The ventilator liberation process: update on technique, timing, and termination of tracheostomy

Early Tracheostomy May Reduce the Length of Hospital Stay

Introduction

There is evidence that prolonged invasive mechanical ventilation has negative consequences for critically ill patients and that performing tracheostomy (TQT) could help to reduce these consequences. The ideal period for performing TQT is still not clear in the literature since few studies have compared clinical aspects between patients undergoing early or late TQT.

Objective

To compare the mortality rate, length of stay in the intensive care unit, length of hospital stay, and number of days free of mechanical ventilation in patients undergoing TQT before or after ten days of orotracheal intubation.

Methods

A retrospective cohort study carried out by collecting data from patients admitted to an intensive care unit between January 2008 and December 2017. Patients who underwent TQT were divided into an early TQT group (i.e., time to TQT ≤ 10 days) or late TQT (i.e., time to TQT > 10 days) and the clinical outcomes of the two groups were compared.

Results

Patients in the early TQT group had a shorter ICU stay than the late TQT group (19 ± 16 vs. 32 ± 22 days, p < 0.001), a shorter stay in the hospital (42 ± 32 vs. 52 ± 50 days, p < 0.001), a shorter duration of mechanical ventilation (17 ± 14 vs. 30 ± 18 days, p < 0.001), and a higher proportion of survivors in the ICU outcome (57% vs. 46%, p < 0.001).

Conclusion

Tracheostomy performed within 10 days of mechanical ventilation provides several benefits to the patient and should be considered by the multidisciplinary team as a part of their clinical practice.

A Holistic Approach to Managing Secondary Dysphagia Following Prolonged Intubation and Tracheostomy: A Case Report

The ability to swallow and maintain the airway is a critical rehabilitation milestone for patients with swallowing disorders following prolonged tracheal intubation. Tracheostomy and dysphagia often coexist in critically ill patients and given the medical complexity analyzing the evidence to optimize swallowing assessment and management is challenging. It takes a holistic approach to dealing with issues in a critical care patient as we also need to deal with issues other than medical. We present a case of a 68-year-old gentleman who was admitted to the critical care unit following a double barrel ileostomy and had multiple complications and organ dysfunction requiring prolonged supportive management, tracheostomy, and mechanical ventilation. After recovering from primary illness and complications, he had a swallowing disorder (secondary dysphagia), which was managed successfully over the next month. The case highlights the need for screening, a multidisciplinary team, empathy, and effort as a part of a holistic management approach.

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.

Tracheostomy in patients with SARS-CoV-2 reduces time on mechanical ventilation but not intensive care unit stay

Cross-sectional study to know if tracheostomy influences the time on mechanical ventilation and reduces the ICU stay in patients with SARS-CoV2. From February 14 to May 31, 2020, 29 patients: 23 men and 6 women, with an average age (SD) of 66.4 years (±6,2) required tracheostomy. The average intensive care unit (ICU) stay was 36 days [31–56.5]. The average days on mechanical ventilation was 28,5 days (±9.7). Mean time to tracheostomy was 15.2 days (±9.5) with an average disconnection time after procedure of 11.3 days (±7.4). The average hospital stay was 55 days [39–79]. A directly proportional relation between the number of days of MV and the number of days from ICU admission until tracheostomy showed a significant value of p = 0.008. For each day of delay in tracheostomy, the days of mechanical ventilation were increased by 0.6 days. There was no relation between days to tracheostomy and days to disconnection (p = 0.092). PaO2 / FiO2 (PAFI) before tracheostomy and Simplified Acute Physiology Score III (SAPS III) at admission presented a statistical relation with mortality, with an OR of 1.683 (95%CI; 0.926–2.351; p = 0.078) and an OR of 1.312 (CI95%: 1.011–1.703; p = 0.034) respectively. The length of stay in the ICU until the tracheostomy was not related to the risk of death (p = 0.682). PEEP and PaO2/FiO2 (PAFI) at admission and before tracheostomy and APACHE II, SAPS III and SOFA at admission did not show influence over time on MV. We conclude that the delay in tracheostomy increase the days on mechanical ventilation but does not influence stay or mortality.

[Endoscopy-assisted dilatational tracheostomy in patients with COVID-19]

OBJECTIVE

To summarize an experience of endoscopy-assisted dilatational tracheostomies in patients with COVID-19.

MATERIAL AND METHODS

There were 31 endoscopy-assisted dilatational tracheostomies in patients with COVID-19 for the period from April 17 to June 10, 2020 (11 women and 19 men). Mean age of patients was 66.7 years (range 48-87). Tracheostomy was performed using Ciaglia (22) and Griggs (9) techniques. All procedures were carried out at the intensive care unit in elective fashion.

RESULTS

Tracheostomy was performed in 19.8% of ICU patients or 36.9% of all patients on mechanical ventilation within 6.5±2.5 days [min 3, max 11]. There were 22 survivors with tracheostomy (70.9%) that is comparable with survival of patients without mechanical ventilation (79.7%) and slightly higher than in patients on ventilation without tracheostomy (65.4%). No complications during the procedure were noted.

CONCLUSION

Endoscopy-assisted dilatational tracheostomy is preferred for prolonged mechanical ventilation, including patients with COVID-19. The undeniable advantages of this operation are fewer intraoperative complications due to endoscopic control, and lower risk of tracheal strictures.

Machine Learning Methods to Predict Acute Respiratory Failure and Acute Respiratory Distress Syndrome

Acute respiratory failure (ARF) is a common problem in medicine that utilizes significant healthcare resources and is associated with high morbidity and mortality. Classification of acute respiratory failure is complicated, and it is often determined by the level of mechanical support that is required, or the discrepancy between oxygen supply and uptake. These phenotypes make acute respiratory failure a continuum of syndromes, rather than one homogenous disease process. Early recognition of the risk factors for new or worsening acute respiratory failure may prevent that process from occurring. Predictive analytical methods using machine learning leverage clinical data to provide an early warning for impending acute respiratory failure or its sequelae. The aims of this review are to summarize the current literature on ARF prediction, to describe accepted procedures and common machine learning tools for predictive tasks through the lens of ARF prediction, and to demonstrate the challenges and potential solutions for ARF prediction that can improve patient outcomes.

Tracheotomy, closure of long-term tracheostomy and standard tracheal segmental resections

Tracheotomy is a surgical procedure commonly employed to establish stable and long-term airway access. Iatrogenic airway injury post procedure may have serious consequences with limited treatment options. Tracheostoma or long standing tracheostomies require special closing techniques. Tracheotomies, tracheostomies, complications of these and treatment options, long standing tracheostomy closure techniques, and standard tracheal segmental resections are discussed.

Comparison of the efficacy of surgical tracheostomy and percutaneous dilatational tracheostomy with flexible lightwand and ultrasonography in geriatric intensive care patients

AIM

To compare the applicability, technical difficulties and postoperative complications of surgical tracheostomy and percutaneous dilatational tracheostomy with the flexible lightwand + ultrasonography method applied because of prolonged intubation to geriatric patients in the intensive care unit.

METHODS

A retrospective evaluation was made of 76 patients who received surgical tracheostomy (group 1) and 78 patients who received percutaneous dilatational tracheostomy (group 2). The patients were evaluated in respect of demographic data, duration of intubation, length of stay in the intensive care unit and discharge status, and after the intervention, the development of tube-related complications, early stage local complications and late-stage complications.

RESULTS

The time from intubation to tracheostomy was determined as 22.73 ± 15.23 days in group 1 and 12.65 ± 7.64 days in group 2. The mortality rate of patients in group 1 was determined to be statistically significantly higher than that of group 2 (P = 0.048). When evaluated in respect to early and late complications, nine early- and seven late-stage complications developed in group 1, and three early- and three late-stage complications developed in group 2 (P = 0.05). In the evaluation of factors related to mortality, the time from intubation to tracheostomy (r = 0.249, P = 0.01) and the presence of a comorbidity (r = 0.325, P = 0.004) were determined to have a positive correlation with the development of mortality.

CONCLUSION

Percutaneous dilatational tracheostomy with the flexible lightwand + ultrasonography technique is a safe, rapid and effective method with the advantage of management in respect to early complications, such as bleeding, and can be used safely in the geriatric patient population in intensive care conditions. Geriatr Gerontol Int 2020; ••: ••-••.

The impact of tracheotomy timing in critically ill patients undergoing mechanical ventilation: A meta-analysis of randomized controlled clinical trials with trial sequential analysis

BACKGROUND

The optimal timing of tracheotomy in critically ill ventilated patients remains controversial.

OBJECTIVES

The objective of this meta-analysis was to assess tracheotomy timing for critically ill ventilated patients and determine the outcomes' reliability.

METHODS

We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials.

RESULTS

Compared with late tracheotomy, early tracheotomy presented a lower incidence of ventilator-associated pneumonia (VAP), shorter duration of mechanical ventilation (MV), and shorter intensive care unit (ICU) stay. However, trial sequential analysis (TSA), a kind of cumulative meta-analysis, indicated that the evidence was unreliable and inconclusive.

CONCLUSIONS

The Findings suggest that early tracheotomy seems to be associated with a lower incidence of VAP, shorter duration of MV, shorter duration of sedation, and shorter ICU stay. However, the apparent benefits revealed in traditional meta-analysis contrast with the post-TSA results. More fully powered, randomized controlled trials focused on the outcomes of tracheotomy are highly warranted.

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.

Respiratory muscle strength and state of consciousness values measured prior to the decannulation in different levels of complexity. A longitudinal prospective case series study

OBJECTIVE

To describe the variables related to effective cough capacity and the state of consciousness measured prior to decannulation and compare their measured values between the different areas of care such as the Intensive Care Unit (ICU), General ward and Mechanical Ventilation Weaning and Rehabilitation Centers (MVWRC). Secondarily analyze the evolution of patients once decannulated.

DESIGN

Case series, longitudinal and prospective.

SCOPE

Multicentric 31 ICUs (polyvalent) and 5 MVWRC.

PATIENTS

Tracheostomized adults prior to decannulation.

MEASUREMENTS

Maximum expiratory pressure, peak expiratory flow coughed (PEFC), Glasgow Coma Scale (GCS).

RESULTS

Two hundred and seven decannulated patients, 124 (60%) in ICU, 59 (28%) General ward and 24 (12%) in MVWRC. The PEFC presented differences between the patients (ICU 110 - 190 l/min versus MVWRC 167.5 - 232.5 l/min, p <.01). The GCS was different between General ward (9 -15) versus ICU (10-15) and MVWRC (12-15); p <.01 and p <.01, respectively. There were differences in the days of hospitalization (p <.01), days with tracheostomy (<0.01) and the number of patients referred at home (p =.02) between the different scenarios.

CONCLUSION

There are differences in the values of PEFC and GCS observed when decannulating between different areas. A considerable number of patients are decannulated with values of PEFC and maximum expiratory pressure below the suggested cut-off points as predictors of failure in the literature. No patient in our series was decanulated with an GCS <8, this reflects the importance that the treating team gives to the state of consciousness prior to decannulation.

Tracheostomy Tube Placement: Early and Late Complications

Tracheostomy tube placement is a therapeutic procedure that has gained increased favor over the past decade. Upper airway obstructions, failure to liberate from the ventilator, and debilitating neurological conditions are only a few indications for tracheostomy tube placement. Tracheostomy tubes can be placed either surgically or percutaneously. A percutaneous approach offers fewer surgical site infections and postsurgical bleeding than a surgical approach. A surgical placement posses a lower risk of injury to the posterior tracheal wall and spontaneous decannulation is less common. Late complications of both approaches include stenosis, malacia, along with tracheoesophageal, tracheoinnominate, and tracheocutaneous fistulas. This review describes the indications and methods of placement of tracheostomy tubes along with early and late complications that may occur following placement.

Tracheostomy in the Intensive Care Unit: a University Hospital in a Developing Country Study

Introduction Tracheostomy is the commonest surgical procedure in intensive care units (ICUs). It not only provides stable airway and facilitates pulmonary toilet and ventilator weaning, but also decreases the direct laryngeal injury of endotracheal intubation, and improves patient comfort and daily living activity.

Objective The objective of this study is to assess the incidence, indications, timing, complications (early and late), and the outcome of tracheostomy on patients in the intensive care units (ICU) at a university hospital in a developing country.

Methods This study is an observational prospective study. It was performed at the otolaryngology department and ICU new surgery hospital on 124 ICU admitted patients. We collected patients' demographic records, cause of admission, indications of tracheostomy, mechanical ventilation, and duration of ICU stay. We also gathered patientś tracheostomy records including the incidence, timing, technique, type, early and late complications, and outcome. All tracheostomized patients received follow-up for 12 months.

Results The indication for tracheostomy in ICU patients was mostly prolonged intubation (80.5%), followed by diaphragmatic paralysis (19.5%). All tracheostomies were done by the open approach technique. Tracheostomy for prolonged intubation was done within 17 to 26 days after intubation with a mean of 19.4 ± 2.07 days. Complications after tracheostomy were 13.9% tracheal stenosis and 25% subglottic stenosis.

Conclusion Prolonged endotracheal intubation is the man indication of tracheostomy, performed after two weeks of intubation. Although there were no major early complications, laryngotracheal stenosis is still a challenging sequel for tracheostomy that needs to be investigated to be prevented.

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.

Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials

Introduction

The optimal timing of tracheotomy in critically ill patients remains a topic of debate. We performed a systematic review to clarify the potential benefits of early versus late tracheotomy.

Methods

We searched PubMed and CENTRAL for randomized controlled trials that compared outcomes in patients managed with early and late tracheotomy. A random-effects meta-analysis, combining data from three a priori-defined categories of timing of tracheotomy (within 4 versus after 10 days, within 4 versus after 5 days, within 10 versus after 10 days), was performed to estimate the weighted mean difference (WMD) or odds ratio (OR).

Results

Of the 142 studies identified in the search, 12, including a total of 2,689 patients, met the inclusion criteria. The tracheotomy rate was significantly higher with early than with late tracheotomy (87 % versus 53 %, OR 16.1 (5.7-45.7); p <0.01). Early tracheotomy was associated with more ventilator-free days (WMD 2.12 (0.94, 3.30), p <0.01), a shorter ICU stay (WMD -5.14 (-9.99, -0.28), p = 0.04), a shorter duration of sedation (WMD -5.07 (-10.03, -0.10), p <0.05) and reduced long-term mortality (OR 0.83 (0.69-0.99), p = 0.04) than late tracheotomy.

Conclusions

This updated meta-analysis reveals that early tracheotomy is associated with higher tracheotomy rates and better outcomes, including more ventilator-free days, shorter ICU stays, less sedation, and reduced long-term mortality, compared to late tracheotomy.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1138-8) contains supplementary material, which is available to authorized users.

Swallowing disorders in tracheostomised patients: a multidisciplinary/multiprofessional approach in decannulation protocols

Safe removal of tracheal cannula is a major goal in the rehabilitation of tracheostomised patients to achieve progressive independence from mechanical support and reduce the risk of respiratory complications. A tracheal cannula may also cause significant discomfort to the patient, making verbal communication difficult. Particularly when cuffed, tracheal cannula reduces the normal movement of the larynx which can further compromise the basic swallowing defect. A close connection between respiratory, phonating, swallowing and feeding abilities to be recovered, implies a strict integration among different professionals of the rehabilitation team. An appropriate management of tracheostomy cannula is closely connected with assessment and treatment of swallowing disorders in order to limit the development of severe pulmonary and nutritional complications, but at present there are no uniform protocols in the scientific literature. Furthermore, several studies report as an essential criterion for decannulation the presence of good patient consciousness, which is often altered in patients with tracheostomy, but a general agreement is lacking.

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.