The Impact of Early Tracheostomy in Neurotrauma Patients: A Retrospective Study

Tracheostomy decannulation outcomes in 131 consecutive neurosurgical patients

OBJECTIVES

This study was a retrospective study to investigate factors related to difficult tracheostomy decannulation, and to evaluate outcomes of tracheostomized neurosurgical patients.

METHODS

All consecutive tracheostomized neurosurgical patients in the Prince of Wales Hospital between 1st September 2016 and 31st August 2019 were reviewed retrospectively. Patients were grouped into easy decannulation and difficult decannulation groups using 3 months as cut-off time. Risk factors were analysed and outcomes were compared.

RESULTS

One hundred thirty-one patients were included. In univariate analyses, male gender, GCS less than or equal to 8 on admission, the presence of vocal cord palsy at 3 months, and pneumonia within 1-month post-tracheostomy were associated with difficult decannulation. In multivariable logistic regression for difficult decannulation, GCS on admission, the presence of vocal cord palsy at 3 months, and the presence of pneumonia within 1-month post-tracheostomy remained statistically significant. The easy decannulation group had a shorter length of in-patient stay, higher survival rate, and more favourable neurological outcome (GOS 4-5) than the difficult decannulation group at both 6 months and 1 year. The majority of easy decannulation group patients (54%) were discharged to home, while the majority of the difficult decannulation group (42%) of patients were discharged to the infirmary.

CONCLUSION

GCS less than or equal to 8 on admission, the presence of vocal cord palsy, and the presence of pneumonia were associated with difficult tracheostomy decannulation in neurosurgical patients. Difficult decannulation is associated with a longer length of in-patient stay and poor neurological outcomes.

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

Impact of early versus late tracheostomy on patient outcomes in a tertiary care multispeciality ICU

Background and Aims:

Tracheostomy is a commonly performed procedure in critically ill patients because patients requiring chronic mechanical ventilation (MV) are rising by as much as 5.5% per year. The controversy on likely benefits of early versus late tracheostomy is ongoing. We aimed to study the impact of early versus late tracheostomy on patient outcomes.

Material and Methods:

A retrospective observational study was performed in intensive care unit (ICU) patients who underwent tracheostomy in a 31-bedded multispeciality ICU of a 350-bedded tertiary care hospital, over a period of 1 year. Data collected included the age, sex, APACHE II score, indication for tracheostomy, timing of procedure, whether surgical or percutaneous, any complication, MV days, ICU stay, and patient outcome. Patients were divided into two groups for statistical comparison: early ≤7 days and late >7 days of MV.

Results:

A total of 102 patients underwent tracheostomy over the study period, of which 19 were excluded because of inadequate data and exclusion criteria. Of the 83 study patients, 60 had percutaneous, while 23 had surgical tracheostomy. About 51 (61.45%) had early, while 32 (38.55%) had late tracheostomy. On statistical analysis, there was a significant difference in MV days (5 vs 12.5 days, P = 0.002), ICU stay (10 vs 16 days, P = 0.004), mortality (21.6% vs 43.8%, P = 0.032), and decannulation rate (29.41% vs 6.25%, P = 0.009). No difference was observed in hospital stay or complication rates.

Conclusion:

Early tracheostomy is associated with both morbidity and mortality benefits. Patients requiring MV should be given an option of early tracheostomy.

Current Status of Indications, Timing, Management, Complications, and Outcomes of Tracheostomy in Traumatic Brain Injury Patients

Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.

Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT)

Introduction

Tracheostomy is among the common procedures performed in the intensive care unit (ICU), with percutaneous dilatational tracheostomy (PDT) being the preferred technique. We sought to understand the current practice of tracheostomy in Indian ICUs.

Materials and methods

A pan-India multicenter prospective observational study, endorsed and peer-reviewed by the Indian Society of Critical Care Medicine (ISCCM), on various aspects of tracheostomy performed in critically ill patients was conducted between September 1, 2019 and December 31, 2019. The SPSS software was used for the statistical analysis. Cross tables were generated and the chi-square test was used for testing of association. The p value < 0.05 was considered statistically significant.

Results

Out of 67 ICUs that participated, 88.1% were from private sector hospitals. A total of 923 tracheostomies were performed during the study period; out of which, 666 were PDT and 257 were surgical tracheostomy (ST). Coagulopathic patients received more platelet transfusion [p = 0.037 with platelet count (PC) < 50 × 10⁹, p = 0.021 with PC 50–100 × 10⁹] and fresh frozen plasma transfusion in the ST group (p = 0.0001). The performance of PDT vs ST by day 7 of admission was 28.4% vs 21% (p = 0.023). The single dilator technique (60.4%) was the preferred technique for PDT followed by the Grigg's forceps and then the multiple dilator technique. Fiberoptic bronchoscope (FOB) and ultrasonography (USG) were used in 29.3% and 16.8%, respectively, for guidance during tracheostomy. Most of the PDTs were performed by a trained intensivist (74.2%), whereas ST was mostly done by an ENT surgeon (56.8%). Percutaneous dilatational tracheostomy resulted in less hemorrhagic (2.6% vs 7%, p = 0.002) and desaturation complications (2.3% vs 6.6%, p = 0.001) as compared to ST. The duration of procedure was shorter in the PDT group (average shortening by 9.2 minutes) and the ventilator-free days (VFD) were higher in the PDT group. The cost was less in PDT by approximately Rs. 13,104.

Conclusion

Percutaneous dilatational tracheostomy, especially the single dilator technique, is preferred by clinicians in Indian ICUs. The incidence of minor complications like hemorrhagic episodes is lower with PDT. Percutaneous dilatational tracheostomy was found to be cheaper on cost per patient basis as compared to ST (with or without complications).

How to cite this article

Gupta S, Tomar DS, Dixit S, Zirpe K, Choudhry D, Govil D, et al. Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study (DISSECT). Indian J Crit Care Med 2020;24(7):514–526.

Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations

BACKGROUND AND AIM

Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs.

MATERIALS AND METHODS

All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation.

RESULTS

After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity.

CONCLUSION

This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients.

HOW TO CITE THIS ARTICLE

Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31-S42.

The Outcome Analysis and Complication Rates of Tracheostomy Tube Insertion in Critically Ill Neurosurgical Patients; A Data Mining Study

Objectives:

To assess the impact, timing, the intra and early post-operative complications and the survival outcome of tracheostomy in critically ill neurosurgery patients.

Methods:

This study was a retrospective data mining where data was collected from hospital records from 175 consecutive patients who underwent tracheostomy in the department of Neurosurgery at the Narayna Medical College Hospital, Nellore, India from Jan 2016 to April 2018. A proforma was used to note down the details on the patient status before and after tracheostomy: Glasgow coma scale (GCS), procedure and intra and post-operative complications, type of tracheostomy cannula, details of decannulation, respiration difficulties, and problems with wound, swallowing difficulties, and voice difficulties, stay in intensive care unit (ICU) and hospital and survival status of the patient.

Results:

In our series, mean age of TBI cases was 47.42±16.62; mean hospital stay and ICU stay was 18.81±10.22 and 12.58±7.36 days respectively. In all age groups, more tracheostomy was needed in cranial injury cases and surgery was major intervention. Commoner complications were mucous deposition (6.86%), blockage of tracheostomy canula (6.29%), bleeding from multiple attempts (6.06%), excessive bleeding (2.94%). Cranial injury needed tracheostomy more in all age groups and more done at operation theatre without significant improvement of GCS score. Survival was statistically higher after tracheostomy irrespective of GCS status or venue of intervention.

Conclusion:

Tracheostomy should be considered as soon as the need for airway access is identified during intervention of the critically ill neurosurgical patients.

Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days

OBJECTIVES

To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy.

DESIGN

Retrospective cohort analysis.

SETTING

The Pediatric Trauma Quality Improvement Program (TQIP) database.

PATIENTS

One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups.

CONCLUSION

Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings.

ARTICLE TWEET

Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.

Changes in Swallowing and Cough Functions Among Stroke Patients Before and After Tracheostomy Decannulation

We investigated the functional changes in swallowing and voluntary coughing before and after tracheostomy decannulation among stroke patients who had undergone a tracheostomy. We also compared these functions between stroke patients who underwent tracheostomy tube removal and those who did not within 6 months of their stroke. Seventy-seven stroke patients who had undergone a tracheostomy were enrolled. All patients were evaluated by videofluoroscopic swallowing studies and a peak flow meter through the oral cavity serially until 6 months after their stroke. During the intensive rehabilitation period, if a patient satisfied the criteria for tracheostomy tube removal, the tube was removed. The patients were divided into the 'decannulated' group and the 'non-decannulated' group according to their tracheostomy tube removal status. In the decannulated group, swallowing function did not change before and after tracheostomy decannulation; however, cough function was significantly improved after decannulation. Although both groups exhibited functional improvement in swallowing and coughing over time, the improvement in the decannulated group was more significant than the improvement in the non-decannulated group. Our results revealed that stroke patients who had better functional improvement in swallowing and coughing were more likely to be potential candidates for tracheostomy decannulation. Stroke patients who recovered from neurogenic dysphagia, they were no longer affected by the mechanical effect of the tracheostomy tube on swallowing function. This study suggests that if patients show improvement in swallowing and coughing after their stroke, a multidisciplinary approach to tracheostomy decannulation would be needed to achieve better rehabilitation outcomes.

Speech and Swallowing Function Outcome Following Early Tracheostomy in Patients Who Underwent Neurosurgical Intervention

Background:

Evaluation of late-onset speech and swallowing complications of tracheostomy on neurotrauma cases, as the most common intensive care unit procedure, needs to be evaluated.

Objectives:

A prospective study conducted in a tertiary care teaching hospital to find the late-onset speech and swallowing complications of tracheostomy in neurotrauma cases.

Materials and Methods:

This prospective observational study was conducted in the intensive care unit on intubated patients needing elective tracheostomy at a tertiary care teaching institute in South India with a dedicated referral trauma center. A data collection tool was prepared to find age, gender, date of admission, tracheostomy, and discharge, contact address and number, initial and final diagnosis, initial Glasgow Coma Scale (GCS) on admission and subsequent GCS before and after tracheostomy, ventilator settings before and after the tracheostomy, procedure and intraoperative complications, type of cannula used, details of decannulation, and respiratory difficulties.

Results:

In our study among 69 cases between 16 and 75 years' age range with mean 46.67 ± 16.65, majority were males (75.36%) and 60 were cranial cases (86.96%). Of the alive cases (21 [30.43%]) who underwent tracheostomy; 18 were performed in operation theater and 3 as bedside procedure. Major problems reported were: Speech problems (not able to phonate) (9), feeble voice (6), pain while speaking (6), and reduced loudness (6), frequent throat clearing while speaking (4), cough while speaking (3); breathlessness while speaking (1), gasping while speaking (1) and vocal tiredness (1); aspirations (2) and painful swallowing (1).

Conclusions:

Our study suggested that though, majority of neurotrauma patients require tracheostomy for long term ventilator support and associated speech and swallowing problems are expected.