A Novel COVID-19 Severity Score is Associated With Survival in Patients Undergoing Percutaneous Dilational Tracheostomy

INTRODUCTION

Tracheostomy in patients with COVID-19 is a controversial and difficult clinical decision. We hypothesized that a recently validated COVID-19 Severity Score (CSS) would be associated with survival in patients considered for tracheostomy.

METHODS

We reviewed 77 mechanically ventilated COVID-19 patients evaluated for decision for percutaneous dilational tracheostomy (PDT) from March to June 2020 at a public tertiary care center. Decision for PDT was based on clinical judgment of the screening surgeons. The CSS was retrospectively calculated using mean biomarker values from admission to time of PDT consult. Our primary outcome was survival to discharge, and all patient charts were reviewed through August 31, 2021. ROC curve and Youden index were used to estimate an optimal cut-point for survival.

RESULTS

The mean CSS for 42 survivors significantly differed from that of 35 nonsurvivors (CSS 52 versus 66, P = 0.003). The Youden index returned an optimal CSS of 55 (95% confidence interval 43-72), which was associated with a sensitivity of 0.8 and a specificity of 0.6. The median CSS was 40 (interquartile range 27, 49) in the lower CSS (<55) group and 72 (interquartile range 66, 93) in the high CSS (≥55 group). Eighty-seven percent of lower CSS patients underwent PDT, with 74% survival, whereas 61% of high CSS patients underwent PDT, with only 41% surviving. Patients with high CSS had 77% lower odds of survival (odds ratio = 0.2, 95% confidence interval 0.1-0.7).

CONCLUSIONS

Higher CSS was associated with decreased survival in patients evaluated for PDT, with a score ≥55 predictive of mortality. The novel CSS may be a useful adjunct in determining which COVID-19 patients will benefit from tracheostomy. Further prospective validation of this tool is warranted.

A clinical retrospective study of percutaneous dilatational tracheostomy without guide wire for critically ill patients

OBJECTIVE

This study aimed to introduce a novel tracheostomy method, the non-guide-wire percutaneous dilatational tracheostomy (NGPDT) technique, and evaluate its effectiveness for critically ill patients undergoing neurosurgery under special conditions.

METHODS

The clinical data of 48 critically ill patients who underwent NGPDT under special conditions with controlled steps were analyzed retrospectively. The patients' demographic, preoperative state of illness, and diagnosis data were collected. Moreover, their intraoperative and postoperative variables were accessed, e.g., operation times, bleeding, saturation of pulse oxygen (SPO₂), and early and late complications related to NGPDT.

RESULTS

The mean patient age was 47.7 ± 13.7 years. The mean GCS (Glasgow Coma Scale) was 8.1 ± 2.9, and the mean BMI (Body Mass Index) was 25.2 ± 5.6. There were 38 patients with an endotracheal tube. The mean duration of onset to NGPDT was 4.0 ± 1.3 days. The mean operation time was 4.2 ± 1.9 min. There were 41 patients with mild intraoperative bleeding, 5 with moderate bleeding, and 2 with severe bleeding as well as 46 with mild postoperative bleeding and 2 with moderate bleeding. Additionally, 41 patients required complete extubation after NGPDT. The mean duration of incision healing was 4.8 ± 3.1 days. There was 1 patient with a decrease of SPO₂ ≥ 10%. Three patients presented with a transient violent cough at the primary tracheostomy stage; however, no patients suffered from pneumothorax, subcutaneous emphysema, false passage, or surgery-related death during this procedure.

CONCLUSION

Overall, NGPDT with controlled steps is a fast, safe, and microinvasive procedure. It mildly stimulates the trachea with a low rate of complications.

Early Percutaneous Dilational Tracheostomy in Trauma Patients After Anterior Cervical Fusion: Propensity-Matched Cohort Study

BACKGROUND

Patients with cervical spinal cord injuries (CSCIs) may be required to undergo tracheostomy. However, in patients undergoing anterior cervical fusion (ACF), percutaneous dilational tracheostomy (PDT) may be delayed given the risk of cross-contamination. We aimed to evaluate the risk of surgical site infection (SSI) in early PDT in patients with traumatic CSCI after ACF.

METHODS

All trauma patients admitted to the intensive care unit from 2008 to 2018 were retrospectively analyzed. Patients with CSCIs who underwent both ACF and PDT were identified, with or without posterior cervical fusion. Cases were classified as having undergone early PDT (≤4 days after ACF) versus late PDT (>4 days after ACF). Propensity scores were matched, and outcomes were compared between matched groups to reduce confounding by indication.

RESULTS

From a total of 133 enrolled patients, a well-balanced propensity-matched cohort of 68 patients was defined. On the basis of the comparison of outcomes after matching, no significant difference in SSI was observed between both groups. There was no patient with SSI in the early PDT group (0%), whereas there were 2 SSI patients (5.9%) in the late PDT group (P = 0.493): The tracheostomy site was involved in 1, and the posterior approach site was involved in the other. Early PDT was associated with a shorter duration of mechanical ventilation (P = 0.042). There were no significant differences in the length of intensive care unit stay and hospital mortality between groups.

CONCLUSIONS

Early PDT within 4 days after ACF did not increase the risk of SSI compared with late PDT in patients with traumatic CSCIs.

Application Value of Minimally Invasive Percutaneous Dilational Tracheostomy for ICU Critical Patients

Objective:

To find out the application value of minimally invasive percutaneous dilational tracheostomy in critically ill patients in intensive care unit (ICU).

Methods:

One hundred and forty critically ill patients who underwent tracheostomy in ICU of our hospital were included in the study from August 2016 to December 2017. They were divided into an observation group and a control group by random number table method, 70 in each group. The control group received conventional tracheotomy, while the observation group received percutaneous dilational tracheostomy. The operation time, incision length, amount of intraoperative bleeding and healing time of incision were compared between the two groups, and the changes of vital signs and complications after operation were recorded. The family members of the patients signed the informed consent.

Results:

The operation time, healing time and incision length of the observation group were (9.92±4.13) min, (1.31±0.21) cm and (6.91±0.72) d respectively, shorter than (24.09±6.82) min, (3.40±0.65) cm and (67.48±0.61) d in the control group, and the differences were statistically significant (P<0.05). The amount of intraoperative bleeding of the observation group was (7.81±1.83) mL, less than (16.34±2.83) mL in the control group; the difference was statistically significant (P<0.05). The heart rate and oxygen saturation of the observation group before and during the operation were not significantly different (P>0.05). The heart rate of the control group during the operation was significantly higher than that before the operation (P<0.05); the oxygen saturation of the control group before and during the operation had no significant difference (P>0.05). The incidence of complications in the observation group was 24.3%, which was significantly lower than that in the control group (55.7%, X²=8.279, P=0.014).

Conclusion:

Minimally invasive percutaneous dilational tracheostomy has advantages of small trauma, less infection and beautiful incision, and it will not increase postoperative complications. It is of great value in the treatment of ICU critical patients.

Antiplatelet agents and anticoagulants increased the bleeding risk of bedside percutaneous dilational tracheostomy in critically ill patients

BACKGROUND

The main objective of this study was to investigate the safety of bedside percutaneous dilational tracheostomy (PDT) by pulmonologists in critically ill patients, and the factors associated with complications resulting from PDT.

METHODS

We retrospectively enrolled critically ill patients who had undergone bedside PDT in the intensive care units (ICUs) and respiratory care center from February 2016 to December 2018.

RESULTS

A total of 312 patients were included for analysis, with a mean age of 69.6 ± 17.7 years. Two hundred and eight of the patients were male (66.7%). The mean acute physiology and chronic health evaluation II score was 25.3 ± 6.3, and the mean body mass index was 22.4 ± 4.2. Most of the patients were intubated due to respiratory disorders (51.3%). Fifty-six patients (17.9%) received antiplatelet agents or an anticoagulant regularly prior to PDT. All enrolled patients were undergone bedside PDT successfully. The total complication rate of PDT was 14.4%. Patients who took antiplatelet agents or anticoagulants regularly before PDT had a higher risk of bleeding than patients who went without (26.8% versus 7.0%, adjusted odds ratio 4.93 [95% f 2.16-11.25], p < 0.001). Finally, a longer length of intubation resulted in a higher probability in the length of ICU stay being ≧28 days (adjusted odds ratio 1.11 [95% CI 1.08-1.14], p < 0.001).

CONCLUSION

Our study demonstrated that it was feasible for pulmonologists to perform bedside PDT in critically ill patients. However, antiplatelet agents and anticoagulants use increased the risk of bleeding in PDT patients.

Percutaneous Dilational Tracheostomy

Tracheostomy tubes can be inserted surgically or percutaneously via percutaneous dilational tracheostomy (PDT). Tracheostomy is performed for upper airway obstruction, though more often to allow prolonged mechanical ventilation in place of endotracheal tubes. Preparation, performance, and postoperative management for PDT are best provided by a multidisciplinary team. Although PDT is a safe procedure in the hands of experienced operators, both early and late complications can arise. Caution must also be taken during early tracheostomy tube exchange given that immaturity of the stomal tract can risk loss of the airway.

Tracheostomy Update: When and How

Tracheostomy remains one of the most commonly performed surgical procedures in the setting of acute respiratory failure. Tracheostomy literature focuses on 2 aspects of this procedure: when (timing) and how (technique). Recent trials have failed to demonstrate an effect of tracheostomy timing on most clinically important endpoints. Nonetheless, relative to continued translaryngeal intubation, studies suggest that tracheostomy use is associated with less need for sedation and enhanced patient comfort. Evidence likewise suggests that percutaneous dilational tracheostomy is advantageous with respect to cost and complication profile and should be considered the preferred approach in appropriately selected patients.

The role of cricothyrotomy, tracheostomy, and percutaneous tracheostomy in airway management

Cricothyrotomy, percutaneous dilation tracheostomy, and surgical tracheostomy are cost-effective and safe techniques employed in the management of critically ill patients requiring insertion of an artificial airway. These procedures have been well characterized and studied in the surgical, emergency medicine, and critical care literature. This article focuses on the role of each of these modalities in airway management, specifically comparing the data for each procedure in regard to procedural outcomes. The authors discuss the techniques available and the relevant background data regarding choice of each method and its integration into clinical practice.

Percutaneous dilational tracheostomy

Tracheostomy is a commonly performed intervention with several benefits in the treatment of patients with chronic respiratory failure. Percutaneous dilational tracheostomy techniques have allowed bedside tracheostomy placement in the modern intensive care unit. Percutaneous dilational tracheostomy can be safely performed by interventional pulmonologists, medical intensive care physicians, and surgical specialists. When performed with the assistance of adjuncts, such as flexible bronchoscopy, the percutaneous dilational method has a favorable complication rate, efficiency, and cost profile compared with surgical tracheostomy.