (5%). In-hospital mortality was 33%. The one- and five-year survival rate was 60% and 44%, respectively. CONCLUSIONS We describe a whole-nation practice of tracheostomies. A notable finding is the relatively low rate of extubation attempts prior to tracheostomy insertion. Future work should focus on standardization of assessing the need for tracheostomy and the role of extubation attempts prior to tracheostomy placement.
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Affiliation(s)
- Eyrun A Kristinsdottir
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Kristinn Sigvaldason
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sigurbergur Karason
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Rannveig J Jonasdottir
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Regina Bodvarsdottir
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Oddur Olafsson
- Division of Anaesthesia and Intensive Care, Perioperative Services at Akureyri Hospital, Akureyri, Iceland
| | - Geir Tryggvason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Otorhinolaryngology at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Tomas Gudbjartsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Cardiothoracic Surgery at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Division of Anaesthesia and Intensive Care, Perioperative Services at Landspitali, the National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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18
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Fior G, Colon ZFV, Peek GJ, Fraser JF. Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects. Semin Respir Crit Care Med 2022; 43:417-425. [PMID: 35760300 DOI: 10.1055/s-0042-1749450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.
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Affiliation(s)
- Gabriele Fior
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Zasha F Vazquez Colon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Florida, Shands Children's Hospital, Gainesville, Florida
| | - Giles J Peek
- Department of Surgery, Congenital Heart Center, Shands Children's Hospital, Gainesville, University of Florida, Gainesville, Florida
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital and The Wesley Hospital, Uniting Care Hospitals, Brisbane, QLD, Australia
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19
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Chong WH, Tan CK. Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1121-1132. [PMID: 35506907 DOI: 10.1177/08850666221098930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated. OBJECTIVES To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients. METHODS Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021. RESULTS Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups. CONCLUSIONS Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.
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Affiliation(s)
- Woon Hean Chong
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
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20
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Prefer early tracheostomy. Int J Health Sci (Qassim) 2022. [DOI: 10.53730/ijhs.v6ns3.6204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Tracheotomies are commonly performed for the patients with low GCS who needs a respiratory support. Still over the period there existed a controversy when to do tracheotomy ? Early or late. Our study aimed at reassessing the complications of delayed tracheotomy versus the advantages of the early tracheostomy. This was a prospective comparative, observational study comprising of 140 patients in 2 different hospitals admitted to the neurosurgery ICU with poor GCS. Group A: Early tracheostomy (2-5 days) and Group B: Late tracheostomy (7-14 days). Both groups were followed ,Early tracheostomy required a mechanical ventilator support for average 5-8 days with early weaning whereas late tracheostomy required 12-20 days of mechanical
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21
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Craven J, Slaughter A, Potter KF. Early tracheostomy: on the cutting edge, some benefit more than others. Curr Opin Anaesthesiol 2022; 35:236-241. [PMID: 35131970 DOI: 10.1097/aco.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The decision to undergo early tracheostomy in critically ill patients has been the subject of multiple studies in recent years, including several meta-analyses and a large-scale examination of the National in-patient Sampling (NIS) database. The research has focused on different patient populations, and identified common outcomes measures related to ventilation. At the crux of the new research is the decision to undergo an additional invasive procedure, mainly tracheostomy, rather than attempt endotracheal tube ventilation with or without early extubation. Notably, recent research indicates that neurological and SARS-CoV-2 (COVID-19) patients seem to have an exaggerated benefit from early tracheostomy. RECENT FINDINGS Recent studies of patients undergoing early tracheostomy have shown decreases in ventilator associated pneumonia, ventilator duration and duration of ICU stay. However, these studies have shown mixed data with respect to mortality and length of hospitalization. Such advantages only become apparent with large-scale examination. Confounding the overall discussion is that the research has focused on heterogeneous groups, including neurosurgical ICU patients, general ICU patients, and most recently, intubated COVID-19 patients. SUMMARY Specific populations such as neurosurgical and COVID-19 patients have clearly defined benefits following early tracheostomy. Although the benefit is less pronounced, there does seem to be an advantage in general ICU patients with regards to ventilator-free days and lower incidence of ventilator-associated pneumonia. In these patients, large-scale examination points to a clear mortality benefit.
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Affiliation(s)
- Jack Craven
- Virginia Commonwealth University Health System, Department of Anesthesiology
| | - Ashley Slaughter
- Virginia Commonwealth University Health System, Department of Surgery, Richmond, Virginia, USA
| | - Kenneth F Potter
- Virginia Commonwealth University Health System, Department of Anesthesiology - Division of Critical Care Medicine
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22
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Goo ZQ, Muthusamy KA. Early versus standard tracheostomy in ventilated patients in neurosurgical intensive care unit: A randomized controlled trial. J Clin Neurosci 2022; 98:162-167. [PMID: 35182846 DOI: 10.1016/j.jocn.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Tracheostomy is performed in patients with prolonged mechanical ventilation, who suffered catastrophic neurologic insult or upper airway obstruction. Thus far, there is no consensus on the optimal timing in performing a tracheostomy. This study aims to test whether early tracheostomy in mechanically ventilated patients in a neurosurgical setting would be associated with a shorter time of mechanical ventilation as compared to standard tracheostomy. METHODS This single-center prospective randomized controlled trial was conducted at University Malaya Medical Centre from July 2019 to July 2021. The likelihood of prolonged ventilation was determined objectively using the TRACH score and the patient's clinical presentation. The outcomes measured were days of mechanical ventilation post-tracheostomy, days of neuro-intensive care unit stay, and days of hospital stay. Tracheostomy-related complications were collected. The data collected were analyzed using Statistical Package for the Social Sciences version 25 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS In all, 39 patients were randomly assigned. Of these, 20 were allocated to the early tracheostomy group (ET) and 19 were allocated to the standard tracheostomy group (ST). The demographic characteristics were similar between the groups. The primary outcome, mean (SD) days of mechanical ventilation post-tracheostomy, was statistically different in the 2 groups- early 11.9 (9.3) days, standard 18.9 (32.5) days; p = 0.014. There were comparable tracheostomy-related complications in both groups. CONCLUSION Early tracheostomy is associated with a shorter duration of mechanical ventilation in a neurosurgical intensive care unit setting.
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Affiliation(s)
- Zhen Qiang Goo
- Division of General Surgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Kalai Arasu Muthusamy
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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23
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Cagle LA, Hopper K, Epstein SE. Indications and outcome associated with positive-pressure ventilation in dogs and cats: 127 cases. J Vet Emerg Crit Care (San Antonio) 2022; 32:365-375. [PMID: 35043547 DOI: 10.1111/vec.13176] [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: 08/11/2020] [Revised: 12/31/2020] [Accepted: 01/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the indications and outcomes of positive-pressure ventilation (PPV) and identify factors associated with successful weaning. DESIGN Retrospective study from October 2009 to September 2013. SETTING University teaching hospital. ANIMALS One hundred and eleven dogs and 16 cats. MEASUREMENTS AND MAIN RESULTS Medical records were retrospectively reviewed; signalment, indication for PPV, patient characteristics, blood gas, and ventilator variables during PPV, duration of PPV, and outcome were recorded. Dogs were most commonly ventilated for pneumonia (36/111; 32%) and cats for multiple pulmonary diseases (8/16; 50%). The median duration of PPV for all animals was 25.7 h (range, 0.1-957 h). Long-term PPV (≥24 h) was performed in 53% of cases. No differences were noted in successful weaning rates between cases ventilated for pulmonary etiologies (23/99; 23%) versus nonpulmonary etiologies (9/28; 32%). Overall, 32 of 127 (25%; 30 dogs, 2 cats) animals were successfully weaned from PPV and 28 of 127 (22%; 26 dogs, 2 cats) survived to hospital discharge. Long-term ventilation had a higher likelihood of successful weaning (26/67 [39%] vs 6/60 [10%], P = 0.0002) and higher rates of survival to discharge (23/67 [34%] vs 5/60 [8%], P = 0.0005) than short-term ventilation. Animals with higher Pao2 /Fio2 and Spo2 /Fio2 and lower APPLE and SOFA scores on day 1 of PPV were more likely to be weaned (P < 0.03). CONCLUSIONS The outcome of PPV appears to be most heavily determined by the underlying disease process and no clear improvement in outcome could be demonstrated in this study, despite advances in veterinary critical care and ventilator management strategies since previous studies. Dogs and cats receiving PPV for more than 24 h in this study had a higher likelihood of a positive outcome. Several indices of oxygenation and illness severity at the onset of PPV were predictive of outcome and maybe useful when considering prognosis of these cases.
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Affiliation(s)
- Laura A Cagle
- William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Kate Hopper
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
| | - Steven E Epstein
- Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, Davis, California, USA
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24
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Amadi N, Trivedi R, Ahmed N. Timing of tracheostomy in mechanically ventilated COVID-19 patients. World J Crit Care Med 2021; 10:345-354. [PMID: 34888160 PMCID: PMC8613720 DOI: 10.5492/wjccm.v10.i6.345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/09/2021] [Accepted: 10/27/2021] [Indexed: 02/06/2023] Open
Abstract
According to the World Health Organization as of September 16, 2021, there have been over 226 million documented cases of coronavirus disease 2019 (COVID-19), which has resulted in more than 4.6 million deaths and approximately 14% develop a more severe disease that requires respiratory assistance such as intubation. Early tracheostomy is recommended for patients that are expected to be on prolonged mechanical ventilation; however, supporting data has not yet been provided for early tracheostomies in COVID-19 patients. The aim of this study was to explore established guidelines for performing tracheostomies in patients diagnosed with COVID-19. Factors considered were patient outcomes such as mortality, ventilator-associated pneumonia, intensive care unit length of stay, complications associated with procedures, and risks to healthcare providers that performed tracheostomies. Various observational studies, meta-analyses, and systematic reviews were collected through a PubMed Database search. Additional sources were found through Google. The search was refined to publications in English and between the years of 2003 and 2021. The keywords used were “Coronavirus” and/or “guidelines'' and/or “tracheostomy” and/or “intensive care”. Twenty-three studies were retained. Due to the complex presentation of the respiratory virus COVID-19, previously established guidelines for tracheostomies had to be reevaluated to determine if these guidelines were still applicable to these critically ill ventilated patients. More specifically, medical guidelines state benefits to early tracheostomies in critically ill ventilated non-COVID-19 patients. However, after having conducted this review, the assumptions about the benefits of early tracheostomies in critically ill ventilated patients may not be appropriate for COVID-19 patients.
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Affiliation(s)
- Nwonukwuru Amadi
- Division of Trauma, Jersey Shore University Medical Center, Neptune, NJ 07754, United States
| | - Radhika Trivedi
- Division of Trauma, Jersey Shore University Medical Center, Neptune, NJ 07754, United States
| | - Nasim Ahmed
- Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Nepune, NJ 07754, United States
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25
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Kapp CM, Latifi A, Feller-Kopman D, Atkins JH, Ben Or E, Dibardino D, Haas AR, Thiboutot J, Hutchinson CT. Sedation and Analgesia in Patients Undergoing Tracheostomy in COVID-19, a Multi-Center Registry. J Intensive Care Med 2021; 37:240-247. [PMID: 34636705 DOI: 10.1177/08850666211045896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS. STUDY DESIGN AND METHODS A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected. RESULTS 128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012). INTERPRETATION This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.
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Affiliation(s)
| | | | | | - Joshua H Atkins
- 6569University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - David Dibardino
- 6569University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew R Haas
- 6569University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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26
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Ghattas C, Alsunaid S, Pickering EM, Holden VK. State of the art: percutaneous tracheostomy in the intensive care unit. J Thorac Dis 2021; 13:5261-5276. [PMID: 34527365 PMCID: PMC8411160 DOI: 10.21037/jtd-19-4121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
Percutaneous tracheostomy is a commonly performed procedure for patients in the intensive care unit (ICU) and offers many benefits, including decreasing ICU length of stay and need for sedation while improving patient comfort, effective communication, and airway clearance. However, there is no consensus on the optimal timing of tracheostomy in ICU patients. Ultrasound (US) and bronchoscopy are useful adjunct tools to optimize procedural performance. US can be used pre-procedurally to identify vascular structures and to select the optimal puncture site, intra-procedurally to assist with accurate placement of the introducer needle, and post-procedurally to evaluate for a pneumothorax. Bronchoscopy provides real-time visual guidance from within the tracheal lumen and can reduce complications, such as paratracheal puncture and injury to the posterior tracheal wall. A step-by-step detailed procedural guide, including preparation and procedural technique, is provided with a team-based approach. Technical aspects, such as recommended equipment and selection of appropriate tracheostomy tube type and size, are discussed. Certain procedural considerations to minimize the risk of complications should be given in circumstances of patient obesity, coagulopathy, or neurologic illness. Herein, we provide a practical state of the art review of percutaneous tracheostomy in ICU patients. Specifically, we will address pre-procedural preparation, procedural technique, and post-tracheostomy management.
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Affiliation(s)
- Christian Ghattas
- Division of Pulmonary, Critical Care, & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sammar Alsunaid
- Division of Pulmonary & Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Edward M Pickering
- Division of Pulmonary & Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Van K Holden
- Division of Pulmonary & Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
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27
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Barash M, Kurman JS. Patient selection and preoperative evaluation of percutaneous dilation tracheostomy in the intensive care unit. J Thorac Dis 2021; 13:5251-5260. [PMID: 34527364 PMCID: PMC8411154 DOI: 10.21037/jtd-2019-ipicu-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/10/2020] [Indexed: 11/06/2022]
Abstract
Percutaneous dilation tracheostomy (PDT) is increasingly performed at the bedside of critically ill patients in the intensive care unit (ICU). PDT is safe overall and has a number of benefits compared to surgical tracheostomy. A tracheostomy tube has numerous advantages compared to an endotracheal tube, including decreased work of breathing, ease of connecting to a mechanical ventilator, improved patient comfort and pulmonary hygiene. Common patient populations include those unable to wean from mechanical ventilation, those requiring enhanced pulmonary hygiene, and those with progressive neuromuscular weakness. Clinicians performing this procedure should be familiar with common indications for performing tracheostomy as well as absolute and relative contraindications. Special patient populations, including those with morbid obesity, aberrant anatomic and vascular anatomy, cervical spine injury, and high ventilatory requirements, should be approached with careful planning. Pre-procedure evaluation for coagulopathy, including basic laboratory analysis and medication review, should be undertaken. Pre-procedure ultrasound may be used to more accurately identify landmarks and vascular structures. The optimal timing for performing PDT is unknown and depends on the unique characteristics of each patient, perceived natural history of the disease process being addressed and open conversations with the patient or surrogate decision maker. In this review, we identify patient populations most likely to benefit from PDT and outline data behind optimal timing, pre-procedural laboratory evaluation and patient specific factors that may influence procedural success.
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Affiliation(s)
- Mark Barash
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jonathan S Kurman
- Division of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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28
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COVIDTrach: a prospective cohort study of mechanically ventilated patients with COVID-19 undergoing tracheostomy in the UK. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2021; 3:e000077. [PMID: 34282409 PMCID: PMC8275367 DOI: 10.1136/bmjsit-2020-000077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 06/09/2021] [Indexed: 12/23/2022] Open
Abstract
Objectives COVIDTrach is a UK multicentre prospective cohort study project that aims to evaluate the outcomes of tracheostomy in patients with COVID-19 receiving mechanical ventilation and record the incidence of SARS-CoV-2 infection among healthcare workers involved in the procedure. Design Data on patient demographic, clinical history and outcomes were entered prospectively and updated over time via an online database (REDCap). Clinical variables were compared with outcomes, with logistic regression used to develop a model for mortality. Participants recorded whether any operators tested positive for SARS-CoV-2 within 2 weeks of the procedure. Setting UK National Health Service departments involved in treating patients with COVID-19 receiving mechanical ventilation. Participants The cohort comprised 1605 tracheostomy cases from 126 UK hospitals collected between 6 April and 26 August 2020. Main outcome measures Mortality following tracheostomy, successful wean from mechanical ventilation and length of time from tracheostomy to wean, discharge from hospital, complications from tracheostomy, reported SARS-CoV-2 infection among operators. Results The median time from intubation to tracheostomy was 15 days (IQR 11, 21). 285 (18%) patients died following the procedure. 1229 (93%) of the survivors had been successfully weaned from mechanical ventilation at censoring and 1049 (81%) had been discharged from hospital. Age, inspired oxygen concentration, positive end-expiratory pressure setting, fever, number of days of ventilation before tracheostomy, C reactive protein and the use of anticoagulation and inotropic support independently predicted mortality. Six reports were received of operators testing positive for SARS-CoV-2 within 2 weeks of the procedure. Conclusions Tracheostomy appears to be safe in mechanically ventilated patients with COVID-19 and to operators performing the procedure and we identified clinical parameters that are predictive of mortality. Trial registration number The study is registered with ClinicalTrials.Gov (NCT04572438).
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Schmidt M, Fisser C, Martucci G, Abrams D, Frapard T, Popugaev K, Arcadipane A, Bromberger B, Lino G, Serra A, Rozencwajg S, Lubnow M, Petrikov S, Mueller T, Combes A, Pham T, Brodie D. Tracheostomy management in patients with severe acute respiratory distress syndrome receiving extracorporeal membrane oxygenation: an International Multicenter Retrospective Study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:238. [PMID: 34233748 PMCID: PMC8261805 DOI: 10.1186/s13054-021-03649-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/21/2021] [Indexed: 01/19/2023]
Abstract
Background Current practices regarding tracheostomy in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown. Our objectives were to assess the prevalence and the association between the timing of tracheostomy (during or after ECMO weaning) and related complications, sedative, and analgesic use. Methods International, multicenter, retrospective study in four large volume ECMO centers during a 9-year period. Results Of the 1,168 patients treated with ECMO for severe ARDS (age 48 ± 16 years, 76% male, SAPS II score 51 ± 18) during the enrollment period, 353 (30%) and 177 (15%) underwent tracheostomy placement during or after ECMO, respectively. Severe complications were uncommon in both groups. Local bleeding within 24 h of tracheostomy was four times more frequent during ECMO (25 vs 7% after ECMO, p < 0.01). Cumulative sedative consumption decreased more rapidly after the procedure with sedative doses almost negligible 48–72 h later, when tracheostomy was performed after ECMO decannulation (p < 0.01). A significantly increased level of consciousness was observed within 72 h after tracheostomy in the “after ECMO” group, whereas it was unchanged in the “during-ECMO” group. Conclusion In contrast to patients undergoing tracheostomy after ECMO decannulation, tracheostomy during ECMO was neither associated with a decrease in sedation and analgesia levels nor with an increase in the level of consciousness. This finding together with a higher risk of local bleeding in the days following the procedure reinforces the need for a case-by-case discussion on the balance between risks and benefits of tracheotomy when performed during ECMO. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03649-8.
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Université, Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France. .,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Gennaro Martucci
- IRCCS-ISMETT Instituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione - Department of Anesthesia and Intensive Care, Palermo, Italy
| | - Darryl Abrams
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Thomas Frapard
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Konstantin Popugaev
- Sklifosovsky Research Institute of Emergency Medicine, Bolshaya Sukharevskaya squire, 3, Moscow, Russia
| | - Antonio Arcadipane
- IRCCS-ISMETT Instituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione - Department of Anesthesia and Intensive Care, Palermo, Italy
| | - Bianca Bromberger
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Giovanni Lino
- IRCCS-ISMETT Instituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione - Department of Anesthesia and Intensive Care, Palermo, Italy
| | - Alexis Serra
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Sacha Rozencwajg
- Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Sergey Petrikov
- Sklifosovsky Research Institute of Emergency Medicine, Bolshaya Sukharevskaya squire, 3, Moscow, Russia
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alain Combes
- Sorbonne Université, Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651, Paris Cedex 13, France.,Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Tài Pham
- Université Paris-Saclay, AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France.,Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Equipe d'Epidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
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Skrzypiec Ł, Rot P, Fus M, Witkowska A, Możański M, Jurkiewicz D. Early or late tracheotomy in patients after multiple organ trauma. Otolaryngol Pol 2021; 75:23-27. [PMID: 35175216 DOI: 10.5604/01.3001.0015.0083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The analysis of the study group of 124 patients revealed a statistically significant shortening of mechanical ventilation requirement period in patients in whom tracheotomy had been performed before hospitalization day 10 (G1). The average length of mechanical ventilation was shorter by 20.3 days in G1 as compared to G2. On average, the duration of ICU stay was shorter by 39.4 days in G1 as compared to G2. Total hospitalization time was also significantly shorter in this group of patients (G1). The overall length of hospital stay for patients in whom tracheotomy had been performed prior to hospitalization day 10 was on average 43.1 days shorter as compared to patients in whom the procedure had been performed at a later date. Tab. I. provides the comparison of the results obtained in both study groups. Statistically significant differences (p < 0.05) were demonstrated between G1 and G2 regarding the length of the mechanical ventilation, the length of ICU stay, and length of hospitalization. null null No statistically significant differences were observed in mortality rates between the study groups (Fig. 1.) (P = 0.256). The mortality rate in early tracheotomy group (G1) was lower and amounted to 2%. In patients in whom tracheotomy was performed on day 10 or later (G2), the mortality rate was slightly higher and amounted to 9%. In some patients, initiation of treatment was required due to pneumonia developing as a complication in mechanically ventilated patients and referred to as ventilator-associated pneumonia. This complication developed in 6 patients in G1 and 26 patients in G2. The study assessed the relationship between the occurrence of this complication and the timing of tracheotomy. Pneumonia was significantly more frequent in patients in whom tracheotomy had been performed on hospitalization day 10 or later (P = 0.011). null null The comparison of results is presented in Tab. II.</br> </br>Another analyzed aspect of the study consisted in the results obtained by the patients in the baseline evaluation of the level of consciousness as assessed using the Glasgow Coma Scale (GCS). Data were checked for potential correlation between the GCS scores and the timing of the tracheotomy and the lengths of mechanical ventilation, ICU stay, and hospitalization. Correlation between GCS scores and the duration of stay within the ICU was demonstrated with a statistically significant correlation coefficient (Spearman's rank coefficient in the range of -0.4 to -0.2). </br> </br>ICU stay and total hospitalization lengths were shorter in patients with higher baseline GCS scores compared to patients with lower baseline GCS scores. The results are illustrated graphically (Fig. 2., 3.).
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Affiliation(s)
- Łukasz Skrzypiec
- Department of Otolaryngology and Laryngological Oncology with Clinical Department of Cranio-Maxillofacial Surgery, Military Medical Institute, Warsaw, Poland
| | - Piotr Rot
- Department of Otolaryngology and Laryngological Oncology with Clinical Department of Cranio-Maxillofacial Surgery, Military Medical Institute, Warsaw, Poland
| | - Maciej Fus
- Department of Otolaryngology and Laryngological Oncology with Clinical Department of Cranio-Maxillofacial Surgery, Military Medical Institute, Warsaw, Poland
| | - Agnieszka Witkowska
- Department of Otolaryngology and Laryngological Oncology with Clinical Department of Cranio-Maxillofacial Surgery, Military Medical Institute, Warsaw, Poland
| | - Marcin Możański
- Department of Anaesthesiology and Intensive Therapy, Military Institute of Medicine, Central Clinical Hospital of the Ministry of National Defense, Warsaw, Poland
| | - Dariusz Jurkiewicz
- Klinika Otolaryngologii i Onkologii Laryngologicznej, Wojskowy Instytut Medyczny w Warszawie
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Staibano P, Levin M, McHugh T, Gupta M, Sommer DD. Association of Tracheostomy With Outcomes in Patients With COVID-19 and SARS-CoV-2 Transmission Among Health Care Professionals: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:646-655. [PMID: 34042963 PMCID: PMC8160928 DOI: 10.1001/jamaoto.2021.0930] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/08/2021] [Indexed: 12/16/2022]
Abstract
Importance Approximately 5% to 15% of patients with COVID-19 require invasive mechanical ventilation (IMV) and, at times, tracheostomy. Details regarding the safety and use of tracheostomy in treating COVID-19 continue to evolve. Objective To evaluate the association of tracheostomy with COVID-19 patient outcomes and the risk of SARS-CoV-2 transmission among health care professionals (HCPs). Data Sources EMBASE (Ovid), Medline (Ovid), and Web of Science from January 1, 2020, to March 4, 2021. Study Selection English-language studies investigating patients with COVID-19 who were receiving IMV and undergoing tracheostomy. Observational and randomized clinical trials were eligible (no randomized clinical trials were found in the search). All screening was performed by 2 reviewers (P.S. and M.L.). Overall, 156 studies underwent full-text review. Data Extraction and Synthesis We performed data extraction in accordance with Meta-analysis of Observational Studies in Epidemiology guidelines. We used a random-effects model, and ROBINS-I was used for the risk-of-bias analysis. Main Outcomes and Measures SARS-CoV-2 transmission between HCPs and levels of personal protective equipment, in addition to complications, time to decannulation, ventilation weaning, and intensive care unit (ICU) discharge in patients with COVID-19 who underwent tracheostomy. Results Of the 156 studies that underwent full-text review, only 69 were included in the qualitative synthesis, and 14 of these 69 studies (20.3%) were included in the meta-analysis. A total of 4669 patients were included in the 69 studies, and the mean (range) patient age across studies was 60.7 (49.1-68.8) years (43 studies [62.3%] with 1856 patients). We found that in all studies, 1854 patients (73.8%) were men and 658 (26.2%) were women. We found that 28 studies (40.6%) investigated either surgical tracheostomy or percutaneous dilatational tracheostomy. Overall, 3 of 58 studies (5.17%) identified a small subset of HCPs who developed COVID-19 that was associated with tracheostomy. Studies did not consistently report the number of HCPs involved in tracheostomy. Among the patients, early tracheostomy was associated with faster ICU discharge (mean difference, 6.17 days; 95% CI, -11.30 to -1.30), but no change in IMV weaning (mean difference, -2.99 days; 95% CI, -8.32 to 2.33) or decannulation (mean difference, -3.12 days; 95% CI, -7.35 to 1.12). There was no association between mortality or perioperative complications and type of tracheostomy. A risk-of-bias evaluation that used ROBINS-I demonstrated notable bias in the confounder and patient selection domains because of a lack of randomization and cohort matching. There was notable heterogeneity in study reporting. Conclusions and Relevance The findings of this systematic review and meta-analysis indicate that enhanced personal protective equipment is associated with low rates of SARS-CoV-2 transmission during tracheostomy. Early tracheostomy in patients with COVID-19 may reduce ICU stay, but this finding is limited by the observational nature of the included studies.
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Affiliation(s)
- Phillip Staibano
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Marc Levin
- Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tobial McHugh
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Michael Gupta
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
| | - Doron D. Sommer
- Department of Surgery, Otolaryngology–Head and Neck Division, McMaster University, Hamilton, Ontario, Canada
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Battaglini D, Missale F, Schiavetti I, Filauro M, Iannuzzi F, Ascoli A, Bertazzoli A, Pascucci F, Grasso S, Murgolo F, Binda S, Maraggia D, Montrucchio G, Sales G, Pascarella G, Agrò FE, Faccio G, Ferraris S, Spadaro S, Falò G, Mereto N, Uva A, Maugeri JG, Agrippino B, Vargas M, Servillo G, Robba C, Ball L, Mora F, Signori A, Torres A, Giacobbe DR, Vena A, Bassetti M, Peretti G, Rocco PRM, Pelosi P. Tracheostomy Timing and Outcome in Severe COVID-19: The WeanTrach Multicenter Study. J Clin Med 2021; 10:jcm10122651. [PMID: 34208672 PMCID: PMC8235219 DOI: 10.3390/jcm10122651] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Tracheostomy can be performed safely in patients with coronavirus disease 2019 (COVID-19). However, little is known about the optimal timing, effects on outcome, and complications. METHODS A multicenter, retrospective, observational study. This study included 153 tracheostomized COVID-19 patients from 11 intensive care units (ICUs). The primary endpoint was the median time to tracheostomy in critically ill COVID-19 patients. Secondary endpoints were survival rate, length of ICU stay, and post-tracheostomy complications, stratified by tracheostomy timing (early versus late) and technique (surgical versus percutaneous). RESULTS The median time to tracheostomy was 15 (1-64) days. There was no significant difference in survival between critically ill COVID-19 patients who received tracheostomy before versus after day 15, nor between surgical and percutaneous techniques. ICU length of stay was shorter with early compared to late tracheostomy (p < 0.001) and percutaneous compared to surgical tracheostomy (p = 0.050). The rate of lower respiratory tract infections was higher with surgical versus percutaneous technique (p = 0.007). CONCLUSIONS Among critically ill patients with COVID-19, neither early nor percutaneous tracheostomy improved outcomes, but did shorten ICU stay. Infectious complications were less frequent with percutaneous than surgical tracheostomy.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.I.); (C.R.); (L.B.); (P.P.)
- Department of Medicine, University of Barcelona, 08007 Barcelona, Spain
- Correspondence:
| | - Francesco Missale
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.M.); (M.F.); (A.A.); (F.M.); (G.P.)
| | - Irene Schiavetti
- Department of Health Sciences, Section of Biostatistics, University of Genoa, 16132 Genoa, Italy; (I.S.); (A.S.)
| | - Marta Filauro
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.M.); (M.F.); (A.A.); (F.M.); (G.P.)
| | - Francesca Iannuzzi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.I.); (C.R.); (L.B.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Alessandro Ascoli
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.M.); (M.F.); (A.A.); (F.M.); (G.P.)
| | - Alberto Bertazzoli
- First Division of Anesthesiology and Intensive Care Unit, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (A.B.); (F.P.)
| | - Federico Pascucci
- First Division of Anesthesiology and Intensive Care Unit, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (A.B.); (F.P.)
| | - Salvatore Grasso
- Dipartimento dell’Emergenza e Trapianti d’Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari “Aldo Moro”, Ospedale Policlinico, 70124 Bari, Italy; (S.G.); (F.M.)
| | - Francesco Murgolo
- Dipartimento dell’Emergenza e Trapianti d’Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari “Aldo Moro”, Ospedale Policlinico, 70124 Bari, Italy; (S.G.); (F.M.)
| | - Simone Binda
- Anaesthesia and Intensive Care Department, University Hospital, Ospedale di Circolo, 21100 Varese, Italy; (S.B.); (D.M.)
| | - Davide Maraggia
- Anaesthesia and Intensive Care Department, University Hospital, Ospedale di Circolo, 21100 Varese, Italy; (S.B.); (D.M.)
| | - Giorgia Montrucchio
- Anestesia e Rianimazione 1U, Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, 10121 Turin, Italy; (G.M.); (G.S.)
| | - Gabriele Sales
- Anestesia e Rianimazione 1U, Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, 10121 Turin, Italy; (G.M.); (G.S.)
| | - Giuseppe Pascarella
- Department of Anaesthesia, Intensive Care and Pain Management, Universita Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy; (G.P.); (F.E.A.)
| | - Felice Eugenio Agrò
- Department of Anaesthesia, Intensive Care and Pain Management, Universita Campus Bio-Medico di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy; (G.P.); (F.E.A.)
| | - Gaia Faccio
- U.O. di Anestesia e Rianimazione, Ospedale di Treviglio-Caravaggio, 24047 Treviglio, Italy; (G.F.); (S.F.)
| | - Sandra Ferraris
- U.O. di Anestesia e Rianimazione, Ospedale di Treviglio-Caravaggio, 24047 Treviglio, Italy; (G.F.); (S.F.)
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Faculty of Medicine, University of Ferrara, 44121 Ferrara, Italy; (S.S.); (G.F.)
| | - Giulia Falò
- Department of Morphology, Surgery and Experimental Medicine, Faculty of Medicine, University of Ferrara, 44121 Ferrara, Italy; (S.S.); (G.F.)
| | - Nadia Mereto
- Anestesia e Rianimazione, Ospedale Villa Scassi, 16132 Genoa, Italy; (N.M.); (A.U.)
| | - Alessandro Uva
- Anestesia e Rianimazione, Ospedale Villa Scassi, 16132 Genoa, Italy; (N.M.); (A.U.)
| | - Jessica Giuseppina Maugeri
- Anesthesia and Intensive Care, “Garibaldi Centro” Hospital, ARNAS Garibaldi, 95100 Catania, Italy; (J.G.M.); (B.A.)
| | - Bellissima Agrippino
- Anesthesia and Intensive Care, “Garibaldi Centro” Hospital, ARNAS Garibaldi, 95100 Catania, Italy; (J.G.M.); (B.A.)
| | - Maria Vargas
- Dipartimento di Neuroscienze, Scienze Riproduttive e Odontostomatologiche, Università degli Studi di Napoli Federico II, 80126 Napoli, Italy; (M.V.); (G.S.)
| | - Giuseppe Servillo
- Dipartimento di Neuroscienze, Scienze Riproduttive e Odontostomatologiche, Università degli Studi di Napoli Federico II, 80126 Napoli, Italy; (M.V.); (G.S.)
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.I.); (C.R.); (L.B.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.I.); (C.R.); (L.B.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Francesco Mora
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.M.); (M.F.); (A.A.); (F.M.); (G.P.)
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genoa, 16132 Genoa, Italy; (I.S.); (A.S.)
| | - Antoni Torres
- Department of Pulmonology, Hospital Clinic of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, SGR 911-Ciber de Enfermedades Respiratorias (CIBERES), 08007 Barcelona, Spain;
| | - Daniele Roberto Giacobbe
- Dipartimento di Scienze della Salute (DISSAL), Università degli Studi di Genova, 16132 Genova, Italy; (D.R.G.); (M.B.)
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l’Oncologia e le Neuroscienze, 16132 Genova, Italy;
| | - Antonio Vena
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l’Oncologia e le Neuroscienze, 16132 Genova, Italy;
| | - Matteo Bassetti
- Dipartimento di Scienze della Salute (DISSAL), Università degli Studi di Genova, 16132 Genova, Italy; (D.R.G.); (M.B.)
- Clinica Malattie Infettive, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) per l’Oncologia e le Neuroscienze, 16132 Genova, Italy;
| | - Giorgio Peretti
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Genoa, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.M.); (M.F.); (A.A.); (F.M.); (G.P.)
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941, Brazil;
- COVID-19 Virus Network (RedeVírus MCTI), Ministry of Science, Technology, and Innovation, Brasília 70007, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, 16132 Genoa, Italy; (F.I.); (C.R.); (L.B.); (P.P.)
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
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Nanao T, Nishizawa H, Fujimoto J, Ogawa T. Additional medical costs associated with ventilator-associated pneumonia in an intensive care unit in Japan. Am J Infect Control 2021; 49:340-344. [PMID: 32721417 DOI: 10.1016/j.ajic.2020.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Additional health care costs associated with ventilator-associated pneumonia (VAP) vary widely per country; none of which have been explored in Japan. Thus, we aimed to examine the economic and clinical effects of VAP in Japan. METHODS This was a retrospective matched case-control study of 22 patients with VAP who were treated in the intensive care unit of Yokohama Rosai Hospital between January 2012 and December 2018. Twenty-two matched controls were selected based on 5 variables (ie, sex, age, diagnosis and surgical procedure, underlying disease with or without advanced malignant tumor, and best motor response). The additional health care costs incurred owing to VAP were calculated from the difference between the mean costs of VAP and control cases. RESULTS VAP incurred an additional cost of approximately United States Dollars (USD) 34,884 per case. The length of hospitalization itself was the major factor contributing to additional medical costs, generating a difference of 9,824 USD. DISCUSSION VAP not only worsens patient outcomes but also generates significant additional medical costs. Patients who had developed VAP required more medical resources such as the performance of a tracheostomy. CONCLUSIONS VAP incurs a higher mean total hospital medical cost. Thus, appropriate infection control strategies should be implemented.
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Affiliation(s)
- Taikan Nanao
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan; International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan.
| | - Hideo Nishizawa
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Junichi Fujimoto
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Toshio Ogawa
- International University of Health and Welfare Graduate School of Public Health, Tokyo, Japan
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Mubashir T, Arif AA, Ernest P, Maroufy V, Chaudhry R, Balogh J, Suen C, Reskallah A, Williams GW. Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:384-394. [PMID: 33009136 DOI: 10.1213/ane.0000000000005212] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy. METHODS We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD). RESULTS Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24-3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, -19.18 to -7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, -24.33 to -12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32-1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted. CONCLUSIONS Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term outcomes of tracheostomy timing following acute SCI.
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Affiliation(s)
- Talha Mubashir
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Abdul A Arif
- Department of Life Science, University of Toronto, Toronto, Ontario, Canada
| | - Prince Ernest
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Vahed Maroufy
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Rabail Chaudhry
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Julius Balogh
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Colin Suen
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Alexander Reskallah
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - George W Williams
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
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Araujo de Franca S, Tavares WM, Salinet ASM, Paiva WS, Teixeira MJ. Early tracheostomy in stroke patients: A meta-analysis and comparison with late tracheostomy. Clin Neurol Neurosurg 2021; 203:106554. [PMID: 33607581 DOI: 10.1016/j.clineuro.2021.106554] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 01/22/2021] [Accepted: 02/06/2021] [Indexed: 11/17/2022]
Abstract
Tracheostomy (TQT) timing and its benefits is a current discussion in medical society. We aimed to compare the outcomes of early (ET) versus late tracheostomy (LT) in stroke patients with systematic review and meta-analysis, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Five hundred and nineteen studies were retrieved, whereas three were selected for the systematic review and meta-analysis. There were 5636 patients in the ET group (3151 male, 2470 female, 15 not reported - NR) and 7637 patients in the LT group (4098 male, 3542 female, and 33 NR). ET was significantly associated with fewer days in the hospital (weighted mean difference: -7.73 [95 % CI -8.59-6.86], p < 0.001) and reduced cases of ventilator-associated pneumonia (VAP) (risk difference: 0.71 [95 % CI 0.62-0.81], p < 0.001). There were no between-group statistical differences in intensive care unit stay duration, mechanical ventilation duration, or mortality. The findings from this meta-analysis cannot state that ET in severe stroke patients contributes to better outcomes when compared with LT. Scandalized assessments and randomized trials are encourage for better assessment.
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Affiliation(s)
- Sabrina Araujo de Franca
- Department of Research of IPSPAC, Instituto Paulista de Saúde para Alta Complexidade, 199 Padre Anchieta Avenue - Room 2, Jardim, Santo Andre, SP, 09090-710, Brazil.
| | - Wagner M Tavares
- Department of Research of IPSPAC, Instituto Paulista de Saúde para Alta Complexidade, 199 Padre Anchieta Avenue - Room 2, Jardim, Santo Andre, SP, 09090-710, Brazil; Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
| | - Angela S M Salinet
- Department of Research of IPSPAC, Instituto Paulista de Saúde para Alta Complexidade, 199 Padre Anchieta Avenue - Room 2, Jardim, Santo Andre, SP, 09090-710, Brazil; Division of Functional Neurosurgery, Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar Avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
| | - Wellingson S Paiva
- Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
| | - Manoel J Teixeira
- Institute of Neurology, University of São Paulo, 255 Dr. Enéas de Carvalho Aguiar avenue, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
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Deng H, Fang Q, Chen K, Zhang X. Early versus late tracheotomy in ICU patients: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e24329. [PMID: 33546065 PMCID: PMC7837817 DOI: 10.1097/md.0000000000024329] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 12/19/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study aimed to quantitatively analyze the available randomized controlled trials (RCTs) and investigate whether early tracheotomy can improve clinical endpoints compared with late tracheotomy in critically ill patients undergoing mechanical ventilation. METHODS The electronic databases of PubMed, Embase, and the Cochrane library were systematically searched in August 2019. The investigated outcomes were calculated using relative risks (RRs) and standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) through the random-effects model for categories and continuous data, respectively. RESULTS The electronic searches yielded 2289 records, including 15 RCTs comprising a total of 3003 patients and found to be relevant for the final quantitative analysis. The summary RRs that indicated early versus late tracheotomy were not associated with the risk of short-term mortality (RR: 0.87; 95% CI: 0.74-1.03; P = .114) and ventilator-associated pneumonia (RR: 0.90; 95% CI: 0.78-1.04; P = .156). Moreover, early tracheotomy was associated with shorter intensive care unit (ICU) stay (SMD: -1.81; 95% CI: -2.64 to -0.99; P < .001) and mechanical ventilation duration (SMD: -1.17; 95% CI: -2.10 to -0.24; P = .014). Finally, no significant difference was observed between early and late tracheotomy for hospital stay (SMD: -0.42; 95% CI: -1.36-0.52; P = .377). CONCLUSIONS The present meta-analysis suggests that early tracheotomy can reduce the length of ICU stay and mechanical ventilation duration, but the timing of the tracheotomy was not associated with the short-term clinical endpoints in critically ill patients undergoing mechanical ventilation.
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Affiliation(s)
- Hongsheng Deng
- Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
- Intensive Care Unit, Affiliated Jinhua hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Qiang Fang
- Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
| | - Kun Chen
- Intensive Care Unit, Affiliated Jinhua hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
| | - Xiaoling Zhang
- Intensive Care Unit, Affiliated Jinhua hospital, Zhejiang University School of Medicine, Jinhua, Zhejiang, China
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Starkov YG, Lukich KV, Dzhantukhanova SV, Plotnikov GP, Zamolodchikov RD, Zvereva AA. [Endoscopy-assisted dilatational tracheostomy in patients with COVID-19]. Khirurgiia (Mosk) 2020:16-21. [PMID: 33301248 DOI: 10.17116/hirurgia202012116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To summarize an experience of endoscopy-assisted dilatational tracheostomies in patients with COVID-19. MATERIAL AND METHODS There were 31 endoscopy-assisted dilatational tracheostomies in patients with COVID-19 for the period from April 17 to June 10, 2020 (11 women and 19 men). Mean age of patients was 66.7 years (range 48-87). Tracheostomy was performed using Ciaglia (22) and Griggs (9) techniques. All procedures were carried out at the intensive care unit in elective fashion. RESULTS Tracheostomy was performed in 19.8% of ICU patients or 36.9% of all patients on mechanical ventilation within 6.5±2.5 days [min 3, max 11]. There were 22 survivors with tracheostomy (70.9%) that is comparable with survival of patients without mechanical ventilation (79.7%) and slightly higher than in patients on ventilation without tracheostomy (65.4%). No complications during the procedure were noted. CONCLUSION Endoscopy-assisted dilatational tracheostomy is preferred for prolonged mechanical ventilation, including patients with COVID-19. The undeniable advantages of this operation are fewer intraoperative complications due to endoscopic control, and lower risk of tracheal strictures.
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Affiliation(s)
- Yu G Starkov
- Vishnevsky National Medical Research Center for Surgery, Moscow, Russia
| | - K V Lukich
- Vishnevsky National Medical Research Center for Surgery, Moscow, Russia
| | | | - G P Plotnikov
- Vishnevsky National Medical Research Center for Surgery, Moscow, Russia
| | - R D Zamolodchikov
- Vishnevsky National Medical Research Center for Surgery, Moscow, Russia
| | - A A Zvereva
- Vishnevsky National Medical Research Center for Surgery, Moscow, Russia
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Trust MD, Lara S, Hecht J, Teixeira PG, Coopwood B, Aydelotte J, Cardenas TCP, Guerra E, Ali S, Brown CVR. A Prospective Study of Family Satisfaction Changes After Tracheostomy Placement in Trauma Patients. Am Surg 2020; 87:961-964. [PMID: 33295184 DOI: 10.1177/0003134820954831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Tracheostomy is a commonly performed procedure in surgical intensive care units. Although the indications and benefits of this procedure are well known, little has been studied in the adult surgical/trauma population about patient family satisfaction after tracheostomy placement. MATERIALS AND METHODS We performed a prospective study at our academic level I trauma center from 2015-2016 in patients who underwent elective tracheostomy. Family members were asked to complete an eight-point questionnaire using a forced Likert scale of graded responses. Questionnaires were administered prior to tracheostomy and again at 24-and 72-hour post-tracheostomy placement. Responses were compared using univariate analysis. RESULTS A total of 26 family members completed all 3 surveys. Family members believed loved ones appeared more comfortable, were more interactive, and were better progressing clinically. After 72 hours, family members felt less anxiety. There was no difference in perceptions of patient distress, ability to provide support, or their worry about scars, or comfort in visiting them. DISCUSSION Family members believed tracheostomies provided greater patient comfort, increased interactive abilities, better progress in their care, and experienced less anxiety after placement. Family satisfaction may therefore be an additional benefit in support of earlier tracheostomy.
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Affiliation(s)
- Marc D Trust
- Dell Medical School, The University of Texas, Austin, USA
| | - Sabino Lara
- Dell Medical School, The University of Texas, Austin, USA
| | - Jonathan Hecht
- Dell Medical School, The University of Texas, Austin, USA
| | | | - Ben Coopwood
- Dell Medical School, The University of Texas, Austin, USA
| | | | | | - Erin Guerra
- Dell Medical School, The University of Texas, Austin, USA
| | - Sadia Ali
- Dell Medical School, The University of Texas, Austin, USA
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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Altinsoy S, Catalca S, Sayin MM, Tutuncu EE. The risk factors of Ventilator Associated Pneumonia and relationship with type of tracheostomy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2020. [DOI: 10.1016/j.tacc.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Mesolella M. Is Timing of Tracheotomy a Factor Influencing the Clinical Course in COVID-19 Patients? EAR, NOSE & THROAT JOURNAL 2020; 100:120S-121S. [PMID: 33172287 DOI: 10.1177/0145561320974140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The timing of tracheotomy is a complex decision that requires understanding of the relative risks and benefits as compared with prolonging intubation. The role of tracheotomy during the COVID-19 pandemic remains to be determined. There is no evidence that early tracheostomy improves patient's clinical course and it is not impact on the natural history of these patients. In our opinion, the tracheotomy should be proposed in stable COVID-19 patients after 18th days after orotracheal intubation when the viral load is finished. Only in the case of patients with difficult of intubation do we perform earlier tracheotomies.
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Affiliation(s)
- Massimo Mesolella
- Department of Neuroscience, Reproductive Sciences and Dentistry, Unit of Otorhinolaryngology, 9307Federico II University Naples, Italy
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Moussa MK, Moussa A, Nasr F, Khalaf Z, Sarout S, Moukarzel N, Dib A. Comparison of the Outcomes of Early Versus Late Tracheostomy in the Treatment of Critically Ill Patients: A Retrospective Multicenter Measurement Study Done in Two Hospital Centers in Lebanon. Cureus 2020; 12:e11361. [PMID: 33304694 PMCID: PMC7720922 DOI: 10.7759/cureus.11361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Benefits of early tracheostomy (ET) versus late tracheostomy (LT) while treating critically ill patients have been a matter of big debate in the last few years. Several meta-analyses tried to prove the benefits of ET in decreasing the duration of mechanical ventilation (MV), the length of intensive care unit (ICU) stay, and the mortality rates. However, no clear guidelines are available yet. This study will focus on comparing the outcomes of early tracheostomy versus late one. Methods This is a retrospective study done in two medical and surgical ICUs at “Sacre-Coeur Hospital” and “Rafik Hariri University Hospital” at Beirut, where we reviewed various files of patients who underwent elective tracheostomy for prolonged MV from January 2015 to June 2016. ET and LT were assumed to be procedures performed respectively before and after 10 days of MV. These two groups were subdivided based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) score calculated in the first 24 hours of ICU admission. Data about short- and long-term mortality, the duration of MV, and the length of ICU stay were collected and compared. Results From a total of 45 patients, only 25 patients met the inclusion and exclusion criteria of whom 12 (48%) underwent ET and 13 (52%) patients underwent LT. In patients with APACHE II <25 (6 ET and 6 LT), ET was associated with 50% long-term mortality, 9.6 days mean duration of MV and 23 days mean length of ICU stay compared to 57% (P-value=0.05), 78 days (P-value=0.04) and 79 days (P-value=0.012) of respective parameters in LT groups. In patients with APACHE II >25 (6 ET and 7 LT), ET was associated with 50% long-term mortality, 8.6 days mean duration of MV and 24 days mean length of ICU stay compared to 84%, 105 days, 84 days of respective parameter in LT groups. Conclusions Our results are suggestive of the superiority of ET because it was associated with a reduced duration of MV, a decrease in the length of ICU stay, and, most importantly, a lower long-term mortality rate.
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Affiliation(s)
- Mohamad K Moussa
- Orthopedic Surgery, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Ali Moussa
- Pediatrics, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Firas Nasr
- Internal Medicine and Geriatrics, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Zaynab Khalaf
- Endocrinology: Diabetes and Metabolism, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Safaa Sarout
- Pediatrics, Lebanese University, Faculty of Medical Sciences, Beirut, LBN
| | - Nabil Moukarzel
- Otolaryngology: Head and Neck Surgery, Sacre-Coeur Hospital, Beirut, LBN
| | - Alfred Dib
- Critical Care Medicine, Sacre-Coeur Hospital, Beirut, LBN
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Pincherle A, Jöhr J, Pancini L, Leocani L, Dalla Vecchia L, Ryvlin P, Schiff ND, Diserens K. Intensive Care Admission and Early Neuro-Rehabilitation. Lessons for COVID-19? Front Neurol 2020; 11:880. [PMID: 32982916 PMCID: PMC7477378 DOI: 10.3389/fneur.2020.00880] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/10/2020] [Indexed: 12/29/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) requires admission to intensive care (ICU) for the management of acute respiratory distress syndrome in about 5% of cases. Although our understanding of COVID-19 is still incomplete, a growing body of evidence is indicating potential direct deleterious effects on the central and peripheral nervous systems. Indeed, complex and long-lasting physical, cognitive, and functional impairments have often been observed after COVID-19. Early (defined as during and immediately after ICU discharge) rehabilitative interventions are fundamental for reducing the neurological burden of a disease that already heavily affects lung function with pulmonary fibrosis as a possible long-term consequence. In addition, ameliorating neuromuscular weakness with early rehabilitation would improve the efficiency of respiratory function as respiratory muscle atrophy worsens lung capacity. This review briefly summarizes the polymorphic burden of COVID-19 and addresses possible early interventions that could minimize the neurological and systemic impact. In fact, the benefits of early multidisciplinary rehabilitation after an ICU stay have been shown to be advantageous in several clinical conditions making an early rehabilitative approach generalizable and desirable to physicians from a wide range of different specialties.
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Affiliation(s)
- Alessandro Pincherle
- Acute Neuro-Rehabilitation Unit and Neurology Unit, Department of Clinical Neurosciences, Lausanne University Hospital-CHUV, Lausanne, Switzerland
- Neurology Unit, Department of Medicine, Hopitaux Robert Schuman—Luxembourg, Luxembourg, Luxembourg
- Departments of Cardiac and Pulmonary Rehabilitation, IRCSS Istituto Clinico Scientifico Maugeri, Milan, Italy
| | - Jane Jöhr
- Acute Neuro-Rehabilitation Unit and Neurology Unit, Department of Clinical Neurosciences, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Lisa Pancini
- Departments of Cardiac and Pulmonary Rehabilitation, IRCSS Istituto Clinico Scientifico Maugeri, Milan, Italy
| | - Letizia Leocani
- Department of Neuro-Rehabilitation, Hospital San Raffaele, University Vita Salute, Milan, Italy
| | - Laura Dalla Vecchia
- Departments of Cardiac and Pulmonary Rehabilitation, IRCSS Istituto Clinico Scientifico Maugeri, Milan, Italy
| | - Philippe Ryvlin
- Acute Neuro-Rehabilitation Unit and Neurology Unit, Department of Clinical Neurosciences, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Nicholas D. Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, United States
| | - Karin Diserens
- Acute Neuro-Rehabilitation Unit and Neurology Unit, Department of Clinical Neurosciences, Lausanne University Hospital-CHUV, Lausanne, Switzerland
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Park C, Bahethi R, Yang A, Gray M, Wong K, Courey M. Effect of Patient Demographics and Tracheostomy Timing and Technique on Patient Survival. Laryngoscope 2020; 131:1468-1473. [PMID: 32996189 DOI: 10.1002/lary.29000] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/06/2020] [Accepted: 07/19/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The ideal timing and technique of tracheostomy vary among patients and may impact outcomes. We aim to examine the association between tracheostomy timing, placement technique, and patient demographics on survival. STUDY DESIGN Retrospective cohort study. METHODS A retrospective review was performed for all patients who underwent tracheostomy in 2016 and 2017 at one urban academic tertiary-care hospital. Kaplan-Meier curves were created based on combinations of tracheostomy timing and technique (early percutaneous, early non-percutaneous, late percutaneous, and late non-percutaneous). Cox proportional hazard models were used to determine multivariable effects of timing, technique, and other demographic factors. Primary outcome measures were tracheostomy-related mortality and overall survival. Secondary outcomes were in-hospital, 30-day, and 90-day mortality. RESULTS Our study included 523 patients. There were six tracheostomy-related deaths, with hemorrhage and tracheoesophageal fistula being the most common causes. Tracheostomy timing and technique combinations were not associated with differences in all-cause mortality or survival following discharge. Cox proportional hazard models showed that Charlson Comorbidity Index (CCI) and unknown partner status were associated with a decrease in survival (P < .01 and P = .05, respectively). Additionally, patient age, gender, race, CCI, and body mass index were not independently associated with changes in survival. CONCLUSION Late and non-percutaneous tracheostomies were associated with more tracheostomy-related deaths, but timing and technique were not associated with differences in patient survival. Multiple regression analysis showed that increased patient comorbidities, measured via CCI, and unknown partner status were independently associated with decreased survival. Proceduralists should discuss timing, technique, and patient social factors together with the medical care team when constructing plans for postdischarge management. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1468-1473, 2021.
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Affiliation(s)
| | | | - Anthony Yang
- Icahn School of Medicine at Mount Sinai, New York, USA
| | - Mingyang Gray
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kevin Wong
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Mark Courey
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, USA
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Zaga CJ, Pandian V, Brodsky MB, Wallace S, Cameron TS, Chao C, Orloff LA, Atkins NE, McGrath BA, Lazarus CL, Vogel AP, Brenner MJ. Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:1320-1334. [PMID: 32525695 DOI: 10.1044/2020_ajslp-20-00089] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Austin Health, Melbourne, Victoria, Australia
- Centre for Neuroscience of Speech, University of Melbourne, Victoria, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Victoria, Australia
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University, Baltimore, MD
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD
| | - Martin B Brodsky
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University, Baltimore, MD
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Sarah Wallace
- Department of Speech Voice and Swallowing, Manchester University NHS Foundation Trust, United Kingdom
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Victoria, Australia
| | - Caroline Chao
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Austin Health, Melbourne, Victoria, Australia
| | - Lisa Ann Orloff
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, CA
| | - Naomi E Atkins
- Department of Respiratory Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Brendan A McGrath
- Anaesthetics & Intensive Care Medicine, Manchester University NHS Foundation Trust, United Kingdom
| | - Cathy L Lazarus
- Department of Otolaryngology-Head & Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Adam P Vogel
- Centre for Neuroscience of Speech, University of Melbourne, Victoria, Australia
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, Tübingen, Germany
- Redenlab, Melbourne, Victoria, Australia
| | - Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School, Ann Arbor
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Nam IC, Shin YS, Jeong WJ, Park MW, Park SY, Song CM, Lee YC, Jeon JH, Lee J, Kang CH, Park IS, Kim K, Sun DI. Guidelines for Tracheostomy From the Korean Bronchoesophagological Society. Clin Exp Otorhinolaryngol 2020; 13:361-375. [PMID: 32717774 PMCID: PMC7669309 DOI: 10.21053/ceo.2020.00353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/19/2020] [Indexed: 12/17/2022] Open
Abstract
The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.
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Affiliation(s)
| | - Inn-Chul Nam
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Seob Shin
- Department of Otolaryngology-Head and Neck Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Woo Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Myeon Song
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Young Chan Lee
- Department of Otolaryngology-Head and Neck Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Hyun Jeon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Il Sun
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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47
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Radhakrishnan S, Perumbally HA, Surya S, Ponneth MS. Guidelines for Surgical Tracheostomy and Tracheostomy Tube Change During the COVID-19 Pandemic: A Review Article. Indian J Otolaryngol Head Neck Surg 2020; 72:398-401. [PMID: 32719738 PMCID: PMC7306934 DOI: 10.1007/s12070-020-01893-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
The novel corona virus disease (COVID-19) has unfolded into a pandemic and is continuing to propagate at a frightening speed. The aim of this article is to share our protocol for performing a safe surgical tracheostomy in this COVID-19 era. Tracheostomy procedures have a high risk of aerosol generation. To standardize institutional safety measures with tracheostomy, we advocate using a dedicated tracheostomy protocol applicable to all patients including those suspected of having COVID-19. We also did explore the current literature and recommendations for tracheostomy in patients with COVID-19 and studied the previous data from severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1), the virus responsible for the SARS outbreak of 2003. We have prepared a protocol for performing a safe surgical tracheotomy in patients affected by COVID-19. Surgeons who might be involved in performing the tracheostomies should become familiar with these guidelines.
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Affiliation(s)
- Suma Radhakrishnan
- Department of Otorhinolaryngology and Head and Neck Surgery, Government Medical College, Manjeri, Kerala India
| | - Hafees Abdullah Perumbally
- Department of Otorhinolaryngology and Head and Neck Surgery, Government Medical College, Manjeri, Kerala India
| | - Sai Surya
- Department of Otorhinolaryngology and Head and Neck Surgery, Government Medical College, Manjeri, Kerala India
| | - Mohammed Shareef Ponneth
- Department of Otorhinolaryngology and Head and Neck Surgery, Government Medical College, Manjeri, Kerala India
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48
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Recommendation of a practical guideline for safe tracheostomy during the COVID-19 pandemic. Eur Arch Otorhinolaryngol 2020; 277:2173-2184. [PMID: 32314050 PMCID: PMC7170707 DOI: 10.1007/s00405-020-05993-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/15/2020] [Indexed: 12/22/2022]
Abstract
Purpose The COVID-19 pandemic is placing unprecedented demand upon critical care services for invasive mechanical ventilation. There is current uncertainty regarding the role of tracheostomy for weaning ventilated patients with COVID-19 pneumonia. This is due to a number of factors including prognosis, optimal healthcare resource utilisation, and safety of healthcare workers when performing such a high-risk aerosol-generating procedure. Methods Literature review and proposed practical guideline based on the experience of a tertiary healthcare institution with 195 critical care admissions for COVID-19 up until 4th April 2020. Results A synthesis of the current international literature and reported experience is presented with respect to prognosis, viral load and staff safety, thus leading to a pragmatic recommendation that tracheostomy is not performed until at least 14 days after endotracheal intubation in COVID-19 patients. Practical steps to minimise aerosol generation in percutaneous tracheostomy are outlined and we describe the process and framework for setting up a dedicated tracheostomy team. Conclusion In selected COVID-19 patients, there is a role for tracheostomy to aid in weaning and optimise healthcare resource utilisation. Both percutaneous and open techniques can be performed safely with careful modifications to technique and appropriate enhanced personal protective equipment. ORL-HNS surgeons can play a valuable role in forming tracheostomy teams to support critical care teams during this global pandemic.
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Moreno Torres A, Rojas Gutiérrez A, Vásconez Escobar JN, Silva Rueda R, Morales Rubio L, Herrera Chaparro JA, Rodríguez Sabogal C, Jiménez Díaz LH. Recomendaciones para realización de traqueostomías y atención de los pacientes traqueostomizados en Colombia durante la pandemia COVID-19. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Establecer una serie de recomendaciones para la realización de las traqueostomías, que se centren en la seguridad de los pacientes y de los equipos de atención médica durante la pandemia de COVID-19, minimizando el riesgo, la exposición viral y agotamiento del equipo de protección personal (EPP). Este documento está destinado a proporcionar los antecedentes, consideraciones y recomendaciones basadas en la literatura e información de primera línea de esta etapa de la pandemia. Estas recomendaciones pueden requerir individualización en función de la región del país, la institución, la capacidad instalada, los recursos y los factores específicos del paciente. Se encuentran en constante actualización según la evolución de la enfermedad y aparición de nuevos datos.
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50
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Abdelaal Ahmed Mahmoud M Alkhatip A, Younis M, Jamshidi N, Hussein HA, Farag E, Hamza MK, Bahr MH, Goda Ahmed A, Sallam AM, Mohamed H, Elayashy M, Hosny H, Yassin HM, Abdelhaq M, Elramely MA, Reeves D, Mills KE, Kamal AM, Zakaria D. Timing of Tracheostomy in Pediatric Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2020; 48:233-240. [PMID: 31939793 DOI: 10.1097/ccm.0000000000004114] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation. DATA SOURCES We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational studies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. Included articles were subjected to manual searching. STUDY SELECTION Studies in mechanically ventilated children that compared early with late tracheostomy were included. DATA EXTRACTION Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). DATA SYNTHESIS Data were meta-analyzed using an inverse variance, random effects model. Continuous outcomes were calculated as mean differences with 95% CIs, and dichotomous outcomes were calculated as Mantel-Haenszel risk ratios with 95% CIs. We included eight studies (10 study arms). These studies were all retrospective cohort studies. Early tracheostomy was associated with significant reductions in mortality, days on mechanical ventilation, and length of intensive care and total hospital stay, although the lack of randomized, controlled trials limits the validity of these findings. Although variance was imputed for some studies, these conclusions did not change after removing these studies from the analysis. CONCLUSIONS In children on mechanical ventilation, early tracheostomy may improve important medical outcomes. However, our data demonstrate the urgent need for high-quality, randomized controlled trials in the pediatric population.
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Affiliation(s)
- Ahmed Abdelaal Ahmed Mahmoud M Alkhatip
- Department of Anesthesia, Pain Management and Surgical Intensive Care, Beni-Suef University Hospital and Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Mohamed Younis
- Department of Anaesthesia, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Negar Jamshidi
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Hazem A Hussein
- Department of Anesthesia, Pain Management and Surgical Intensive Care, Beni-Suef University Hospital and Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ehab Farag
- Department of Anesthesia, Pain Management and Surgical Intensive Care, Beni-Suef University Hospital and Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Mohamed K Hamza
- Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt
| | - Mahmoud H Bahr
- Department of Anesthesia, Pain Management and Surgical Intensive Care, Beni-Suef University Hospital and Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Ahmed Goda Ahmed
- Department of Anesthesia, Pain Management and Surgical Intensive Care, Beni-Suef University Hospital and Faculty of Medicine, Beni Suef University, Beni Suef, Egypt
| | - Amr M Sallam
- Department of Anesthesia, Ain Shams University Hospital and Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hassan Mohamed
- Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt
| | - Mohamed Elayashy
- Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt
| | - Hisham Hosny
- Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt
- The Department of Cardiothoracic Anaesthesia and Intensive Care, Essex Cardiothoracic Center, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, United Kingdom
| | - Hany M Yassin
- Department of Anesthesia, Faculty of Medicine and Fayoum University Hospital, Fayoum University, Faiyum, Egypt
| | - Mohamed Abdelhaq
- Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt
| | - Mohamed A Elramely
- Department of Anesthesia, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | - Kerry E Mills
- Department of Science and Technology, University of Canberra, Canberra, ACT, Australia
| | - Ahmed M Kamal
- Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt
| | - Dina Zakaria
- Department of Anesthesia, Kasr Al Ainy Faculty of Medicine and Cairo University Hospitals, Cairo University, Cairo, Egypt
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