Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

Evaluation of Tracheostomy Patients in Our Pediatric Intensive Care Unit: A Single-Center Study

OBJECTIVES

A tracheostomy is a surgical procedure that can be performed on critically ill patients of all ages in intensive care units as indicated, and its use has been increasing in recent years. The most common indications are prolonged mechanical ventilation and upper airway obstruction. This study aimed to examine the indications for tracheostomy, assess the outcomes of patients who underwent the procedure, and identify the factors affecting these outcomes.  Material and method: A retrospective analysis of patients who underwent tracheostomy between 2013 and 2019 at Dicle University Faculty of Medicine Hospital Paediatric Intensive Care Unit (PICU). The patients' age, gender, distribution by age, primary diagnosis at admission to the intensive care unit, indication for tracheostomy, presence of additional disease, type of respiratory support before and after tracheostomy, development of complications (perioperative/postoperative), decannulation status, mortality, and discharge status were recorded.  Results: A total of 61 patients were enrolled into the study. The average age of the patients was 81.72 months (SD = 17.5), with the youngest being eight months old and the oldest being 203 months old. Of the 61 patients included in the study, 32 (52%) were male and 29 (48%) were female. The majority of patients (32 patients) were in the preschool age group (25-84 months). The primary diagnosis of 27 patients (44.3%) who underwent tracheostomy was neuromuscular diseases, and the most common indication for tracheostomy was prolonged intubation (24 patients, 39.3%). Concomitant chronic diseases were present in 54 patients (88.5%). Patients received mechanical ventilation support for an average of 47.34 days before tracheostomy. Early tracheostomy (0-21 days after initiation of mechanical ventilation) was performed on 14 patients, and late tracheostomy (21 days and later) was performed on 47 patients. Complications developed in nine patients (14.8%) in the perioperative period and in 19 patients (31.1%) in the postoperative period, while no complications developed in 39 patients (63.9%). Six patients (9.8%) were decannulated. Furthermore, 28 patients (45.9%) died. No tracheostomy-related mortality was documented.

CONCLUSION

Despite most patients being of preschool age, having prolonged intubation prior to tracheostomy, and having accompanying chronic illnesses, tracheostomy remains a frequently used procedure in paediatric intensive care units due to its low complication rates, making it an essential intervention that facilitates discharge from paediatric intensive care.

Comparison Between Early and Late Tracheostomy in ICU Patients Including COVID-19 and Non-COVID-19 Patients: A Retrospective Cohort Study at a Tertiary Care Hospital

Background Tracheostomy is a common intervention for intensive care unit (ICU) patients for various reasons. The superiority of early versus late tracheostomy is still unfounded for non-COVID-19 cases. The COVID-19 pandemic complicated the matter, as little literature was available on the ideal timing of tracheostomy for patients with COVID-19. Research question This study aimed to establish the superiority of early or late tracheostomy for COVID-19 and non-COVID-19 cases by comparing outcomes, including ICU mortality, ventilation days after tracheostomy, and ICU length of stay (LOS). Study design and methods A single-center retrospective cohort study was conducted on ventilated ICU patients both with and without COVID-19 at a university hospital between January 2020 and December 2021. During the study period, 1,393 ventilated patients were scanned, and 156 were found to be tracheostomized. Tracheostomy was considered to be early when performed within 10 days of intubation, after which it was considered to be late. Results Tracheostomy was performed early for 84/156 (53.8%) of tracheostomized patients and late for 72/156 (46.2%) of patients. The overall mortality was 42.9% (36/84) versus 69.4% (50/72) (P=0.001, OR=3.03, 95% CI=1.563-5.874), 31.4% versus 65.5% in the non-COVID-19 group and 60.6% versus 72.1% (P=0.005, OR=2.640, 95% CI=1.345-5.181) in the COVID-19 group for the early and late tracheostomy groups, respectively. Ventilation days were higher for the late tracheostomy group than for the early tracheostomy group in the non-COVID-19 group (17.10 versus 9.18 days, P<0.001). However, it was almost the same for the early and late tracheostomy groups in the COVID-19 group (14.15 versus 13.86 days, P=0.821). The ICU LOS was greater for the late tracheostomy group for both the COVID-19 and non-COVID-19 groups. Multivariate analysis revealed that ICU mortality is significantly associated with age, ventilation days, and ICU LOS. Interpretation The results of this study indicate that early tracheostomy was associated with lower mortality, fewer ventilation days, and shorter LOS in both the COVID-19 and non-COVID-19 groups.

A historical cohort study on predictors for successful weaning from prolonged mechanical ventilation and up to 3-year survival follow-up in a rehabilitation center

BACKGROUND

We followed prolonged mechanically ventilated (PMV) patients for weaning attempts and explored factors associated with successful weaning and long-term survival.

METHODS

This historical cohort study included all adult PMV patients admitted to a single rehabilitation hospital during 2015-2018 and followed for survival according to weaning success up to 3 years or the end of 2021.

RESULTS

The study included 223 PMV patients. Of them, 124 (55.6 %) underwent weaning attempts, with 69 (55.6 %) successfully weaned, 55 (44.4 %) unsuccessfully weaned, and 99 patients with no weaning attempts. The mean age was 67 ± 20 years, with 39 % female patients. Age, sex distributions and albumin levels at admission were not significantly different among the groups. The successful weaning group had a 6 % higher proportion of conscious patients than the failed weaning group (55 % vs. 49 %, respectively, p = 0.45). Patients successfully weaned were less frequently treated with antibiotics for 5 days or more than those unsuccessfully weaned (74 % vs 80 %, respectively, p = 0.07). They also had a lower proportion of time from intubation to tracheostomy greater than 14 days (45 % vs 66 %, p = 0.02). The age, sex, antibiotic treatment, time to tracheostomy exceeding 14 days and time from admission to first weaning attempt adjusted one-year mortality risk of successful vs. failed weaning was somewhat lower, HR = 0.75, 95%CI: 0.33-1.60, p = 0.45, with the same trend by the end of 3 years, HR = 0.77, 95%CI: 0.42-1.39, p = 0.38.

CONCLUSION

Successful weaning from PMV may be associated with better survival and allows chronically ventilated patients to become independent on a ventilator. A larger study is needed to further validate our findings.

Machine Learning Algorithms Predict Successful Weaning From Mechanical Ventilation Before Intubation: Retrospective Analysis From the Medical Information Mart for Intensive Care IV Database

BACKGROUND

The prediction of successful weaning from mechanical ventilation (MV) in advance of intubation can facilitate discussions regarding end-of-life care before unnecessary intubation.

OBJECTIVE

We aimed to develop a machine learning-based model that predicts successful weaning from ventilator support based on routine clinical and laboratory data taken before or immediately after intubation.

METHODS

We used the Medical Information Mart for Intensive Care IV database, which is an open-access database covering 524,740 admissions of 382,278 patients in Beth Israel Deaconess Medical Center, United States, from 2008 to 2019. We selected adult patients who underwent MV in the intensive care unit (ICU). Clinical and laboratory variables that are considered relevant to the prognosis of the patient in the ICU were selected. Data collected before or within 24 hours of intubation were used to develop machine learning models that predict the probability of successful weaning within 14 days of ventilator support. Developed models were integrated into an ensemble model. Performance metrics were calculated by 5-fold cross-validation for each model, and a permutation feature importance and Shapley additive explanations analysis was conducted to better understand the impacts of individual variables on outcome prediction.

RESULTS

Of the 23,242 patients, 19,025 (81.9%) patients were successfully weaned from MV within 14 days. Using the preselected 46 clinical and laboratory variables, the area under the receiver operating characteristic curve of CatBoost classifier, random forest classifier, and regularized logistic regression classifier models were 0.860 (95% CI 0.852-0.868), 0.855 (95% CI 0.848-0.863), and 0.823 (95% CI 0.813-0.832), respectively. Using the ensemble voting classifier using the 3 models above, the final model revealed the area under the receiver operating characteristic curve of 0.861 (95% CI 0.853-0.869), which was significantly better than that of Simplified Acute Physiology Score II (0.749, 95% CI 0.742-0.756) and Sequential Organ Failure Assessment (0.588, 95% CI 0.566-0.609). The top features included lactate and anion gap. The model's performance achieved a plateau with approximately the top 21 variables.

CONCLUSIONS

We developed machine learning algorithms that can predict successful weaning from MV in advance to intubation in the ICU. Our models can aid the appropriate management for patients who hesitate to decide on ventilator support or meaningless end-of-life care.

Prediction prolonged mechanical ventilation in trauma patients of the intensive care unit according to initial medical factors: a machine learning approach

The goal of this study was to develop a predictive machine learning model to predict the risk of prolonged mechanical ventilation (PMV) in patients admitted to the intensive care unit (ICU), with a focus on laboratory and Arterial Blood Gas (ABG) data. This retrospective cohort study included ICU patients admitted to Rajaei Hospital in Shiraz between 2016 and March 20, 2022. All adult patients requiring mechanical ventilation and seeking ICU admission had their data analyzed. Six models were created in this study using five machine learning models (PMV more than 3, 5, 7, 10, 14, and 23 days). Patients' demographic characteristics, Apache II, laboratory information, ABG, and comorbidity were predictors. This study used Logistic regression (LR), artificial neural networks (ANN), support vector machines (SVM), random forest (RF), and C.5 decision tree (C.5 DT) to predict PMV. The study enrolled 1138 eligible patients, excluding brain-dead patients and those without mechanical ventilation or a tracheostomy. The model PMV > 14 days showed the best performance (Accuracy: 83.63-98.54). The essential ABG variables in our two optimal models (artificial neural network and decision tree) in the PMV > 14 models include FiO₂, paCO₂, and paO₂. This study provides evidence that machine learning methods outperform traditional methods and offer a perspective for achieving a consensus definition of PMV. It also introduces ABG and laboratory information as the two most important variables for predicting PMV. Therefore, there is significant value in deploying such models in clinical practice and making them accessible to clinicians to support their decision-making.

[Weaning from invasive ventilation : Challenges in the clinical routine]

Modern intensive care medicine is caught between the conflicting demands of an efficient but also increasingly more technical intensive care treatment with numerous therapeutic options and, at the same time, an ageing society with increasing morbidity. This is reflected, among other things, in an increasing number of ventilated patients in intensive care units and an increasing proportion of patients for whom ventilation cannot easily be discontinued. Weaning from a ventilator, which can account for more than 50% of the total ventilation time, therefore plays a central role in this process. This main topic article presents the need for strategically wise and holistic actions to minimize the consequences of invasive mechanical ventilation for patients. An attempt is made to shed more light on individual aspects of the ventilation weaning process with high relevance for clinical practice. Especially for prolonged weaning from ventilation, many more concepts are needed than simply ending ventilation.

Temporal trend of tracheostomy in patients hospitalized in the Brazilian National Unified Health System from 2011 to 2020

OBJECTIVE

to analyze the temporal trend in the tracheostomy use in patients hospitalized by the Sistema Único de Saúde in Brazil from 2011 to 2020.

METHODS

ecological observational study with a quantitative approach and including the Brazilian population aged 20 or over that were admitted by Sistema único de Saúde and had a record of performing the tracheostomy procedure at any time during hospitalization.

RESULTS

113.569.570 Hospitalizations studied were identified 172.456 tracheostomies realized in Brazil (0,15%). The average tax of this procedure showed a downward trend during the study procedure. The highest tracheostomy rate was found in the southern region, and the most affected age group was 80 years old or more. The average rate of tracheostomy in males was 1.8 times higher than in females. The average mortality and lethality rates of admissions with tracheostomy were 3.36 and 28.57% in the period but showed a tendency to decrease in the period studied. The main causes associated with the performance of tracheostomy were respiratory, oncological, and external causes. Respiratory causes contributed to 73% of the total procedures performed in the analyzed period.

CONCLUSION

the average mortality and lethality rates of hospitalizations with tracheostomy in Brazil were 3.36 and 28.57%, but showed a downward trend in the period.

Prefer early tracheostomy

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

Immersive virtual reality (VR) training increases the self-efficacy of in-hospital healthcare providers and patient families regarding tracheostomy-related knowledge and care skills: A prospective pre-post study

BACKGROUND

Virtual reality (VR)-based simulation in hospital settings facilitates the acquisition of skills without compromising patient safety. Despite regular text-based training, a baseline survey of randomly selected healthcare providers revealed deficiencies in their knowledge, confidence, comfort, and care skills regarding tracheostomy. This prospective pre-post study compared the effectiveness of regular text- and VR-based intervention modules in training healthcare providers' self-efficacy in tracheostomy care skills.

METHODS

Between January 2018 and January 2020, 60 healthcare providers, including physicians, nurses, and respiratory therapists, were enrolled. For the intervention, a newly developed head-mounted display (HMD) and web VR materials were implemented in training and clinical services. Subsequently, in-hospital healthcare providers were trained using either text or head-mounted display virtual reality (HMD-VR) materials in the regular and intervention modules, respectively. For tracheostomy care skills, preceptors directly audited the performance of trainees and provided feedback.

RESULTS

At baseline, the degree of trainees' agreement with the self-efficacy-related statements, including the aspects of familiarity, confidence, and anxiety about tracheostomy-related knowledge and care skills, were not different between the control and intervention groups. At follow-up stage, compared with the regular group, a higher percentage of intervention group' trainees reported that they are "strongly agree" or "somewhat agree" that the HMD-VR simulation increases their self-efficacy, including the aspects of familiarity and confidence, and reduced their anxiety about tracheostomy-related knowledge and care skills. After implementation, a higher degree of trainees' average satisfaction with VR-based training and VR materials was observed in the intervention group than in the regular group. Most reported that VR materials enabled accurate messaging and decreased anxiety. The increasing trend of the average written test and hands-on tracheostomy care skills scores among the intervention group trainees was significant compared to those in the regular group. The benefits of HMD-VR simulations and web-VR material-based clinical services for in-hospital healthcare providers and patient families persisted until 3 to 4 weeks later.

CONCLUSION

The current study suggests that VR materials significantly enhance trainees' self-efficacy (increased familiarity, increased confidence, and reduced anxiety) and their satisfaction with the training, while motivating them to use acquired knowledge and skills in clinical practice.

Tendência temporal da utilização da traqueostomia em pacientes hospitalizados pelo Sistema Único de Saúde no Brasil no período de 2011 a 2020

RESUMO Objetivo: analisar a tendência temporal da utilização da traqueostomia em pacientes hospitalizados pelo Sistema Único de Saúde no Brasil no período de 2011 a 2020. Método: estudo observacional de tipo ecológico, com abordagem quantitativa, e incluiu a população brasileira com 20 anos ou mais que, internadas pelo Sistema Único de Saúde, tiveram registro de realização do procedimento de traqueostomia em qualquer momento da hospitalização. Resultados: das 113.569.570 hospitalizações estudadas, foram identificadas 172.456 traqueostomias realizadas no Brasil (0,15%). A taxa média de realização deste procedimento apresentou tendência de queda no período estudado. A maior taxa média de traqueostomia foi encontrada na Região Sul, e a faixa etária mais afetada foi a dos 80 anos ou mais. A taxa média de traqueostomia no sexo masculino foi de 1,8 vezes maior do que no sexo feminino. As principais causas associadas à realização de traqueostomia foram as patologias respiratórias, oncológicas e decorrentes de causas externas, sendo que as causas respiratórias contribuíram com 73% do total de procedimentos estudados. Conclusões: as taxas médias de mortalidade e letalidade das internações com traqueostomia no Brasil foram de 3,36 e 28,57%, mas apresentaram tendência de redução no período.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Systematic Review, level III.

Timing of tracheostomy in mechanically ventilated COVID-19 patients

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.

Deep learning to predict long-term mortality in patients requiring 7 days of mechanical ventilation

Background

Among patients with acute respiratory failure requiring prolonged mechanical ventilation, tracheostomies are typically placed after approximately 7 to 10 days. Yet half of patients admitted to the intensive care unit receiving tracheostomy will die within a year, often within three months. Existing mortality prediction models for prolonged mechanical ventilation, such as the ProVent Score, have poor sensitivity and are not applied until after 14 days of mechanical ventilation. We developed a model to predict 3-month mortality in patients requiring more than 7 days of mechanical ventilation using deep learning techniques and compared this to existing mortality models.

Methods

Retrospective cohort study. Setting: The Medical Information Mart for Intensive Care III Database. Patients: All adults requiring ≥ 7 days of mechanical ventilation. Measurements: A neural network model for 3-month mortality was created using process-of-care variables, including demographic, physiologic and clinical data. The area under the receiver operator curve (AUROC) was compared to the ProVent model at predicting 3 and 12-month mortality. Shapley values were used to identify the variables with the greatest contributions to the model.

Results

There were 4,334 encounters divided into a development cohort (n = 3467) and a testing cohort (n = 867). The final deep learning model included 250 variables and had an AUROC of 0.74 for predicting 3-month mortality at day 7 of mechanical ventilation versus 0.59 for the ProVent model. Older age and elevated Simplified Acute Physiology Score II (SAPS II) Score on intensive care unit admission had the largest contribution to predicting mortality.

Discussion

We developed a deep learning prediction model for 3-month mortality among patients requiring ≥ 7 days of mechanical ventilation using a neural network approach utilizing readily available clinical variables. The model outperforms the ProVent model for predicting mortality among patients requiring ≥ 7 days of mechanical ventilation. This model requires external validation.

Surgical tracheostomy in a cohort of COVID-19 patients

Background

One of the main symptoms of severe infection with the new coronavirus‑2 (SARS-CoV-2) is hypoxemic respiratory failure because of viral pneumonia with the need for mechanical ventilation. Prolonged mechanical ventilation may require a tracheostomy, but the increased risk for contamination is a matter of considerable debate.

Objective

Evaluation of safety and effects of surgical tracheostomy on ventilation parameters and outcome in patients with COVID-19.

Study design

Retrospective observational study between March 27 and May 18, 2020, in a single-center coronavirus disease-designated ICU at a tertiary care German hospital.

Patients

Patients with COVID-19 were treated with open surgical tracheostomy due to severe hypoxemic respiratory failure requiring mechanical ventilation.

Measurements

Clinical and ventilation data were obtained from medical records in a retrospective manner.

Results

A total of 18 patients with confirmed SARS-CoV‑2 infection and surgical tracheostomy were analyzed. The age range was 42–87 years. All patients received open tracheostomy between 2–16 days after admission. Ventilation after tracheostomy was less invasive (reduction in PEAK and positive end-expiratory pressure [PEEP]) and lung compliance increased over time after tracheostomy. Also, sedative drugs could be reduced, and patients had a reduced need of norepinephrine to maintain hemodynamic stability. Six of 18 patients died. All surgical staff were equipped with N99-masks and facial shields or with powered air-purifying respirators (PAPR).

Conclusion

Our data suggest that open surgical tracheostomy can be performed without severe complications in patients with COVID-19. Tracheostomy may reduce invasiveness of mechanical ventilation and the need for sedative drugs and norepinehprine. Recommendations for personal protective equipment (PPE) for surgical staff should be followed when PPE is available to avoid contamination of the personnel.

Immediate Postoperative Complications in Adult Tracheostomy

Objective

Tracheostomy is one of the oldest operations for the management of airway obstruction. With time, indications expanded to prolonged mechanical ventilation, and currently, the majority of tracheostomies are done for this reason. There are several techniques used in a tracheostomy procedure, depending on surgeon preference. Immediate complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal wall perforation with esophageal injury are rare, although they do occur, and must be managed accordingly. This study aimed to assess differences in types and rates of immediate postoperative complications in patients undergoing tracheostomy when performed under general anesthesia and local anesthesia (awake tracheostomies) at a large academic institution. This is a continuing ongoing literature reporting tracheostomy adverse events.

Methods

A retrospective chart review was performed to identify patients who underwent tracheostomy placement between January 1, 2013 and December 31, 2019 at the Detroit Medical Center, USA. Postoperative complications such as bleeding, pneumothorax, pneumomediastinum, airway fire, and posterior tracheal perforation were collected along with gender, age, and revision tracheostomy status. IBM SPSS Statistics (IBM Inc., Armonk, USA) was used for statistical analysis with the statical significance defined as a p<0.05.

Results

A total of 1,469 patient charts were reviewed. Of these, 1,342 met the inclusion and exclusion criteria, of which, males were 57.2% (n=768), and females were 42.8% (n=574). The age range was 18 years to 96 years (mean=58.03; SD= 15.97), and BMI range was 12-83 (mean=28.77; SD=7.885).

Multinomial logistic regression was performed to determine whether age, BMI, sex, and revision tracheostomies were represented across both general and awake tracheostomy groups proportionally to their numbers in the total sample. It showed non-significant value for age (χ2=0.776, p=0.378), BMI (χ2=0.004, p=0.947), but significant value for sex (χ2=4.645, p=0.031), revision tracheostomy (χ2=18.282, p<0.001), indicating that males and revision tracheostomies over-represented in awake tracheostomies.

Next, Pearson correlation analysis was performed to determine any significant linear relationship between age, sex, and tracheostomy complications. It showed a significant positive correlation between age and tracheal stomal infection [r(1,340)=0.062, p=0.022].

An independent sample t-test showed a statistically significant difference between the mean pneumothorax and pneumomediastinum of general (n=1,277, mean=0.01, SD=0.088) and awake tracheostomies (n=65, mean=0.08, SD=0.269, t=2.069, p=0.043).

Pneumothorax pneumomediastinum complications between the general tracheostomy and awake tracheostomy odds ratio (OR)-6.22, indicates the chance of pneumothorax /pneumomediastinum complication is 6.22 times more in awake tracheostomy than general tracheostomy. Based on the above statistical analysis, we rejected the null hypothesis.

Conclusions

Tracheostomy is the procedure of choice to relieve the upper airway obstruction and treat patients requiring prolonged mechanical ventilation. A slightly higher number of Immediate postoperative complications in awake tracheostomy were noticed in patients with more surgically challenging revision tracheostomies.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

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.

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

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

Effect of Patient Demographics and Tracheostomy Timing and Technique on Patient Survival

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.

The Impact of Tracheostomy Timing on the Duration and Complications of Mechanical Ventilation

Background:

Mechanical ventilation is a life support for ICU patients and is indicated in case of acute or chronic respiratory failure. 75% of patients admitted to ICU require this support and most of them stay on prolonged MV. Tracheostomy plays a fundamental role in airway management, facilitating ventilator weaning and reducing the duration of MV. Early tracheostomy is defined when the procedure is conducted up to 10 days after the beginning of MV and late tracheostomy when the procedure is performed after this period. Controversy still exists over the ideal timing and classification of early and late tracheostomy.

Objective:

Evaluate the impact of timing of tracheostomy on ventilator weaning.

Method:

Single-center retrospective study. Patients were divided into three groups: very early tracheostomy (VETrach), intermediate (ITrach) and late (LTrach): >10 days.

Results:

One hundred two patients were included: VETrach (n=21), ITrach (n=15), and LTrach (n=66). ITrach group had lower APACHE II (p=0.004) and SOFA (p≤0.001). Total ICU length of stay, and incidence of post-tracheostomy ventilator-associated pneumonia were significantly lower in the VETrach and ITrach groups. The GCS and RASS scores improved in all groups, while the maximal inspiratory pressure and rapid shallow breathing index showed a tendency towards improvement on discharge from the ICU.

Conclusion:

Very early tracheostomy did not reduce the duration of MV or length of ICU stay after the procedure when compared to late tracheostomy, but was associated with low rates of ventilatorassociated pneumonia. Neurological patients benefitted more from tracheostomy, particularly very early and intermediate tracheostomy.

The effect of tracheostomy delay time on outcome of patients with prolonged mechanical ventilation: A STROBE-compliant retrospective cohort study

The tracheostomy timing for patients with prolonged mechanical ventilation (PMV) was usually delayed in our country. Both physician decision time and tracheostomy delay time (time from physician's suggestion of tracheostomy to procedure day) affect tracheostomy timing. The effect of tracheostomy delay time on outcome has not yet been evaluated before.Patients older than 18 years who underwent tracheostomy for PMV were retrospectively collected. The outcomes between different timing of tracheostomy (early: ≤14 days; late: >14 days of intubation) were compared. We also analyzed the effect of physician decision time, tracheostomy delay time, and procedure type on clinical outcomes.A total of 134 patients were included. There were 57 subjects in the early tracheostomy group and 77 in the late group. The early group had significantly shorter mechanical ventilation duration, shorter intensive care unit stays, and shorter hospital stays than late group. There was no difference in weaning rate, ventilator-associated pneumonia, and in-hospital mortality. The physician decision time (8.1 ± 3.4 vs 18.2 ± 8.1 days, P < .001) and tracheostomy delay time (2.1 ± 1.9 vs 6.1 ± 6.8 days, P < .001) were shorter in the early group than in the late group. The tracheostomy delay time [odds ratio (OR) = 0.908, 95% confidence interval (CI) = 0.832-0.991, P = .031) and procedure type (percutaneous dilatation, OR = 2.489, 95% CI = 1.057-5.864, P = .037) affected successful weaning. Platelet count of >150 × 10/μL (OR = 0.217, 95% CI = 0.051-0.933, P = .043) and procedure type (percutaneous dilatation, OR = 0.252, 95% CI = 0.069-0.912, P = .036) were associated with in-hospital mortality.Shorter tracheostomy delay time is associated with higher weaning success. Percutaneous dilatation tracheostomy is associated with both higher weaning success and lower in-hospital mortality.

Tracheostomy as a Risk Factor for Paroxysmal Sympathetic Hyperactivity in Severe Traumatic Brain Injury

BACKGROUND

Paroxysmal sympathetic hyperactivity (PSH) is an uncommon complication of severe traumatic brain injury (sTBI). The clinical risk factors for PSH have not been fully characterized, especially regarding tracheostomy, which has usually been recommended for patients with sTBI to facilitate treatment. We examined the effects of tracheostomy on PSH incidence in patients with sTBI.

METHODS

The present single-center, retrospective study included consecutive patients with sTBI who had been admitted to the Shanghai Changzheng Hospital from January 1, 2013 to March 31, 2018. The potential risk factors related to the occurrence of PSH was explored by univariate analysis. Multivariate logistic regression analysis was conducted to determine the independence of the factors associated with PSH development.

RESULTS

Of the 120 patients with sTBI, 17 with PSH were identified (14.16%). We found 3 risk factors were significantly associated with PSH on univariate and multivariate analyses: 1) tracheostomy (odds ratio [OR], 5.368; 95% confidence interval [CI], 1.102-26.151; P = 0.038); 2) age (OR, 0.916; 95% CI, 0.874-0.960; P < 0.001); and 3) hydrocephalus (OR, 6.715; 95% CI, 1.708-26.408; P = 0.006).

CONCLUSIONS

Our results suggest that tracheostomy is independently associated with an increased incidence of PSH.

Timing of Tracheostomy in Intensive Care Unit Patients

Introduction  The ideal timing of tracheostomy in intensive care units (ICUs) for critically ill patients undergoing prolonged mechanical ventilation (MV) is still a controversial issue.

Objectives  To determine the proper timing of tracheostomy and its impact on various clinical outcomes of adult patients in ICUs undergoing prolonged MV.

Methods  The present study consisted of a sample of 67 ICU adult patients who were submitted to open surgical tracheostomy and divided into two groups: 30 patients in the early tracheostomy (ET) group (within 1–10 days post intubation), and 37 patients in the late tracheostomy (LT) group (within 11–21 days post intubation). The correlation between the timing of tracheostomy of each group and various associated ICU clinical parameters were analyzed.

Results  The sample consisted of 61.19% male and 38.81% female patients, with a mean age of 47.263 ± 7.581 years. The mean MV duration in days was 7.91 ± 4.937 standard deviation (SD) in the ET group, and 15.32 ± 7.472 SD in the LT group ( p  = 0.001), with a mean sedation time of 6.13 ± 4.647 SD in the ET group, and of 11.98 ± 6.596 SD in the LT group ( p  = 0.001). The duration of the weaning process duration had a mean of 2.75 ± 2.586 SD days in the ET group, and of 5.39 ± 5.817 SD days in the LT group ( p  = 0.025), with a weaning failure rate of 28.57% in the ET group and 71.42% in the LT group ( p  = 0.01). The Mean ICU stay was 26.18 ± 4.732 SD in the ET group, and 11.98 ± 6.596 SD in the LT group ( p  = 0.879), and the incidence of ventilator-associated pneumonia (VAP) of 23.33% in the ET group and of 27.02% in the LT group ( p  = 0.15).

Conclusion  Early tracheostomy had a notable benefit in shortening the duration of the MV, lessening the sedation time and minimizing the risks of weaning failure, but it had no significant impact on both the overall duration of ICU stay and VAP incidence.

Using artificial intelligence to predict prolonged mechanical ventilation and tracheostomy placement

BACKGROUND

Early identification of critically ill patients who will require prolonged mechanical ventilation (PMV) has proven to be difficult. The purpose of this study was to use machine learning to identify patients at risk for PMV and tracheostomy placement.

MATERIALS AND METHODS

The Multiparameter Intelligent Monitoring in Intensive Care III database was queried for all intensive care unit (ICU) stays with mechanical ventilation. PMV was defined as ventilation >7 d. Classifiers with a gradient-boosted decision trees algorithm were created for the outcomes of PMV and tracheostomy placement. The variables used were six different severity-of-illness scores calculated on the first day of ICU admission including their components and 30 comorbidities. Mean receiver operating characteristic curves were calculated for the outcomes, and variable importance was quantified.

RESULTS

There were 20,262 ICU stays identified. PMV was required in 13.6%, and tracheostomy was performed in 6.6% of patients. The classifier for predicting PMV was able to achieve a mean area under the curve (AUC) of 0.820 ± 0.016, and tracheostomy was predicted with an AUC of 0.830 ± 0.011. There were 60.7% patients admitted to a surgical ICU, and the classifiers for these patients predicted PMV with an AUC of 0.852 ± 0.017 and tracheostomy with an AUC of 0.869 ± 0.015. The variable with the highest importance for predicting PMV was the logistic organ dysfunction score pulmonary component (13%), and the most important comorbidity in predicting tracheostomy was cardiac arrhythmia (12%).

CONCLUSIONS

This study demonstrates the use of artificial intelligence through machine-learning classifiers for the early identification of patients at risk for PMV and tracheostomy. Application of these identification techniques could lead to improved outcomes by allowing for early intervention.

National Variation in the Use of Tracheostomy in Patients With Congenital Heart Disease

OBJECTIVES

The postsurgical care of children with congenital heart disease may be complicated by the need for cardiorespiratory support, including tracheostomy. The variation of the use of tracheostomy across multiple pediatric cardiac surgical centers has not been defined. We describe multicenter variation in the use of tracheostomy in children undergoing congenital heart surgery.

DESIGN

We retrospectively analyzed a multicenter cohort.

SETTING

Pediatric Health Information Systems database retrospective cohort.

PATIENTS

Children less than 18 years who underwent both tracheostomy and cardiac surgery (1/04-6/14).

INTERVENTIONS

Univariate and multivariate statistics were performed, stratifying by high (≥ 75th percentile) and low (≤ 25th percentile) tracheostomy volume and adjusting for patient characteristics in multivariate models.

MEASUREMENTS AND MAIN RESULTS

Out of 123,510 hospitalizations involving cardiac surgery, 1,292 tracheostomies (1.2%) were performed (46 hospitals). The rate of tracheostomy placement ranged from 0.3% to 2.5% with no difference in the rate of tracheostomy placement between high and low tracheostomy use centers (p = 0.8). The median time to tracheostomy was 63 days (interquartile range, 36-100), and there was no difference between high- and low-tracheostomy centers. High-tracheostomy centers had $420,000 lower hospital charges than low-volume centers (p = 0.03). Tracheostomy day greater than the median (63 d), Risk Adjustment for Congenital Heart Surgery-1 score 6, and extracorporeal membrane oxygenation were significantly associated with adjusted increased odds of mortality. Later hospital day of tracheostomy was associated with a $13,000/d increase in total hospital charges (p < 0.001).

CONCLUSIONS

Variation in the usage of tracheostomy in infants and children undergoing congenital heart surgery exists across the country. High-tracheostomy centers had lower hospital charges. Late tracheostomy placement, higher congenital heart disease surgical risk, and extracorporeal membrane oxygenation use are independent predictors of in-hospital mortality in this population.

Preadmission tracheostomy is associated with better outcomes in patients with prolonged mechanical ventilation in the postintensive care respiratory care setting

BACKGROUND/PURPOSE

Prolonged mechanical ventilation (PMV) is the most common situation where tracheostomy is indicated for intensive care unit (ICU) patients. However, it is unknown if this procedure confers survival benefits on PMV patients in a post-ICU setting.

METHODS

Patients who were admitted to the specialized weaning unit from 2005 to 2008 and received PMV were included in this study. On admission, data pertaining to patient characteristics, physiologic status, and type of artificial airway (tracheostomy vs. no tracheostomy) were obtained. Outcomes of tracheostomized and nontracheostomized patients were evaluated using multivariate Cox proportional hazards and propensity score-matching models. The primary outcome of interest was 1-year survival.

RESULTS

A total of 401 patients (mean age 74.4 years, 204 male) were identified. In multivariate analyses, higher Acute Physiology and Chronic Health Evaluation II score [hazard ratio (HR) = 1.061, 95% confidence interval (CI) = 1.016-1.107] and presence of comorbidities, including congestive heart failure (HR = 1.562, 95% CI = 1.119-2.181), malignancy (HR = 1.942, 95% CI = 1.306-2.885), and liver cirrhosis (HR = 2.373, 95% CI = 1.015-5.544), were independently associated with 1-year mortality. An association between having tracheostomy and a better 1-year outcome was observed (HR = 0.625, 95% CI = 0.453-0.863). The matched cohort study also demonstrated a favorable 1-year survival for tracheostomized patients, and these patients had significantly lower in-hospital mortality (24% vs. 36%, p = 0.049) and risk of ventilator-associated pneumonia (10% vs. 20%, p = 0.030) than nontracheostomized ones.

CONCLUSION

Preadmission tracheostomy may be associated with better outcomes of PMV patients in a post-ICU respiratory care setting. The findings suggest that this procedure should be recommended before PMV patients are transferred to specialized weaning units.

Factors related to tracheostomy timing and ventilator weaning: findings from a population in Northern Taiwan

INTRODUCTION

Determining the optimal time for performing a tracheostomy and weaning a patient off a ventilator is typically challenging for physicians, respiratory therapists, patients and patients' families.

PURPOSE

This study examined the factors influencing tracheostomy timing and ventilator weaning and described the transition-care placement of patients who experience unsuccessful ventilator weaning.

METHODS

A retrospective design was employed, and 2 years of data were collected through a medical chart review performed at a hospital in Northern Taiwan. Sixty patients who received tracheostomies in the intensive care unit (ICU) or respiratory care center were enrolled. The data included each patient's demographic information, disease diagnosis, and Glasgow Coma Scale score and Acute Physiology and Chronic Health Evaluation II scores.

RESULTS

For patients on a ventilator in an ICU, the tracheostomy rate was 2.7%. Early (within 21 days) and late (>21 days) tracheostomies accounted for 36.7% and 63.3%, respectively. Of the patients who had received tracheostomies, 36.7% experienced ventilator weaning. The factors related to tracheostomy timing were disease diagnosis (P = 0.036) and days of ventilator use (P = 0.003). The factors related to ventilator weaning included disease diagnosis (P = 0.010) and tracheostomy timing (P = 0.001). Early tracheostomies were 10.9 times more likely than late tracheostomies to result in ventilator weaning (95%CI =2.5-47.7, P = 0.002).

CONCLUSIONS

Tracheostomy timing was strongly correlated with ventilator weaning. Early tracheostomy was higher successful ventilator weaning rates. The surgical patients were more likely to receive an early tracheostomy. However, the number of patients in Taiwan who received tracheostomies was lower than that in other countries. Further study maybe need to understand cultural variations in the acceptance of tracheostomies by patients.

Resuscitating the tracheostomy patient in the ED

BACKGROUND

Emergency physicians must be masters of the airway. The patient with tracheostomy can present with complications, and because of anatomy, airway and resuscitation measures can present several unique challenges. Understanding tracheostomy basics, features, and complications will assist in the emergency medicine management of these patients.

OBJECTIVE OF REVIEW

The aim of this review is to provide an overview of the basics and features of the tracheostomy, along with an approach to managing tracheostomy complications.

DISCUSSION

This review provides background on the reasons for tracheostomy placement, basics of tracheostomy, and tracheostomy tube features. Emergency physicians will be faced with complications from these airway devices, including tracheostomy obstruction, decannulation or tube dislodgement, stenosis, tracheoinnominate fistula, and tracheoesophageal fistula. Critical patients should be evaluated in the resuscitation bay, and consultation with ENT should be completed while the patient is in the department. This review provides several algorithms for management of complications. Understanding these complications and an approach to airway management during cardiac arrest resuscitation is essential to optimizing patient care.

CONCLUSION

Tracheostomy patients can present unique challenges for emergency physicians. Knowledge of the basics and features of tracheostomy tubes can assist physicians in managing life-threatening complications including tube obstruction, decannulation, bleeding, stenosis, and fistula.

Association of timing of tracheostomy on clinical outcomes in PICU patients

OBJECTIVES

Tracheostomy is a common procedure in the ICU when prolonged mechanical ventilation is expected. Although adult data show morbidity and mortality benefits over translaryngeal intubation, there is no consensus on optimal timing. In the pediatric population, there is sparse data regarding morbidities associated with duration of ventilation prior to tracheostomy. Our objective was to associate timing of tracheostomy with clinical outcomes in PICU patients.

DESIGN

This is a retrospective cohort study of patients undergoing tracheostomy. Patient factors and duration of ventilation prior to tracheostomy were collected on each patient. Morbidities such as ventilator-associated pneumonia, central catheter-associated bloodstream infection, and cardiopulmonary arrests were examined both pre- and posttracheostomy. ICU and total hospital length of stay as well as mortality were recorded. For data analysis regarding tracheostomy timing, patients were stratified into early and late groups using a cutoff of 14 days.

SETTING

The PICUs and cardiac ICUs in a quaternary-care children's hospital.

PATIENTS

All patients undergoing tracheostomy over a 3-year period.

MEASUREMENTS AND MAIN RESULTS

Seventy-three patients were analyzed with a median of 22 days of ventilation prior to tracheostomy. Patient factors associated with longer pretracheostomy ventilation included congenital heart disease and vasoactive drug use. Clinical events associated with longer pretracheostomy ventilation included bloodstream infection, ventilator-associated pneumonia, and cardiac arrest. Age, congenital heart disease, vasoactive drug use, bloodstream infection, and ventilator-associated pneumonia each independently increased pretracheostomy ventilator days. Median ICU length of stay after tracheostomy was 18 days. For each pretracheostomy ventilator day, ICU length of stay increased by 0.5 days and hospital length of stay increased by 1.9 days. For patients undergoing early tracheostomy, ICU and total hospital lengths of stay were 4 days and 4 weeks shorter, respectively.

CONCLUSIONS

Analysis of our results suggests that a longer duration of ventilation prior to tracheostomy is associated with increased ICU morbidities and length of stay. Early tracheostomy may have significant benefits without adversely affecting mortality.

Surgical tracheotomy performed with and without dual antiplatelet therapy

Some patients who need dual antiplatelet therapy sometimes require tracheotomy. Aim of this study was to compare the rate of complications during and after surgical tracheotomy between patients requiring dual antiplatelet therapy and those without dual antiplatelet therapy. We retrospectively included 79 patients (62% men, mean age 64 ± 14 years) in the period 2007-2011. The following complications were analyzed: need for surgical revision within 24 hours after tracheotomy, need for bronchoscopy within 24 hour after tracheotomy, need for blood transfusion within 24 hours after tracheotomy, death attributed to tracheotomy and any complication attributed to tracheotomy. We compared patients where tracheotomy was performed while receiving dual antiplatelet therapy (n=27, 34%) to patients where tracheotomy was performed without dual antiplatelet therapy (n=52, 66%). Nonsignificant differences between the two groups were observed general characteristics. There were no statistically significant differences in complications after tracheotomy (surgical revision after tracheotomy p=0.63, bronchoscopy after tracheotomy p=0.74, blood transfusion after tracheotomy p=0.59, death attributed to tracheotomy p=1.00 and any complication attributed to tracheotomy p=1.00). The study shows that tracheotomy is safe in cardiac patients on dual antiplatelet therapy.

Apnea-hypopnea index use among intensive care patients: a case series

INTRODUCTION

ApneaLink™ (RESMED-Munich, Germany) is a simple and inexpensive device that determines the apnea-hypopnea index. The sensitivity and specificity of the apnea-hypopnea index are 100 and 87.5%, respectively. Our hypothesis can be used to create a treatment plan using the apnea-hypopnea index for intensive care unit patients.

CASE PRESENTATION

This treatment plan has been created by determining the apnea-hypopnea index of eight Caucasian patients with a variety of diagnoses. Case 1 is that of a 70-year-old man diagnosed with rectum cancer and scheduled for elective surgery. Case 2 is that of a 65-year-old man diagnosed with rectum cancer and scheduled for elective surgery. Case 3 is that of a 78-year-old woman diagnosed with chronic obstructive pulmonary disease-pneumonia. Case 4 is that of a 26-year-old man diagnosed with head trauma. Case 5 is that of an 80-year-old man diagnosed with cerebrovascular disease. Case 6 is that of a 79-year-old man diagnosed with cerebrovascular disease. Case 7 is that of an 8-year-old girl diagnosed with ventricular septal defect-epidural hemorragia. Case 8 is that of a 42-year-old man diagnosed with subarachnoid hemorrage.

CONCLUSIONS

The apnea-hypopnea index can be informative regarding prognosis and outcomes, and helps to take precautions and develop new treatment strategies among critical patients in intensive care. The integration of developments in sleep medicine to intensive care unit practices means that we can be more informed about critical patients.

Pilot Study of Two Nurse-Led Weaning Protocols in Patients with Tracheostomies

This is a pilot study, comparing two commonly-used weaning techniques in patients with a tracheostomy to establish if one technique resulted in shorter time to successful weaning. In a prospective, single-centre randomised, controlled trial, conducted in a 15-bed multidisciplinary intensive care unit, fifty patients mechanically ventilated for at least 48 hours and who had a tracheostomy inserted primarily for weaning purposes, were randomised to one of two weaning techniques: increasing periods of spontaneous ventilation, or reducing pressure support ventilation. Each technique was protocolised for implementation by the nursing staff and consisted of two stages: a weaning and a verification stage. This pilot study did not find a statistically significant difference in the length of time spent weaning when two nurse-led protocolised weaning techniques of increasing periods of spontaneous ventilation or reducing pressure support ventilation were compared in patients with a tracheostomy inserted primarily for weaning purposes. No safety issues were identified in either protocol.

Tracheostomy care and complications in the intensive care unit

Tracheotomy is a common procedure in intensive care units, and nurses must provide proper care to tracheostomy patients to prevent complications. One of the most important considerations is effective mobilization of secretions, and a suction catheter is the most important tool for that purpose. Each bedside should be equipped with a functional suctioning system, an oxygen source, a manual resuscitation bag, and a complete tracheostomy kit, which should accompany patients wherever they go in the hospital. Complications include infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula. Tracheostomy emergencies include hemorrhage, tube dislodgement and loss of airway, and tube obstruction; such emergencies are managed more effectively when all necessary supplies are readily available at the bedside. This article describes how to provide proper care in the intensive care unit, strategies for preventing complications, and management of tracheostomy emergencies.

Prediction of prolonged mechanical ventilation in patients in the intensive care unit A cohort study

INTRODUCTION

There are no established guidelines for selecting patients for early tracheostomy. The aim was to determine the factors that could predict the possibility of intubation longer than 7 days in critically ill adult patients.

METHODS

This is cohort study made at a general intensive care unit. Patients who required at least 48 hours of mechanical ventilation were included. Data on the clinical and physiologic features were collected for every intubated patient on the third day. Uni- and multivariate statistical analyses were conducted to determine the variables associated with extubation.

RESULTS

163 (62%) were male, and the median age was 59±17 years. Almost one-third (36%) of patients required mechanical ventilation longer than 7 days. The variables strongly associated with prolonged mechanical ventilation were: age (HR 0.97 (95% CI 0.96-0.99); diagnosis of surgical emergency in a patient with a medical condition (HR 3.68 (95% CI 1.62-8.35), diagnosis of surgical condition-non emergency (HR 8.17 (95% CI 2.12-31.3); diagnosis of non-surgical-medical condition (HR 5.26 (95% CI 1.85-14.9); APACHE II (HR 0.91 (95% CI 0.85-0.97) and SAPS II score (HR 1.04 (95% CI 1.00-1.09) The area under ROC curve used for prediction was 0.52. 16% of patients were extubated after day 8 of intubation.

CONCLUSIONS

It was not possible to predict early extubation in critically ill adult patients with invasive mechanical ventilation with common clinical scales used at the ICU. However, the probability of successfully weaning patients from mechanical ventilation without a tracheostomy is low after the eighth day of intubation.

An audit of characteristics and outcomes in adult intensive care patients following tracheostomy

Background:

Tracheostomies are commonly performed on critically ill patients requiring prolonged mechanical ventilation. The purpose of this study was to review our experience with surgical and percutaneous tracheostomies and identify factors affecting outcome.

Materials and Methods:

Patients who underwent tracheostomy between January 1999 and June 2008 were identified on the basis of Diagnostic Related Group coding and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification procedural code. The primary endpoint was in-hospital mortality. Contingency tables were generated for clinical variables and a chi-squared test was used to determine significance.

Results:

One hundred and sixty-eight patients underwent tracheostomy between January 1999 and 30 June 2008. In-hospital mortality was 22.6%. The probability of death was found to be independent of timing of tracheostomy, technique used (percutaneous vs. surgical), number of failed extubations and obesity. On univariate analysis, the null hypothesis of independence was rejected for age on admission (P = 0.014), diagnosis of sepsis (P = 0.0008) or cardiac arrest (P = 0.0016), Acute Physiology and Chronic Health Evaluation II score (P = 0.0319) and the Australasian Outcomes Research Tool for Intensive Care calculated risk of death (P = 0.0432).

Conclusion:

Although a number of patient factors are associated with worse outcome, tracheostomy appears to be a relatively safe technique in the Intensive Care Unit population.

[Results of an artificial airway management protocol in critical patients subjected to mechanical ventilation]

OBJECTIVE

To determine the results of the implementation of a protocol in an intensive care unit (ICU) referred to critically ill patients requiring a prolonged artificial airway.

DESIGN

A prospective, observational cohort study was carried out.

INTERVENTION

Management strategies were established on the airway by endotracheal intubation (ETI) or tracheostomy, and guidelines were developed for action in the decannulation process.

SETTING

A polyvalent ICU.

PATIENTS

We studied 169 patients subjected to mechanical ventilation (MV), 67 with ETI ≥ 10 days of MV and 102 with percutaneous (PT) or surgical tracheostomy (TQ).

VARIABLES OF INTEREST

ICU and hospital stays, days of ETI and MV, mortality, tracheostomy, anatomical risk factors, surgical complications, and postoperative decannulation period.

RESULTS

ETI versus tracheotomy involved fewer days of MV (17 vs. 30 days, p<0.001), a shorter ICU stay (20 vs. 35 days, p<0.001), and a shorter hospital stay (34 vs. 51 days, p<0.001).There were more TQ procedures in patients with risk factors (47% TP vs. 89% TQ, p<0.001). Intraoperative minor bleeding was the most common complication, being associated with TQ (31% vs. 11%, p = 0.03). TP was associated with a shorter cannulationperiod (25 days vs. 34 days, p<0.04).

CONCLUSIONS

The protocol variants showed no differences in terms of complications and mortality, when orienting application to patients with similar characteristics.

Correlation between timing of tracheostomy and duration of mechanical ventilation in patients with potentially normal lungs admitted to intensive care unit

Background:

There is insufficient evidence to conclude that the timing of tracheostomy alters the duration of mechanical ventilation, hence this study was designed to investigate the correlation between timing of tracheostomy and duration of mechanical ventilation for patients admitted to intensive care unit (ICU) with potentially normal lungs.

Materials and Methods:

In a retrospective study for a period of 2 years, all adult patients admitted to the medical ICU of Al-Zahra Hospital in Isfahan University of Medical Sciences who needed endotracheal intubation and prolonged mechanical ventilation were considered for inclusion in this study. Data of underlying disease, causes of respiratory failure, age and gender, duration of mechanical ventilation, and interval between intubation time and tracheostomy were collected. The correlations between intubation period and ventilation period were analyzed using a Pearson correlation test.

Results:

Sixty-six percent of patients (100 patients) were men. The mean ± SD of age of patients was 56.2 ± 20.8 years (18–90 years.). The timing of tracheostomy (duration of endotracheal intubation until tracheostomy) did not exhibit any correlation with the length of mechanical ventilation (P = 0.43, r = 0.08). The timing of tracheostomy had not any correlation with the age of patients (P = 0.20, r = 0.129). The length of mechanical ventilation had not any correlation with the age of patients (P = 0.83, r = 0.02). The timing of tracheostomy was similar in men and women (P = 0.5). Mechanical ventilation period was not significantly different in both genders (P = 0.89).

Conclusion:

Our study with mentioned sample size could not show any relationship between timing of tracheostomy and duration of mechanical ventilation in patients under mechanical ventilation with good pulmonary function in ICU.

Benefits of early tracheostomy in ventilated stroke patients? Current evidence and study protocol of the randomized pilot trial SETPOINT (Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial)

RATIONALE

Ventilated intensive care patients with ischemic or hemorrhagic strokes have a poor prognosis. Early tracheostomy has led to advantages in selected groups of non-cerebrovascular intensive care patients, including shorter ventilation time, shorter intensive care unit length of stay, and reduced complications. It is completely unclear whether ventilated stroke patients might benefit from early tracheostomy, too.

AIM

Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial (SETPOINT) is a pilot trial aiming to investigate the safety, feasibility, and potential benefits of early tracheostomy vs. prolonged intubation (and possibly late tracheostomy) in patients with severe ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. The primary objective is to compare early tracheostomy and prolonged intubation with respect to the intensive care unit - length of stay and the time until the start of rehabilitation in these patients.

DESIGN

SETPOINT is a prospective, randomized, controlled, outcome observer-blinded, monocenter trial. Patients with severe ischemic stroke, intracerebral or subarachnoid hemorrhage requiring intubation and ventilation are eligible. After passing predefined criteria, enrolled patients are randomized to either percutaneous tracheostomy within the first three-days from intubation or to weaning/extubation attempts or percutaneous tracheostomy between days 7 and 14 from intubation (n = 30 per group).

STUDY OUTCOMES

The primary end-point is the intensive care unit length of stay. Secondary end-points are functional outcome and mortality at discharge and after six-months, duration to transferability, duration of ventilation, duration and quality of weaning from respirator, need of analgesia and sedation, procedure-related complications, frequency of pneumonia and sepsis, and costs of treatment.

DISCUSSION

To clarify the potential benefit of early tracheostomy in critical care ventilated stroke patients, a randomized multicenter trial in a larger patient population is clearly needed. If this monocentric pilot gives promising safety, feasibility, and benefit results, such a multicenter trial will be planned. The results will have a relevant direct impact on the critical care of stroke.

Early vs. late tracheostomy for the ICU patients: Experience in a referral hospital

OBJECTIVES

The aim of this study is to present our experience with elective surgical tracheostomy for intensive care unit (ICU) patients who needed prolonged translaryngeal intubation in order to evaluate the proper timing and advantages of early vs. late tracheostomy and to stress upon the risks associated with delayed tracheostomy.

METHODS

Medical records of all patients, who underwent elective tracheostomy for prolonged intubation from September 2006 to August 2010 at Jordan University hospital, were reviewed.

RESULTS

A total of 106 patients (74 males) were included; their age ranged from 2 months to 90 yr with mean age of 46.5 yr. The mean time at which tracheostomy was done after initial tracheal intubation was 23 days (range 3-7 weeks). Trauma was the most frequent cause of ICU admission 38 (35.8%), followed by post-surgery causes 14 (13.2%). An early tracheostomy showed less complication vs late procedure. The length of stay in the ICU for patients who had an early tracheostomy was 26 days while this period for patients who had late tracheostomy was 47 days. Mortality rate among patients who had early tracheostomy was 17.1% while for late tracheostomy patients, it was 36.1%.

CONCLUSION

Proper assessment and early tracheostomy is recommended for patients who require prolonged tracheal intubation in the ICU.

Predictors of successful decannulation using a tracheostomy retainer in patients with prolonged weaning and persisting respiratory failure

BACKGROUND

For percutaneously tracheostomized patients with prolonged weaning and persisting respiratory failure, the adequate time point for safe decannulation and switch to noninvasive ventilation is an important clinical issue.

OBJECTIVES

We aimed to evaluate the usefulness of a tracheostomy retainer (TR) and the predictors of successful decannulation.

METHODS

We studied 166 of 384 patients with prolonged weaning in whom a TR was inserted into a tracheostoma. Patients were analyzed with regard to successful decannulation and characterized by blood gas values, the duration of previous spontaneous breathing, Simplified Acute Physiology Score (SAPS) and laboratory parameters.

RESULTS

In 47 patients (28.3%) recannulation was necessary, mostly due to respiratory decompensation and aspiration. Overall, 80.6% of the patients could be liberated from a tracheostomy with the help of a TR. The need for recannulation was associated with a shorter duration of spontaneous breathing within the last 24/48 h (p < 0.01 each), lower arterial oxygen tension (p = 0.025), greater age (p = 0.025), and a higher creatinine level (p = 0.003) and SAPS (p < 0.001). The risk for recannulation was 9.5% when patients breathed spontaneously for 19-24 h within the 24 h prior to decannulation, but 75.0% when patients breathed for only 0-6 h without ventilatory support (p < 0.001). According to ROC analysis, the SAPS best predicted successful decannulation [AUC 0.725 (95% CI: 0.634-0.815), p < 0.001]. Recannulated patients had longer durations of intubation (p = 0.046), tracheostomy (p = 0.003) and hospital stay (p < 0.001).

CONCLUSION

In percutaneously tracheostomized patients with prolonged weaning, the use of a TR seems to facilitate and improve the weaning process considerably. The duration of spontaneous breathing prior to decannulation, age and oxygenation describe the risk for recannulation in these patients.

All-cause mortality after tracheostomy at a tertiary care hospital over a 10-month period

OBJECTIVE

To evaluate perioperative mortality after tracheostomy in intensive care unit (ICU) patients undergoing routine tracheostomy over a 10-month period.

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary care hospital.

SUBJECTS

Mechanically ventilated patients.

METHODS

Prospective analysis of ICU patients undergoing tracheostomy placement over 10 months was performed. Variables evaluated were demographics, pretracheostomy length of stay, time on ventilator, time to death, preoperative comorbidities, and cause of death.

RESULTS

There were 129 consultations resulting in 115 tracheostomies, of which 100 were included for study. The overall 30-day postoperative mortality rate was 25%, including palliative care deaths. Cause of death in all cases was due to a preexisting condition and not from tracheostomy. Patients who died within the 30-day postoperative period were found to have significant differences in age, pretracheostomy length of stay, location of tracheostomy, and preoperative comorbidity scores. No significant difference was found in time on ventilator, sex, or race/ethnicity. Mean time from consultation to tracheostomy was 2.5 days (range, 0-12 days).

CONCLUSION

High rates of mortality after tracheostomy can possibly affect hospital quality ratings for surgical services. There were no deaths directly related to surgery. Despite this, the mortality rate in this population was quite high. This illustrates the significant disease burden in these patients and the need to stratify postoperative mortality as well as to consider comorbidity and age when evaluating patients for tracheostomy.

Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study

BACKGROUND

Long-term ventilation in intensive care units (ICUs) is associated with several problems such as increased mortality, increased rates of ventilator-associated pneumonia (VAP), and prolonged time of hospitalization, and thus leads to enormous healthcare expenditure. While the influence of tracheostomy on VAP incidence, duration of ventilation, and time of hospitalization has already been analyzed in several studies, the timing of the tracheostomy procedure on patient's mortality is still controversial. The aim of our study was to investigate whether early tracheostomy improved outcome in critically ill patients.

MATERIALS AND METHODS

Within 2 years, 100 critically ill, predominantly surgical patients entered this prospective randomized study. A percutaneous dilatational tracheostomy was performed either early (≤4 days, 2.8 days median) or late (≥6 days, 8.1 days median) after intubation.

RESULTS

We could demonstrate that mortality was not significantly reduced in the early tracheostomy (ET) group in contrast to the late tracheostomy (LT) group. ET was associated with decreased VAP incidence (ET 38% vs. LT 64%), decreased duration of ventilation (ET 367.5 h vs LT 507.5 h), and shorter time of hospitalization both in hospital (ET 31.5 days vs LT 68 days) and in ICU (ET 21.5 days vs LT 27 days).

CONCLUSION

Despite many advantages like reduced time of ventilation and hospitalization, early tracheostomy is not associated with decreased mortality in critically ill patients.