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Evers JM, Minton LA, Webb C, Taylor RM, York NL. Care of the Patient With an Artificial Airway. Dimens Crit Care Nurs 2024; 43:202-211. [PMID: 38787776 DOI: 10.1097/dcc.0000000000000648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Artificial airways are essential in various clinical settings to maintain a patient's airway and provide necessary support for ventilation and oxygenation. These devices are commonly temporary and come in several types, each serving specific purposes. Understanding the indications, types, and proper care of artificial airways is crucial for health care professionals to ensure patients receive optimal care and prevent complications. OBJECTIVE This article aims to review the indications for using artificial airways and discuss the most commonly used types, including supraglottic airway devices, endotracheal tubes, tracheostomy tubes, and laryngectomy tubes. It also provides insights into the procedures involved in intubation and percutaneous tracheostomy and offers guidance on patient management, emphasizing assessment, oral care, suctioning, and humidification for patients with these airway devices. CONCLUSION This article underscores the significance of understanding artificial airways, not just as a set of skills but as a commitment to patient welfare. Health care professionals who master the knowledge and care of these devices can significantly contribute to their patients' well-being and quality of life.
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Charland N, Chervu N, Mallick S, Le N, Curry J, Vadlakonda A, Benharash P. Impact of Early Tracheostomy After Lung Transplantation: A National Analysis. Ann Thorac Surg 2024; 117:1212-1218. [PMID: 38360346 DOI: 10.1016/j.athoracsur.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/04/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Prolonged mechanical ventilation is common among lung transplant recipients, affecting nearly one-third of patients. Tracheostomy has been shown as a beneficial alternative to endotracheal intubation, but delays in tracheostomy tube placement persist. To date, no large-scale study has investigated the effect of tracheostomy timing on posttransplant outcomes. METHODS All adults receiving tracheostomy after primary, isolated lung transplantation were identified in the 2016 to 2020 Nationwide Readmissions Database. Early tracheostomy was defined as placement before postoperative day 8 based on exploratory cohort analysis. Multivariable regression was used to evaluate the association of early tracheostomy with in-hospital mortality, select posttransplant complications, and resource utilization. RESULTS Of an estimated 11,048 patients undergoing first-time lung transplantation, 1509 required a tracheostomy in the postoperative period, with 783 (51.9%) comprising the early cohort. After entropy balancing and risk adjustment, early tracheostomy placement was associated with reduced odds of death (adjusted odds ratio, 0.59; 95% CI, 0.36-0.97) and posttransplant infection (adjusted odds ratio, 0.54; 95% CI, 0.35-0.82). Further, tracheostomy within 1 week of transplantation was associated with decreased length of stay (β-coefficient, -16.5 days; 95% CI, -25.3 to -7.6 days) and index hospitalization costs (β-coefficient, -$97,600; 95% CI, -$153,000 to -$42,100). CONCLUSIONS The present study supports the safety of early tracheostomy among lung transplant recipients and highlights several potential benefits. Among appropriately selected patients, tracheostomy placement before postoperative day 8 may facilitate early discharge, lower costs, and reduced odds of posttransplant infection.
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Affiliation(s)
- Nicole Charland
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California
| | - Nguyen Le
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California.
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Flores Palacios RJ, Hueda Zavaleta M, Gutiérrez Avila AG, Gómez de la Torre JC, Benites Zapata VA. Characteristics and factors associated with mortality in tracheostomized patients with COVID-19: a retrospective cohort study in a hospital in Tacna, Peru. Rev Peru Med Exp Salud Publica 2024; 40:441-450. [PMID: 38597472 PMCID: PMC11138828 DOI: 10.17843/rpmesp.2023.404.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 10/18/2023] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVE We aimed to describe the main demographic, clinical, laboratory and therapeutic characteristics and to identify whether they are associated with mortality in tracheostomized patients. MATERIAL AND METHODS. Retrospective cohort study in adult patients diagnosed with COVID-19, admitted to ICU (Intensive Care Unit) and requiring tracheostomy. Demographic, clinical, laboratory and treatment data were obtained from the medical records of patients admitted to Hospital III Daniel Alcides Carrión in Tacna. The Cox proportional hazards model was used for survival analysis and hazard ratios (HR) with their 95% confidence intervals (95%CI) were calculated. RESULTS. We evaluated 73 patients, 72.6% were men, the most common comorbidities were obesity (68.5%), type 2 diabetes mellitus (35.6%), and arterial hypertension (34.2%). Thirty-seven percent of the participants died during their stay at the ICU. The median time from intubation to tracheostomy and the duration of tracheostomy was 17 (RIC: 15-21) and 21 (RIC: 3-39) days, respectively. Multivariate analysis showed that the factors associated with mortality were procalcitonin > 0.50 ng/dL at the time of tracheostomy (HRa: 2.40 95%CI: 1.03-5.59) and a PaO2/FiO2 ratio less than or equal to 150 mmHg (HRa: 4.44 95%CI: 1.56-12.60). CONCLUSIONS. The factors associated with mortality at the time of tracheostomy were procalcitonin > 0.50 ng/dL and a PaO2/FiO2 ratio less than or equal to 150 mmHg.
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Affiliation(s)
| | - Miguel Hueda Zavaleta
- Hospital III Daniel Alcides Carrión, Tacna, Perú
- Diagnóstico, tratamiento e investigación de enfermedades infecciosas y tropicales, Universidad Privada de Tacna, Tacna, Perú
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Patel D, Devivo A, Leibner E, Shittu A, Govindarajulu U, Tandon P, Lee D, Owen R, Fernandez-Ranvier G, Hiensch R, Marin M, Kohli-Seth R, Bassily-Marcus A. The COVID-19 Tracheostomy Experience at a Large Academic Medical Center in New York during the First Year. J Clin Med 2024; 13:2130. [PMID: 38610895 PMCID: PMC11012500 DOI: 10.3390/jcm13072130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Background: New York City was the epicenter of the initial surge of the COVID-19 pandemic in the United States. Tracheostomy is a critical procedure in the care of patients with COVID-19. We hypothesized that early tracheostomy would decrease the length of time on sedation, time on mechanical ventilation, intensive care unit length of stay, and mortality. Methods: A retrospective analysis of outcomes for all patients with COVID-19 who underwent tracheostomy during the first year of the COVID-19 pandemic at the Mount Sinai Hospital in New York City, New York. All adult intensive care units at the Mount Sinai Hospital, New York. Patients/subjects: 888 patients admitted to intensive care with COVID-19. Results: All patients admitted to the intensive care unit with COVID-19 (888) from 1 March 2020 to 1 March 2021 were analyzed and separated further into those intubated (544) and those requiring tracheostomy (177). Of those receiving tracheostomy, outcomes were analyzed for early (≤12 days) or late (>12 days) tracheostomy. Demographics, medical history, laboratory values, type of oxygen and ventilatory support, and clinical outcomes were recorded and analyzed. Conclusions: Early tracheostomy resulted in reduced duration of mechanical ventilation, reduced hospital length of stay, and reduced intensive care unit length of stay in patients admitted to the intensive care unit with COVID-19. There was no effect on overall mortality.
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Affiliation(s)
- Dhruv Patel
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Anthony Devivo
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Evan Leibner
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Atinuke Shittu
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
| | - Usha Govindarajulu
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Pranai Tandon
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David Lee
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Randall Owen
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | | | - Robert Hiensch
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Michael Marin
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Roopa Kohli-Seth
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Adel Bassily-Marcus
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.P.); (A.D.); (A.B.-M.)
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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5
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Rose L, Messer B. Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy. Crit Care Clin 2024; 40:409-427. [PMID: 38432703 DOI: 10.1016/j.ccc.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, London SE1 8WA, UK; Department of Critical Care and Lane Fox Unit, Guy's & St Thomas' NHS Foundation Trust, King's College London, 57 Waterloo Road, London SE1 8WA, UK.
| | - Ben Messer
- Royal Victoria Infirmary, Newcastle-Upon-Tyne NHS Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Zimmerman FS, Shaul C, Helviz Y, Levin PD. The Effect of Delay Following the Clinical Decision to Perform Tracheostomy in the Critical Care Setting. Respir Care 2024; 69:463-469. [PMID: 38538025 PMCID: PMC11108110 DOI: 10.4187/respcare.10916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
BACKGROUND Tracheostomy in patients who are critically ill is generally performed due to prolonged mechanical ventilation and expected extubation failure. However, tracheostomy criteria and ideal timing are poorly defined, including equivocal data from randomized controlled trials and median intubation to tracheostomy times that range from 7-21 d. However, a consistent finding is that only ∼50% of late tracheostomy groups actually undergo tracheostomy, with non-performance due to recovery or clinical deterioration. Unlike in many jurisdictions, elective surgical procedures in our institution require a court-appointed guardian, which necessitates an approximately 1-week delay between the decision to perform tracheostomy and surgery. This offers a unique opportunity to observe patients with potential tracheostomy during a delay between the decision and the performance. METHODS ICU patients who were ventilated were identified for inclusion retrospectively by an application for guardianship relating to tracheostomy, the intention-to-treat point. The main outcomes of tracheostomy, extubation, or death/palliative care after inclusion were noted. Demographics, outcomes, and event timing were compared for the 3 outcome groups. RESULTS Tracheostomy-related guardianship requests were made for 388 subjects. Of these, 195 (50%) underwent tracheostomy, whereas 127 (33%) were extubated and 66 (17%) either died before tracheostomy (46 [12%]) or were transitioned to palliative care (20 [5%]). The median time (interquartile range) from guardianship request until a defining event was the following: 6.2 (4.0-11) d for tracheostomy, 5.0 (2.9-8.2) d for extubation (P < .001 as compared to tracheostomy group), and 6.5 (2.5-11) d for death/palliative care (P = .55 as compared to tracheostomy). Neurological admissions were more common in the tracheostomy group and less common in the palliative group. Other admission demographics and hospitalization characteristics were similar. Hospital mortality was higher for subjects undergoing tracheostomy (58/195 [30%]) versus extubation (24/127 [19%]) (P = .03). CONCLUSIONS Delay in performing tracheostomy due to legal requirements was associated with a 50% decrease in the need for tracheostomy. This suggests that decision-making with regard to ideal tracheostomy timing could be improved, saving unnecessary procedures.
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Affiliation(s)
- Frederic S Zimmerman
- Drs Zimmerman, Helviz, and Levin are affiliated with the Critical Care Unit, Shaare Zedek Medical Center, Jeusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel. Dr Shaul is affiliated with the Department of Otolaryngology and Head and Neck Surgery, Shaare Zedek Medical Center, Jerusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel.
| | - Chanan Shaul
- Drs Zimmerman, Helviz, and Levin are affiliated with the Critical Care Unit, Shaare Zedek Medical Center, Jeusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel. Dr Shaul is affiliated with the Department of Otolaryngology and Head and Neck Surgery, Shaare Zedek Medical Center, Jerusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Yigal Helviz
- Drs Zimmerman, Helviz, and Levin are affiliated with the Critical Care Unit, Shaare Zedek Medical Center, Jeusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel. Dr Shaul is affiliated with the Department of Otolaryngology and Head and Neck Surgery, Shaare Zedek Medical Center, Jerusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Phillip D Levin
- Drs Zimmerman, Helviz, and Levin are affiliated with the Critical Care Unit, Shaare Zedek Medical Center, Jeusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel. Dr Shaul is affiliated with the Department of Otolaryngology and Head and Neck Surgery, Shaare Zedek Medical Center, Jerusalem, Israel and with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Dolinay T, Hsu L, Maller A, Walsh BC, Szűcs A, Jerng JS, Jun D. Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review. J Clin Med 2024; 13:1909. [PMID: 38610674 PMCID: PMC11012923 DOI: 10.3390/jcm13071909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.
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Affiliation(s)
- Tamás Dolinay
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Lillian Hsu
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Abigail Maller
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Brandon Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Department of Medicine, Division of Palliative Care Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Attila Szűcs
- Department of Anesthesiology, András Jósa County Hospital, 4400 Nyíregyháza, Hungary;
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Dale Jun
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA
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Blackwell T, Alvi S, Curran NR, Germanwala A. Impact of Tracheostomy Timing Within the National Veterans Affairs Population. Laryngoscope 2024. [PMID: 38501701 DOI: 10.1002/lary.31397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/25/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE There is a lack of a definitive study in the literature comparing early versus late tracheostomy and exploring the impact of tracheostomy timing on patient outcomes. This study may help guide treatment paradigms and contribute to a consensus for optimal tracheostomy timing. METHODS A retrospective review was performed comparing early versus late timing of tracheostomy placement and their respective outcomes. The authors used data provided by VA Informatics and Computing Infrastructure (VINCI) to find patients who received a tracheostomy at any VA Medical Center in the United States. There were a total of 25,334 tracheostomies in the database which satisfied our criteria. These occurred between the years 1999 and 2022. Propensity score matching assessed 17,074 tracheostomies, 8537 in either group. The median age of patients in the matched groups was 66 years, and approximately 97.4% of patients were male. Early tracheostomy timing was defined as the placement of the tracheostomy within 10 days of intubation. Outcomes included post-tracheostomy intensive care unit (ICU) days, post-tracheostomy hospital days, successful ventilator weaning, and all-cause mortality. RESULTS Early tracheostomy was associated with significantly fewer ICU days and hospital days, and the early group experienced higher rates of successful ventilator weaning. Survival analysis of data within 5 years of tracheostomy showed that early tracheostomy was associated with significantly lower hazard for all-cause mortality. CONCLUSION Our results add to the body of evidence that an earlier transition to mechanical ventilation by tracheostomy confers benefits in patient morbidity and mortality as well as resource utilization. LEVEL OF EVIDENCE 3 Laryngoscope, 2024.
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Affiliation(s)
- Thomas Blackwell
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Suffia Alvi
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | | | - Arpita Germanwala
- Otolaryngology Section, Department of Surgery, Jesse Brown VA Medical Center, Chicago, Illinois, USA
- Department of Otolaryngology, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
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Asi K, Gorelik D, Syed T, Thekdi A, Yiu Y. Outcomes for COVID-19 Patients Undergoing Tracheostomy With or Without Extracorporeal Membrane Oxygenation (ECMO). Cureus 2024; 16:e55750. [PMID: 38586787 PMCID: PMC10998924 DOI: 10.7759/cureus.55750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19) pandemic led to the more common use of venovenous (VV) extracorporeal membrane oxygenation (ECMO) for adults with acute respiratory distress syndrome (ARDS). While tracheostomy is generally understood to decrease the risks of prolonged endotracheal intubation, there is conflicting data regarding the benefit of tracheostomy in patients on ECMO. The purpose of this study is to determine whether ECMO cannulation before tracheostomy impacted patient outcomes. Methods This is a retrospective chart review of patients who underwent tracheostomy for COVID-19-related ARDS at a tertiary academic center from March 2020 through March 2022. Patients were separated into two groups based on whether they were cannulated for ECMO prior to tracheostomy. Fisher's exact test or Wilcoxon rank sum test was used to compare the two groups. Results A total of 24 patients were included in the study, with 13 in the ECMO group and 11 in the non-ECMO group. There was no significant difference in age, comorbidities, race, or gender between the groups. Patients on ECMO had a longer time from admission to intubation (seven days vs. three days, p=.002), were more likely to have multiple intubations (54% vs 9%, p= .033), had increased rates of postoperative bleeding (62% vs. 18%, p = .047), and had a higher mortality rate (39% vs. 0%, p= .041). Conclusions ECMO cannulation prior to tracheostomy for COVID-19-related ARDS is associated with poorer outcomes. It is unclear whether this is related to a more severe disease burden in these patients. Further study is needed to evaluate this and guide future management.
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Affiliation(s)
- Karim Asi
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School at UTHealth Houston, Houston, USA
| | - Daniel Gorelik
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
| | - Tariq Syed
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
| | - Apurva Thekdi
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
| | - Yin Yiu
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
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10
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Towning R, Rennie C, Ferguson M. Multidisciplinary Simulation Training for Surgical Tracheostomy in Patients Mechanically Ventilated Secondary to Severe Acute Respiratory Syndrome Coronavirus 2. EAR, NOSE & THROAT JOURNAL 2024; 103:NP89-NP97. [PMID: 34427150 DOI: 10.1177/01455613211042119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE A proportion of patients with coronavirus disease (COVID) and severe respiratory manifestations of disease will require admission to intensive care for intubation and ventilation. When anticipating prolonged ventilation, the patient may proceed to surgical tracheostomy to afford safe respiratory wean. As surgical tracheostomy is an aerosol-generating procedure, it poses a high risk of viral transmission and ultimately may prompt anxiety and caution in participating staff members. We aimed to mitigate these risks by providing staff with appropriate training and experience, to improve their confidence as well as practical ability. METHODS We developed a multidisciplinary simulation training experience and checklist in order to optimize team performance during the high-stakes procedure. We evaluated staff confidence before and after the training with questionnaires. RESULTS Post-simulation, surgeons were more confident with donning the high level personal protective equipment, and nurses were more confident in performing their role. CONCLUSIONS Simulation allows the multidisciplinary team an opportunity to practice high-risk procedures and prompts the team to assess staff knowledge base, troubleshoot queries, and teach roles and responsibilities in a safe environment. In the context of COVID-19, simulation encourages staff sense of preparedness and protection for true participation during a high-risk procedure.
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Affiliation(s)
- Rebecca Towning
- Department of Otolaryngology and Head and Neck Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
| | - Catherine Rennie
- Department of Otolaryngology and Head and Neck Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
| | - Mark Ferguson
- Department of Otolaryngology and Head and Neck Surgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom
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Zhao J, Zheng W, Xuan NX, Zhou QC, Wu WB, Cui W, Tian BP. The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a chinese tertiary hospital. BMC Anesthesiol 2024; 24:39. [PMID: 38262946 PMCID: PMC10804499 DOI: 10.1186/s12871-024-02411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES The timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS One thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital. METHODS Tracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death. RESULTS In both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT. CONCLUSIONS In a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes. TRIAL REGISTRATION ChiCTR2100043905. Registered 05 March 2021. http://www.chictr.org.cn/listbycreater.aspx.
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Affiliation(s)
- Jie Zhao
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
- Department of Critical Care Medicine, The First Affiliated Hospital, Ningbo University, Ningbo, Zhejiang, China
| | - Wei Zheng
- Department of Critical Care Medicine, Zhejiang Daishan First People's Hospital, The Second Affiliated Hospital Daishan Branch, Zhejiang University School of Medicine, Zhoushan, China
| | - Nan-Xian Xuan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Qi-Chao Zhou
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Wei-Bing Wu
- Department of Critical Care Medicine, Zhejiang Qingyuan People's Hospital, The Second Affiliated Hospital Qingyuan Branch, Zhejiang University School of Medicine, Lishui, China
| | - Wei Cui
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Bao-Ping Tian
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China.
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12
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Colbert C, Streblow AD, Sherry SP, Dobbertin K, Cook M. Tracheostomies for respiratory failure are associated with a high inpatient mortality: a potential trigger to reconsider goals of care. Trauma Surg Acute Care Open 2024; 9:e001105. [PMID: 38274027 PMCID: PMC10806475 DOI: 10.1136/tsaco-2023-001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 12/10/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Acute care surgeons are frequently consulted for tracheostomy placement in the intensive care unit (ICU). Tracheostomy may facilitate ventilator weaning and improve physical comfort. Short-term outcomes after tracheostomy are not well studied. We hypothesize that a high proportion of ICU patients who underwent tracheostomy died prior to discharge. These data will help guide clinical decision-making at a key pivot point in care. Methods We identified 177 mixed ICU patients who received a tracheostomy for respiratory failure between January 2013 and December 2018. We excluded patients with trauma. Patient information was collected and comparisons made with univariable and multivariable statistics. Results Of the 177 patients who underwent a tracheostomy for respiratory failure, 45% were women, median age was 63 (51-71) years. Of this group 18% died prior to discharge, 63% were discharged to a care facility and only 16% discharged home. Compared with survivors, patients with tracheostomies who died during their admission were older, age 69 (64-76) versus 61 (49-71) years (p<0.01) on univariable analysis. In this model, no single comorbid condition or length of stay (LOS) variable was predictive of death before discharge. A multivariable model controlling for covariation similarly identified age, as well as a longer ICU LOS of 34 (20-49) versus 23 (16-31) days (p=0.003) as factors associated with increased likelihood of death before discharge. Conclusions Tracheostomy placement in a mixed ICU population is associated with a nearly 20% inpatient mortality and the vast majority of surviving patients were discharged to a care facility. This suggests that the need for tracheostomy could be considered a trigger for re-evaluation of patient goals. The high risk of death due to underlying illness and high intensity care after their hospitalization emphasize the need for clear advanced care planning discussions around the time of tracheostomy placement. Level of Evidence Level IV, Retrospective cohort study.
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Affiliation(s)
- Cameron Colbert
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Aaron D Streblow
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Scott P Sherry
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Konrad Dobbertin
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Mackenzie Cook
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
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Peng C, Peng L, Yang F, Yu H, Wang P, Cheng C, Zuo W, Li W, Jin Z. Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis. J Cardiothorac Vasc Anesth 2023; 37:2584-2591. [PMID: 36631378 DOI: 10.1053/j.jvca.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models. DESIGN A retrospective observational study. SETTING Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients. INTERVENTIONS An ET versus late tracheostomy (LT). MEASUREMENTS AND MAIN RESULTS Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups. CONCLUSIONS The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Hang Yu
- Emergency Department, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peng Wang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Chao Cheng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Wei Zuo
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China.
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, Shanghai, China.
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14
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Savel RH, Shiloh AL. Trajectory After Tracheostomy: Sobering Data for Decision Makers. Crit Care Med 2023; 51:1834-1837. [PMID: 37971341 DOI: 10.1097/ccm.0000000000006044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Richard H Savel
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ
| | - Ariel L Shiloh
- Critical Care Consult Service, Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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15
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Morosin M, Azzu A, Antonopoulos A, Kuhn T, Anandanadesan R, Garfield B, Aw TC, Ledot S, Bianchi P. Safety of tracheostomy during extracorporeal membrane oxygenation support: A single-center experience. Artif Organs 2023; 47:1762-1772. [PMID: 37610348 DOI: 10.1111/aor.14633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients. METHODS This is a retrospective observational single-center study. RESULTS Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V-V ECMO support over an 8-year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3-40.1) vs 37.2 (26.5-53.2) days, p = 0.013] and a shorter ECMO-to-tracheostomy time [13.3 (8.5-19.7) vs 27.8 (16.3-36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V-V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID-19, who did not show significantly higher rates of major bleeding when compared to non-COVID-19 patients (p = 0.297). Within the COVID-19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0). CONCLUSIONS Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID-19 patients, if relevant clinical expertise is available.
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Affiliation(s)
- Marco Morosin
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Alessia Azzu
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Alexios Antonopoulos
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Timothy Kuhn
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Rathai Anandanadesan
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Benjamin Garfield
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Tuan-Chen Aw
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Paolo Bianchi
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
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16
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Grasselli Kmet N, Muzlovič I, Martinčič Ž, Štubljar D, Jereb M. Adult patients with tetanus in Slovenia 2006-2021 : Results of a national cohort study. Wien Klin Wochenschr 2023; 135:625-630. [PMID: 37278856 DOI: 10.1007/s00508-023-02222-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/07/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The aim of the present study was to determine the demographic, epidemiological and clinical characteristics of adult patients with tetanus in Slovenia between 2006 and 2021, as well as to determine the therapeutic approaches which have been successfully used in the intensive care unit (ICU) of the Infectious Diseases Department in the University Medical Centre Ljubljana (UMC). METHODS We included all adult patients who were treated for tetanus in the ICU of the Department of Infectious Diseases Ljubljana between January 1st, 2006, and December 31th, 2021, in the retrospective study. Available epidemiological and clinical characteristics were reviewed from the medical documentation. RESULTS There were 31 patients included in the study, four (12.9%) males and 27 (87.1%) females. The vast majority of patients required mechanical ventilation (MV) (87.1%) which lasted (± SD) on average 35.4 ± 16.0 days. Autonomic dysfunction was present in 29 (93.5%) patients and was statistically significantly associated with shorter disease evolution (p = 0.005) and presence of healthcare-associated infection (p = 0.020). During the hospitalization, 27 (87.1%) patients acquired at least one healthcare-associated infection, most commonly ventilator-associated pneumonia. The average length of stay in the ICU (± SD) was 42.5 ± 21.3 days. With increasing age, MV lasted statistically significantly longer (p = 0.001), length of stay was longer (p = 0.015), and healthcare-associated infections occurred (p = 0.003) more frequently. Four patients (12.9%) died. CONCLUSIONS Although the tetanus incidence rate in Slovenia is high in comparison to other European countries on average, our therapeutic approach resulted in a good survival rate and low mortality.
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Affiliation(s)
- Nina Grasselli Kmet
- Infectious Diseases Department, University Medical Centre, Japljeva 2, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Igor Muzlovič
- Infectious Diseases Department, University Medical Centre, Japljeva 2, 1000, Ljubljana, Slovenia
| | | | - David Štubljar
- In-Medico, Department of Research and Development, Mestni trg 11, Metlika, Slovenia
| | - Matjaž Jereb
- Infectious Diseases Department, University Medical Centre, Japljeva 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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17
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Bui R, Kasabali A, Dewan K. A retrospective analysis of COVID-19 tracheostomies: Early versus late tracheostomy. Laryngoscope Investig Otolaryngol 2023; 8:1154-1158. [PMID: 37899865 PMCID: PMC10601556 DOI: 10.1002/lio2.1135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/30/2023] [Accepted: 07/16/2023] [Indexed: 10/31/2023] Open
Abstract
Objectives To assess the impact of early tracheostomy (ET) versus late tracheostomy (LT) placement on mortality and decannulation rates of COVID patients. Methods A retrospective chart review was performed of all patients infected with COVID-19 who underwent tracheostomy tube placement in an Ochsner-affiliated hospital from March 2020 to May 2022. Patients were identified using the electronic medical record and data was collated using the "Epic SlicerDicer" tool. Descriptive statistics were gathered and compared between patients who underwent ET placement and those who underwent LT placement. Patient demographics, previous medical history, tracheostomy procedural details, arterial blood gases, complications, and outcomes including time to wean from the ventilator, and time to decannulation were recorded. Results Two-hundred nineteen patients were included in the study. There were no statistically significant differences in liberation from mechanical ventilation rates between early and LT (62% vs. 55%, p = .19), or in decannulation rates (40% vs. 32%, p = .14). The mean duration of time to liberation from mechanical ventilation for early trach was 13.88 versus 18.17 days for late trach, however, no statistically significant difference was found (p = .12). Similarly, mean duration of time to decannulation was 41.17 days for early versus 47.72 for late trach (p = .15). Conclusion Contrary to some studies in the literature, the results presented here suggest ETs are not associated with hastened liberation from mechanical ventilation or increased decannulation rates. Further prospective studies may be warranted in assessing the impact of early versus LT in the COVID patient population. Level of Evidence III.
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Affiliation(s)
- Roger Bui
- Department of Otolaryngology—Head and Neck SurgeryLouisiana State University ShreveportShreveportLouisianaUSA
| | - Ahmad Kasabali
- Department of Otolaryngology—Head and Neck SurgeryLouisiana State University ShreveportShreveportLouisianaUSA
| | - Karuna Dewan
- Department of Otolaryngology—Head and Neck SurgeryLouisiana State University ShreveportShreveportLouisianaUSA
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18
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Xin M, Wang L, Li C, Hou D, Wang H, Wang J, Jia M, Hou X. Percutaneous dilatation tracheotomy in patients on extracorporeal membrane oxygenation after cardiac surgery. Perfusion 2023; 38:1182-1188. [PMID: 35505642 DOI: 10.1177/02676591221099811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Current practices regarding percutaneous dilatational tracheostomy in adult patients treated with extracorporeal membrane oxygenation (ECMO) after cardiac surgery is not completely defined. This study aimed to evaluate the safety of the percutaneous dilatational tracheostomy in patients with ECMO after cardiac surgery. METHODS Between July 2017 and May 2021, 371 ECMO procedures were performed in more than 35,000 adult patients who underwent cardiac surgery in our hospital. Sixty-two patients underwent percutaneous dilatational tracheostomy (PDT) during or after ECMO. A retrospective analysis was performed comparing the incidence of complications and clinical outcomes of the two groups. RESULTS Of the 371 patients treated with ECMO after adult cardiac surgery during the enrollment period, 22 (7.1%) and 40 (12.8%) underwent PDT during or after ECMO, respectively. The platelet count (PLT) of the day was significantly lower in the PDT during ECMO group (54 (34, 68) vs. 108 (69, 162) (thousands), p < 0.001)). The prothrombin time (PT) and activated partial thromboplastin time (APTT) of the day were longer in the PDT during ECMO group (15.8 (14.6, 19.9) vs. 13.8 (13.2, 15.2) seconds, p = 0.001, 43.8 (38.0, 49.4) vs. 35.2 (28.2, 40.9) seconds, p < 0.001, respectively). There was no significant difference in tracheotomy-related complications between the two groups. Significantly decreased ventilator time was observed in the PDT during ECMO group. CONCLUSIONS Despite poor coagulation of the day, PDT during ECMO is safe and can appropriately reduce the duration of mechanical ventilation compared with PDT after ECMO weaning in adult patients who have undergone cardiac surgery.
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Affiliation(s)
- Meng Xin
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dengbang Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiangang Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Jia
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Grensemann J, Gilmour S, Tariparast PA, Petzoldt M, Kluge S. Comparison of nasotracheal versus orotracheal intubation for sedation, assisted spontaneous breathing, mobilization, and outcome in critically ill patients: an exploratory retrospective analysis. Sci Rep 2023; 13:12616. [PMID: 37537207 PMCID: PMC10400581 DOI: 10.1038/s41598-023-39768-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023] Open
Abstract
Nasotracheal intubation (NTI) may be used for long term ventilation in critically ill patients. Although tracheostomy is often favored, NTI may exhibit potential benefits. Compared to orotracheal intubation (OTI), patients receiving NTI may require less sedation and thus be more alert and with less episodes of depression of respiratory drive. We aimed to study the association of NTI versus OTI with sedation, assisted breathing, mobilization, and outcome in an exploratory analysis. Retrospective data on patients intubated in the intensive care unit (ICU) and ventilated for > 48 h were retrieved from electronic records for up to ten days after intubation. Outcome measures were a Richmond Agitation and Sedation Scale (RASS) of 0 or - 1, sedatives, vasopressors, assisted breathing, mobilization on the ICU mobility scale (ICU-MS), and outcome. From January 2018 to December 2020, 988 patients received OTI and 221 NTI. On day 1-3, a RASS of 0 or - 1 was attained in OTI for 4.0 ± 6.1 h/d versus 9.4 ± 8.4 h/d in NTI, p < 0.001. Propofol, sufentanil, and norepinephrine were required less frequently in NTI and doses were lower. The NTI group showed a higher proportion of spontaneous breathing from day 1 to 7 (day 1-6: p < 0.001, day 7: p = 0.002). ICU-MS scores were higher in the NTI group (d1-d9: p < 0.001, d10: p = 0.012). OTI was an independent predictor for mortality (odds ratio 1.602, 95% confidence interval 1.132-2.268, p = 0.008). No difference in the rate of tracheostomy was found. NTI was associated with less sedation, more spontaneous breathing, and a higher degree of mobilization during physiotherapy. OTI was identified as an independent predictor for mortality. Due to these findings a new prospective evaluation of NTI versus OTI should be conducted to study risks and benefits in current critical care medicine.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Sophie Gilmour
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Pischtaz Adel Tariparast
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Martin Petzoldt
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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20
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Rodriguez AM, Schain K, Jayakar P, Wright MS, Chowdhury S, Salyakina D. Report of two cases of Schaaf-Yang syndrome: Same genotype and different phenotype. Clin Case Rep 2023; 11:e7753. [PMID: 37529132 PMCID: PMC10387585 DOI: 10.1002/ccr3.7753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023] Open
Abstract
We report two, genotypically identical but phenotypically distinct cases of Schaaf-Yang syndrome and propose the early use of Genome Sequencing in patients with nonspecific presentations to facilitate the early diagnosis of children with rare genetic diseases and improve overall health care outcomes.
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Affiliation(s)
- Ana Maria Rodriguez
- Division of Genetics and MetabolismNicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
| | - Katherine Schain
- Division of Genetics and MetabolismNicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
| | - Parul Jayakar
- Division of Genetics and MetabolismNicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
| | - Meredith S. Wright
- Rady Children's Institute for Genomic MedicineSan DiegoCaliforniaUSA
- Keck Graduate InstituteClaremontCaliforniaUSA
| | - Shimul Chowdhury
- Rady Children's Institute for Genomic MedicineSan DiegoCaliforniaUSA
| | - Daria Salyakina
- Personalized Medicine & Health Outcomes Research, Nicklaus Children's Hospital Pediatric SpecialistsMiamiFloridaUSA
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21
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Luo J, Xie W, Hong S, Gao J, Yang C, Shi Y. Comparison of Outcomes Between Early and Late Tracheostomy. Respir Care 2023; 69:respcare.10837. [PMID: 37468334 PMCID: PMC10753616 DOI: 10.4187/respcare.10837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The timing of tracheostomy in ventilated patients remains controversial. This study aimed to compare the effect of early tracheostomy (≤7 d) with late tracheostomy (>7 d) on the prognosis of patients requiring prolonged mechanical ventilation. METHODS This was a retrospective observational cohort study. The data of 175 patients who received tracheostomy at the ICU between January 1, 2015-July 31, 2022, were collected. Patients were excluded from the study if medical records were incomplete or they underwent tracheostomy as part of a planned operation procedure. One-to-one propensity score matching was used to correct the baseline characteristics between the early and late tracheostomy groups. The treatment process and outcomes were compared between the two groups. The primary outcome was the incidence of ventilator-associated pneumonia (VAP) between groups. RESULTS After propensity score matching, 88 subjects were included in the analysis. Compared with the late tracheostomy group, the incidence of VAP, hospital length of stay, sedation-free days, ventilator-free days, and ICU-free days were longer in the early tracheostomy group. There were no significant differences in the 90-d mortality between the two groups. CONCLUSIONS;: Early tracheostomy can reduce the occurrence of complications for ICU patients.
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Affiliation(s)
- Jiaqi Luo
- Department of Otolaryngology, Shenzhen City Baoan District Women's and Children's Hospital, Baoan District, Shenzhen, Guangdong, China
| | - Wenfeng Xie
- Intensive Care Unit, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; and Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shuyi Hong
- Department of Otolaryngology-Head and Neck Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jinliang Gao
- Department of Otolaryngology, Shenzhen City Baoan District Women's and Children's Hospital, Baoan District, Shenzhen, Guangdong, China
| | - Chunhua Yang
- Intensive Care Unit, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; and Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yiming Shi
- Intensive Care Unit, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; and Biomedical Innovation Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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22
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Qiu Y, Yin Z, Wang Z, Xie M, Chen Z, Wu J, Wang Z. Early versus late tracheostomy in stroke-related patients: A systematic review and meta-analysis. J Clin Neurosci 2023; 114:48-54. [PMID: 37302372 DOI: 10.1016/j.jocn.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Tracheostomy is an operative intervention for patients who require ventilator assistance while in the intensive care unit (ICU). This study aimed to compare efficacy and safety between early tracheostomy (ET) and late tracheostomy (LT) in stroke patients. METHODS Embase, PubMed, and the Cochrane Library were searched for available studies. Stroke-related patients were categorized into ET and LT groups using seven days as the cutoff timepoint. The primary efficacy outcome was mortality; secondary efficacy outcomes were modified Rankin Scores (mRS) obtained at follow up, as well as durations of hospital stay, ICU stay, and ventilator use. Safety outcomes were total complication and ventilator associated pneumonia (VAP) incidence. RESULTS Nine studies with 3,789 patients were included in the current analysis. No statistical difference in mortality was observed. ET was associated with shorter hospital stay (MD -5.72, 95% CI -9.76 to -1.67), shorter ICU stay (MD -4.77, 95% CI -6.82 to -2.72), and shorter ventilator duration (MD -4.65, 95% CI -8.39 to -0.90); however, no statistically significant difference was found in follow-up mRS scores. Examination of safety measures found the ET group exhibited a lower rate of VAP compared with LT (OR 0.80, 95 % CI 0.68 to 0.93), while no statistical difference was found in total complications. CONCLUSION Our meta-analysis concluded that ET was associated with shorter hospital stay, less time on a ventilator, and lower incidence of VAP. Future studies are warranted to investigate the functional outcomes and the occurrence of complications of ET in stroke patients.
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Affiliation(s)
- Youjia Qiu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Ziqian Yin
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu Province 215002, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China.
| | - Minjia Xie
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Jiang Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China.
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23
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Kishihara Y, Yasuda H, Ozawa H, Fukushima F, Kashiura M, Moriya T. Effects of tracheostomy timing in adult patients receiving mechanical ventilation: A systematic review and network meta-analysis. J Crit Care 2023; 77:154299. [PMID: 37099823 DOI: 10.1016/j.jcrc.2023.154299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 02/09/2023] [Accepted: 03/29/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE We performed a network meta-analysis (NMA) of multiple tracheostomy timings using data from randomized control trials (RCTs) to investigate the impact on patient prognosis. MATERIALS AND METHODS We searched MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform Search Portal for RCTs on mechanically ventilated patients aged ≥18 years on February 2, 2023. We classified the timing of tracheostomy into three groups based on the clinical importance and previous studies: ≤ 4 days, 5-12 days, and ≥ 13 days. The primary outcome was short-term mortality, defined as mortality at any reported time point up to hospital discharge. RESULTS Eight RCTs were included. The results revealed no effect between ≤4 days vs. 5-12 days and 5-12 days vs. ≥ 13 days and a significant effect in ≤4 days vs. ≥ 13 days as follows: in ≤4 days vs. 5-12 days (RR, 0.79 [95% CI, 0.56-1.11]; very low certainty), ≤ 4 days vs. ≥ 13 days (RR, 0.67 [95% CI, 0.49-0.92]; very low certainty), and 5-12 days vs. ≥ 13 days (RR, 0.85 [95% CI, 0.59-1.24]; very low certainty). CONCLUSIONS Tracheostomy ≤4 days may result in lower short-term mortality than tracheostomy ≥13 days.
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Affiliation(s)
- Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, Japan.
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, Japan; Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center (CTR), 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan.
| | - Hidechika Ozawa
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, Japan.
| | - Fumihito Fukushima
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, Japan.
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama, Japan.
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24
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Tanaka A, Uchiyama A, Kitamura T, Sakaguchi R, Komukai S, Enokidani Y, Koyama Y, Yoshida T, Iguchi N, Sobue T, Fujino Y. Association between tracheostomy and survival in patients with coronavirus disease 2019 who require prolonged mechanical ventilation for more than 14 days: A multicenter cohort study. Auris Nasus Larynx 2023; 50:276-284. [PMID: 35764477 PMCID: PMC9189113 DOI: 10.1016/j.anl.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/20/2022] [Accepted: 06/07/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Tracheostomy is a common procedure with potential prognostic advantages for patients who require prolonged mechanical ventilation (PMV). Early recommendations for patients with coronavirus disease 2019 (COVID-19) suggested delayed or limited tracheostomy considering the risk for viral transmission to clinicians. However, updated guidelines for tracheostomy with appropriate personal protective equipment have revised its indications. This study aimed to evaluate the association between tracheostomy and prognosis in patients with COVID-19 requiring PMV. METHODS This was a multicenter, retrospective cohort study using data from the nationwide Japanese Intensive Care PAtient Database. We included adult patients aged ≥16 years who were admitted to the intensive care unit (ICU) due to COVID-19 and who required PMV (for >14 days or until performance of tracheostomy). The primary outcome was hospital mortality, and the association between implementation of tracheostomy and patient prognosis was assessed using weighted Cox proportional hazards regression analysis with inverse probability of treatment weighting (IPTW) using the propensity score to address confounders. RESULTS Between January 2020 and February 2021, 453 patients with COVID-19 were observed. Data from 109 patients who required PMV were analyzed: 66 (60.6%) underwent tracheostomy and 38 (34.9%) died. After adjusting for potential confounders using IPTW, tracheostomy implementation was found to significantly reduce hospital mortality (hazard ratio [HR]: 0.316, 95% confidence interval [CI]: 0.163-0.612). Patients who underwent tracheostomy had a similarly decreased ICU and 28-day mortality (HR: 0.269, 95% CI: 0.124-0.581; HR 0.281, 95% CI: 0.094-0.839, respectively). A sensitivity analysis using different definitions of PMV duration consistently showed reduced mortality in patients who underwent tracheostomy. CONCLUSION The implementation of tracheostomy was associated with favorable patient prognosis among patients with COVID-19 requiring PMV. Our findings support proactive tracheostomy in critically ill patients with COVID-19 requiring mechanical ventilation for >14 days.
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Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Ryota Sakaguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yusuke Enokidani
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan
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25
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Mc Mahon A, Griffin S, Gorman E, Lennon A, Kielthy S, Flannery A, Cherian BS, Josy M, Marsh B. Patient-Centred Outcomes Following Tracheostomy in Critical Care. J Intensive Care Med 2023:8850666231160669. [PMID: 36883211 PMCID: PMC10374991 DOI: 10.1177/08850666231160669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Around 20% of intensive care unit (ICU) patients undergo tracheostomy insertion and expect high-quality care concentrating on patient-centered outcomes including communication, oral intake, and mobilization. The majority of data has focused on timing, mortality, and resource utilization, with a paucity of information on quality of life following tracheostomy. METHODS Single center retrospective study including all patients requiring tracheostomy from 2017 to 2019. Information collected on demographics, severity of illness, ICU and hospital length of stay (LOS), ICU and hospital mortality, discharge disposition, sedation, time to vocalization, swallow and mobilization. Outcomes were compared for early versus late tracheostomy (early = <day 10) and age category (≤ 65 vs ≥ 66 years). RESULTS In total, 304 patients were included and 71% male, median age 59, APACHE II score 17. Median ICU and hospital LOS 16 and 56 days, respectively. ICU and hospital mortality 9.9% and 22.4%. Median time to tracheostomy 8 days, 8.55% open. Following tracheostomy, median days of sedation was 0, time to noninvasive ventilation (NIV) 1 day (94% of patients achieving this), ventilator-free breathing (VFB) 5 days (72%), speaking valve 7 days (60%), dynamic sitting 5 days (64%), and swallow assessment 16 days (73%). Early tracheostomy was associated with shorter ICU LOS (13 vs 26 days, P < .0001), reduced sedation (6 vs 12 days, P < .0001), faster transition to level 2 care (6 vs 10 days, P < .003), NIV (1 vs 2 days, P < .003), and VFB (4 vs 7 days, P < .005). Older patients received less sedation, had higher APACHE II scores and mortality (36.1%) and 18.5% were discharged home. Median time to VFB was 6 days (63.9%), speaking valve 7 days (64.7%), swallow assessment 20.5 days (66.7%), and dynamic sitting 5 days (62.2%). CONCLUSION Patient-centered outcomes are a worthy goal to consider when selecting patients for tracheostomy in addition to mortality or timing alone, including in older patients.
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Affiliation(s)
- A Mc Mahon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - S Griffin
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Emma Gorman
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aoife Lennon
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Stephen Kielthy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Andrea Flannery
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Bindu Sam Cherian
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - Minu Josy
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
| | - B Marsh
- Department of Critical Care Medicine, 8881Mater Misericordiae University Hospital, Dublin, Ireland
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26
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Sekihara K, Okamoto T, Shibasaki T, Matsuda W, Funai K, Yonehiro Y, Matsubara C, Kimura A. Evaluation of a bundle approach for the prophylaxis of ventilator-associated pneumonia: A retrospective single-center Study. Glob Health Med 2023; 5:33-39. [PMID: 36865901 PMCID: PMC9974225 DOI: 10.35772/ghm.2022.01038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/17/2022] [Accepted: 09/12/2022] [Indexed: 11/08/2022]
Abstract
Ventilator-associated pneumonia (VAP) is defined as pneumonia occurring after the first 48 hours of intubation and mechanical ventilation and is the most frequent hospital-acquired infection associated with intensive care unit (ICU) admissions. Herein, we defined a novel VAP bundle including 10 preventive items. We analyzed compliance rates and clinical effectiveness associated with this bundle in patients undergoing intubation at our medical center. A total of 684 consecutive patients who underwent mechanical ventilation were admitted to the ICU between June 2018 and December 2020. VAP was diagnosed by at least two physicians based on the relevant United States Centers for Disease Control and Prevention criteria. We retrospectively evaluated associations between compliance and VAP incidence. The overall compliance rate was 77%, and compliance generally remained steady during the observation period. Moreover, although the number of ventilatory days remained unchanged, the incidence of VAP improved statistically significantly over time. Low compliance was identified in four categories: head-of-bed elevation of 30- 45º, avoidance of oversedation, daily assessment for extubation, and early ambulation and rehabilitation. The incidence of VAP was lower in those with an overall compliance rate of ≥ 75% than its incidence in the lower compliance group (15.8 vs. 24.1%, p = 0.018). When comparing low-compliance items between these groups, we found a statistically significant difference only for daily assessment for extubation (8.3 vs. 25.9%, p = 0.011). In conclusion, the evaluated bundle approach is effective for the prophylaxis of VAP and is thus eligible for inclusion in the Sustainable Development Goals.
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Affiliation(s)
- Keigo Sekihara
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of First Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tatsuya Okamoto
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Address correspondence to:Tatsuya Okamoto, Department of Intensive Care Medicine, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjuku, Tokyo 162-8655, Japan. E-mail:
| | - Takatoshi Shibasaki
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Wataru Matsuda
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhito Funai
- Department of First Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yuki Yonehiro
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Chieko Matsubara
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Akio Kimura
- Department of Intensive Care Medicine, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan;,Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
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27
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Impact of Early Tracheostomy Versus Late or No Tracheostomy in Nonneurologically Injured Adult Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:310-318. [PMID: 36661455 DOI: 10.1097/ccm.0000000000005699] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The optimal timing of tracheostomy in nonneurologically injured mechanically ventilated critically ill adult patients is uncertain. We conducted a systematic review of randomized controlled trials to evaluate the effect of early versus late tracheostomy or prolonged intubation in this population. DATA SOURCES We searched MEDLINE, Embase, CENTRAL, CINAHL, and Web of science databases for randomized controlled trials comparing early tracheostomy (<10 d of intubation) with late tracheostomy or prolonged intubation in adults. DATA SELECTION We selected trials comparing early tracheostomy (defined as being performed less than 10 d after intubation) with late tracheostomy (performed on or after the 10th day of intubation) or prolonged intubation and no tracheostomy in nonneurologically injured patients. The primary outcome was overall mortality. Secondary outcomes included ventilator-associated pneumonia, duration of mechanical ventilation, ICU, and hospital length of stay. DATA EXTRACTION Two reviewers screened citations, extracted data, assessed the risk of bias, and classification of Grading of Recommendations, Assessment, Development, and Evaluation independently. DATA SYNTHESIS Our search strategy yielded 8,275 citations, from which nine trials (n = 2,457) were included. We did not observe an effect on the overall mortality of early tracheostomy compared with late tracheostomy or prolonged intubation (risk ratio, 0.91, 95% CI, 0.82-1.01; I2 = 18%). Our results were consistent in all subgroup analyses. No differences were observed in ICU and hospital length of stay, duration of mechanical ventilation, incidence of ventilator-acquired pneumonia, and complications. Our trial sequential analysis showed that our primary analysis on mortality was likely underpowered. CONCLUSION In our systematic review, we observed that early tracheostomy, as compared with late tracheostomy or prolonged intubation, was not associated with a reduction in overall mortality. However, we cannot exclude a clinically relevant reduction in mortality considering the level of certainty of the evidence. A well-designed trial is needed to answer this important clinical question.
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28
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When More Could Mean Less Intervention: The Tale Of Tracheostomy Timing in Critical Illness. Crit Care Med 2023; 51:333-335. [PMID: 36661461 DOI: 10.1097/ccm.0000000000005753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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29
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Nicolotti D, Grossi S, Nicolini F, Gallingani A, Rossi S. Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review. J Clin Med 2023; 12:jcm12020497. [PMID: 36675426 PMCID: PMC9867514 DOI: 10.3390/jcm12020497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Respiratory weaning after cardiac surgery can be difficult or prolonged in up to 22.7% of patients. The inability to wean from a ventilator within the first 48 h after surgery is related to increased short- and long-term morbidity and mortality. Risk factors are mainly non-modifiable and include preoperative renal failure, New York Heart Association, and Canadian Cardiac Society classes as well as surgery and cardio-pulmonary bypass time. The positive effects of pressure ventilation on the cardiovascular system progressively fade during the progression of weaning, possibly leading to pulmonary oedema and failure of spontaneous breathing trials. To prevent this scenario, some parameters such as pulmonary artery occlusion pressure, echography-assessed diastolic function, brain-derived natriuretic peptide, and extravascular lung water can be monitored during weaning to early detect hemodynamic decompensation. Tracheostomy is considered for patients with difficult and prolonged weaning. In such cases, optimal patient selection, timing, and technique may be important to try to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Davide Nicolotti
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-703286
| | - Silvia Grossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Francesco Nicolini
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Alan Gallingani
- Department of Cardiac Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care Medicine, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126 Parma, Italy
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30
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Salik I, Das A, Naftchi AF, Vazquez S, Spirollari E, Dominguez JF, Sukul V, Stewart D, Moscatello A. Effect of tracheostomy timing in pediatric patients with traumatic brain injury. Int J Pediatr Otorhinolaryngol 2023; 164:111414. [PMID: 36527981 DOI: 10.1016/j.ijporl.2022.111414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established. OBJECTIVE This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes. DESIGN/METHODS The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median = 9 days). RESULTS Of the 68,793 patients (mean age = 14, IQR 4-18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age = 16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p < 0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence. CONCLUSIONS Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.
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Affiliation(s)
- Irim Salik
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, 10595, USA.
| | - Ankita Das
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | | | - Sima Vazquez
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Eris Spirollari
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Vishad Sukul
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Dylan Stewart
- Department of Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Augustine Moscatello
- Department of Otolaryngology/Head and Neck Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
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Percutaneous tracheostomy in the ICU: a review of the literature and recent updates. Curr Opin Pulm Med 2023; 29:47-53. [PMID: 36378112 DOI: 10.1097/mcp.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW The following article summarizes the current available knowledge regarding tracheostomy techniques, indications, contraindications, procedure timing, use of assisted technologies and tracheostomy feasibility and safety in high-risk populations. In light of the ongoing corona virus disease (COVID-19) pandemic, a focus was placed on tracheostomy in this unique patient group. RECENT FINDINGS Percutaneous dilatation tracheostomy (PDT) is commonly used in the ICU setting. It has been shown to be well tolerated and feasible in a diverse patient population including those regarded to be at high risk such as the obese, coagulopathic and acute respiratory failure patient. This patient profile presented itself frequently in the recent COVID-19 pandemic. Indeed studies showed that PDT is well tolerated in COVID-19 ICU patients leading to reduced ICU length of stay (LOS), decrease in ventilator-associated pneumonia rate (VAP) and reduced duration on invasive mechanical ventilation (IMV). Despite initial concerns, virus transmission from patient to healthcare provider (HCP) was shown to be negligible when proper precautions are taken. SUMMARY Bedside PDT in the ICU is a well tolerated procedure having the potential to benefit both the individual patient as well as to improve resource utilization of the healthcare system.
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Chongcharoenyanon T, Sophonphan J, Samransamruajkit R. Epidemiology, risk factors and outcomes of prolonged mechanical ventilation with different cut-points in a PICU. Front Pediatr 2023; 11:1167595. [PMID: 37124187 PMCID: PMC10130509 DOI: 10.3389/fped.2023.1167595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/28/2023] [Indexed: 05/02/2023] Open
Abstract
Background A consensus on the definition of prolonged mechanical ventilation (PMV) for children does not exist. There is still lack of published work presenting the epidemiology, risk factors and outcomes at different cut-points for PMV patients. These are important for planning the goals of treatment and counseling of the prognosis for patient families. We aimed to determine the incidence, baseline characteristics, risk factors and outcomes of PMV in pediatric patients at various cut-points (>14, >21 or >30days). Methods A retrospective cohort study among children <18-years-old who were PMV > 14 days in the PICU of King Chulalongkorn Memorial Hospital was conducted. The primary outcomes were incidence of PMV with various cut-points. We stratified patients into three groups (Group 1; PMV > 14-21, Group 2; >21-30, Group 3; >30 days) for evaluating the baseline characteristics, risk factors, and outcomes of PMV (extubation success, tracheostomy status and death). Factors associated with PMV and deaths were analyzed using univariate and multivariate logistic regression. Results From January 2018 to August 2022, 1,050 patients were screened. Of these, 114 patients were enrolled. The incidence of PMV > 14, >21 and >30 days were 10.9%, 7.3% and 5.0% respectively. Extubation success was significantly lower in Group 3 than in Groups 1 & 2 (15.4% vs. 62.2% & 56.0%, P < 0.001). Consequently, the tracheostomy rate (63.5% vs. 16.2% & 12.0%, P < 0.001), VAP rate (98.1% vs. 59.5% & 80.0%, P < 0.001), mortality rate by disease (34.6% vs. 5.4% & 20.0%, P = 0.003), median PICU LOS (50.5 vs. 22.0 & 28.0 days, P < 0.001) and median hospital LOS (124.5 vs. 55.0 & 62.0 days, P < 0.001) were also significantly higher for Group 3 compared with Groups 1 & 2. The factor associated with PMV > 30 days was VAP (aOR: 19.53, 95% CI: 2.38-160.34, P = 0.01). Factors associated with non-surviving patients were 3rd degree PEM (aOR: 5.14, 95% CI: 1.57-16.88, P = 0.01), PIM3 score ≥14 (aOR: 6.75, 95% CI: 2.26-20.15, P < 0.001) and muscle relaxant usage (aOR: 5.58, 95% CI: 1.65-18.86, P = 0.01). Conclusion Extubation failure, tracheostomy rate, VAP rate, mortality rate by disease, PICU LOS and hospital LOS were significantly higher for PMV >30 days. Consequently, we suggest that a 30-day duration as a cut-point for PMV in PICUs might be more appropriate.
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Affiliation(s)
- Tatchanapong Chongcharoenyanon
- Division of Pulmonology, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Correspondence: Tatchanapong Chongcharoenyanon
| | - Jiratchaya Sophonphan
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Rujipat Samransamruajkit
- Division of Pediatric Critical Care, Department of Pediatrics, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Exploring the Influence of Dysphagia and Tracheostomy on Pneumonia in Patients with Stroke: A Retrospective Cohort Study. Brain Sci 2022; 12:brainsci12121664. [PMID: 36552123 PMCID: PMC9775301 DOI: 10.3390/brainsci12121664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Pneumonia is common in patients with tracheostomy and dysphagia. However, the influence of dysphagia and tracheostomy on pneumonia in patients with stroke remains unclear. The aim of this study was to explore the risk factors related to pneumonia, and the association between dysphagia, tracheostomy and pneumonia in patients with stroke was investigated. Methods: Patients with stroke who experienced tracheostomy and dysphagia were included and divided into two groups based on record of pneumonia at discharge. Clinical manifestations and physical examination were used to diagnose pneumonia, whereas clinical swallowing examination, and videofluoroscopy swallowing studies (VFSS) were used to evaluate swallowing function. Results: There were significant differences between the pneumonia group and the no pneumonia group in total tracheostomy time (6.3 ± 5.9 vs. 4.3 ± 1.7 months, p = 0.003), number of instances of ventilator support (0.41 ± 0.49 vs. 0.18 ± 0.38, p = 0.007), PAS score (5.2 ± 1.92 vs. 4.3 ± 1.79, p = 0.039), impaired or absent cough reflex (76.4 vs. 55.6%, p = 0.035), oropharyngeal phase dysfunction (60.6 vs. 40.8%, p = 0.047), length of hospital stay (36.0 ± 7.2 vs. 30.5 ± 11.7 days, p = 0.025) and direct medical costs (15,702.21 ± 14,244.61 vs. 10,923.99 ± 7250.14 United States dollar [USD], p = 0.042). Multivariate logistic regression showed that the total tracheostomy time (95% confidence interval [CI], 1.966−12.922, p = 0.001), impaired or absent cough reflex (95% CI, 0.084−0.695, p = 0.008), and oropharyngeal phase dysfunction (95% CI, 1.087−8.148, p = 0.034) were risk factors for pneumonia. Spearman’s correlation analysis demonstrated that PAS scores were significantly correlated with cough reflex dysfunction (r = 0.277, p = 0.03), oropharyngeal phase dysfunction (r = 0.318, p < 0.01) and total tracheostomy time (r = 0.178, p = 0.045). The oropharyngeal phase dysfunction was significantly correlated with cough reflex (r = 0.549, p < 0.001) and UES opening (r = 0.643, p < 0.01). Conclusions: Tracheostomy and dysphagia increased the risk of pneumonia in patients with stroke. Total tracheostomy time, duration of ventilator support, degree of penetration and aspiration, and oropharyngeal phase dysfunction are risk factors. Given this, we also found that there may be a correlation between tracheostomy and dysphagia.
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George TJ, Sheasby J, Taylor JE, Vaquera KA, Curry MW, Harness‐Brumley CL, Myers DP, Erwin GE, Lilly JC, Michael DiMaio J. Early mobilization in coronavirus-19 patients treated with extracorporeal membrane oxygenation. J Card Surg 2022; 37:4536-4542. [PMID: 36316816 PMCID: PMC9877644 DOI: 10.1111/jocs.17079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/14/2022] [Accepted: 09/23/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pneumonia can be associated with refractory respiratory failure requiring extracorporeal membrane oxygenation(ECMO). Although ECMO has helped many COVID patients, optimal management strategies for these patients remain unknown. METHODS We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. Six months into the pandemic, we changed our management strategy to focus on early mobilization. The early mobilization effort included tracheostomy within 48 h of cannulation, decreasing sedation, and an aggressive physical and occupational therapy program progressing toward early ambulation while on ECMO. The primary outcome measured was survival to discharge. The primary stratification was based on the mobilization strategy. RESULTS From 2020 to 2021, 47 COVID patients have been supported with ECMO at our institution. Five are still in the hospital on ECMO. 39 (83%) were supported with venovenous ECMO while 8 (17%) were supported with venoarterial or a right ventricular assist device type configuration. All 47 (100%) were cannulated at bedside with transesophageal echocardiographic guidance. The average age was 47 ± 9 years; 36(77%) were male; and 20 (43%) were Hispanic. The median duration of support was 22 (11-44) days. Excluding those who remain in the hospital and on support, overall survival to discharge was 24/42 (57%). When stratified by mobilization strategy, early tracheostomy and mobilization were associated with significantly improved survival (74% [17/23] vs. 37% [7/19], p = .02). There were no changes in patient acuity or duration of support throughout the study period. CONCLUSION In conclusion, early tracheostomy, decreased sedation, and aggressive mobilization of COVID-19 ECMO patients is associated with improved survival.
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Affiliation(s)
| | | | | | | | | | | | | | - Gary E. Erwin
- Baylor Scott and WhiteThe Heart HospitalPlanoTexasUSA
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Liu Y, Yin S, Chen B, Shen H, Han Y, Wang J, Sheng S, Fu Z, Li X, Wang D, Zhang L, Wang Q, Liu Y. Development and validation of an online nomogram for predicting the outcome of open tracheotomy decannulation: a two-center retrospective analysis. Am J Transl Res 2022; 14:8343-8360. [PMID: 36505299 PMCID: PMC9730114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tracheotomy decannulation is critical for patients in the intensive care unit (ICU) to recover. In this study, we developed and validated an intuitive nomogram to predict the success rate of tracheotomy decannulation. METHODS We collected the data of 627 ICU patients before open tracheotomy decannulation from two medical institutions, including 466 patients (135 success and 331 failure) from the First Affiliated Hospital of Anhui Medical University as a training cohort, and 161 patients (57 success and 104 failure) from the Second Affiliated Hospital of Anhui Medical University as an external validation cohort. A least absolute shrinkage and multivariate logistic regression analysis were performed to determine the independent risk factors and construct the nomogram. The area under the receiver operating characteristic curve (AUC) was used to assess discrimination and the calibration plots were used to assess consistency. The clinical application was assessed using decision curve analysis and the clinical impact curve. RESULTS 7 independent risk factors were eventually included in the prediction model. The AUC of the training cohort, internal validation and external validation were 0.932, 0.926, and 0.915, showing good discrimination. The model performed well in terms of calibration, decision curve analysis, and clinical impact curves. The superior performance of the model was also confirmed by external validation. CONCLUSION This nomogram can help ICU physicians identify high-risk patients for decannulation and plan their pre-decannulation treatment accordingly.
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Affiliation(s)
- Yuchen Liu
- Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China,Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Siyue Yin
- Department of Oncology, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China,Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Bangjie Chen
- Department of Oncology, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China,Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Hailong Shen
- Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China,Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Yanxun Han
- Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China,Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Jianpeng Wang
- Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Shuyan Sheng
- Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Ziyue Fu
- Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Xiaobo Li
- Department of ENT, Second Affiliated Hospital of Anhui Medical UniversityHefei 230031, Anhui, P. R. China
| | - Dong Wang
- Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Liang Zhang
- Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Qin Wang
- Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China
| | - Yehai Liu
- Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical UniversityHefei 230022, Anhui, P. R. China
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Battaglini D, Premraj L, White N, Sutt AL, Robba C, Cho SM, Di Giacinto I, Bressan F, Sorbello M, Cuthbertson B, Bassi GL, Suen J, Fraser J, Pelosi P. Tracheostomy outcomes in critically ill COVID-19 patients: a systematic review, meta-analysis, and meta-regression. Br J Anaesth 2022; 129:679-692. [PMID: 36182551 PMCID: PMC9345907 DOI: 10.1016/j.bja.2022.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/12/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Background We performed a systematic review of mechanically ventilated patients with COVID-19, which analysed the effect of tracheostomy timing and technique (surgical vs percutaneous) on mortality. Secondary outcomes included intensive care unit (ICU) and hospital length of stay (LOS), decannulation from tracheostomy, duration of mechanical ventilation, and complications. Methods Four databases were screened between January 1, 2020 and January 10, 2022 (PubMed, Embase, Scopus, and Cochrane). Papers were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Population or Problem, Intervention or exposure, Comparison, and Outcome (PICO) guidelines. Meta-analysis and meta-regression for main outcomes were performed. Results The search yielded 9024 potentially relevant studies, of which 47 (n=5268 patients) were included. High levels of between-study heterogeneity were observed across study outcomes. The pooled mean tracheostomy timing was 16.5 days (95% confidence interval [CI]: 14.7–18.4; I2=99.6%). Pooled mortality was 22.1% (95% CI: 18.7–25.5; I2=89.0%). Meta-regression did not show significant associations between mortality and tracheostomy timing, mechanical ventilation duration, time to decannulation, and tracheostomy technique. Pooled mean estimates for ICU and hospital LOS were 29.6 (95% CI: 24.0–35.2; I2=98.6%) and 38.8 (95% CI: 32.1–45.6; I2=95.7%) days, both associated with mechanical ventilation duration (coefficient 0.8 [95% CI: 0.2–1.4], P=0.02 and 0.9 [95% CI: 0.4–1.4], P=0.01, respectively) but not tracheostomy timing. Data were insufficient to assess tracheostomy technique on LOS. Duration of mechanical ventilation was 23.4 days (95% CI: 19.2–27.7; I2=99.3%), not associated with tracheostomy timing. Data were insufficient to assess the effect of tracheostomy technique on mechanical ventilation duration. Time to decannulation was 23.8 days (95% CI: 19.7–27.8; I2=98.7%), not influenced by tracheostomy timing or technique. The most common complications were stoma infection, ulcers or necrosis, and bleeding. Conclusions In patients with COVID-19 requiring tracheostomy, the timing and technique of tracheostomy did not clearly impact on patient outcomes. Systematic Review Protocol PROSPERO CRD42021272220.
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Arias-Rivera S, Jam-Gatell R, Nuvials-Casals X, Vázquez-Calatayud M. [Update of the recommendations of the Pneumonia Zero project]. ENFERMERIA INTENSIVA 2022; 33:S17-S30. [PMID: 35911624 PMCID: PMC9326456 DOI: 10.1016/j.enfi.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
La pandemia por el SARS-Cov-2 ha impactado negativamente en la aplicación de las recomendaciones de Neumonía Zero y se ha acompañado de un incremento de las tasas de Neumonía asociada a ventilación mecánica (NAVM) en las unidades de cuidados intensivos de España. Con el objetivo de disminuir las tasas actuales a 7 episodios por 1000 días de VM, se han actualizado las recomendaciones del proyecto inicial. Se identificaron, 27 medidas que se clasificaron en 12 medidas funcionales (posición semisentada, higiene estricta de manos, entrenamiento para manipular la vía aérea, valoración diaria de posible extubación, protocolización del destete, traqueostomía precoz, ventilación no invasiva, vigilancia microbiológica, cambio de tubuladuras, humidificación, fisioterapia respiratoria, nutrición enteral postpilórica), 7 mecánicas (control de la presión del neumotaponamiento, tubos con aspiración subglótica, nutrición con sondas de bajo calibre/en intestino delgado, aspiración de secreciones con circuitos cerrados/abiertos, filtros respiratorios, cepillado de dientes, técnicas de presión negativa en la aspiración de secreciones) y 8 farmacológicas (descontaminación selectiva digestiva, descontaminación orofaríngea, ciclo corto de antibióticos, higiene de boca con clorhexidina, antibióticos inhalados, rotación de antibióticos, probióticos, anticuerpos monoclonales). Cada medida se analizó de forma independiente, por al menos dos miembros del grupo de trabajo, mediante una revisión sistemática de la literatura y una revisión iterativa de las recomendaciones de las sociedades científicas y/o grupos de expertos. Para la clasificación de la calidad de la evidencia y fuerza de las recomendaciones se siguió la propuesta del grupo GRADE. Para determinar el grado de recomendación, cada medida fue puntuada por todos los miembros del grupo de trabajo en relación con su efectividad, tolerabilidad y aplicabilidad en las UCI españolas a corto plazo de tiempo. Se solicitó el apoyo de expertos externos en alguna de las medidas que se revisaron. Se seleccionaron aquellas medidas que alcanzaron la máxima puntuación.
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Affiliation(s)
- S Arias-Rivera
- Investigación de enfermería. Hospital Universitario de Getafe, Getafe. CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, España
| | - R Jam-Gatell
- Área de críticos. Hospital Universitari Parc Taulí, Sabadell, Barcelona, España
| | - X Nuvials-Casals
- Área de Desarrollo Profesional e investigación de Enfermería, Clínica Universidad de Navarra. Universidad de Navarra. IdisNA, Instituto de Investigación Sanitaria de Navarra, Navarra, España
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Subramaniam A, Lim ZJ, Ponnapa Reddy M, Mitchell H, Shekar K. SARS-CoV-2 transmission risk to healthcare workers performing tracheostomies: a systematic review. ANZ J Surg 2022; 92:1614-1625. [PMID: 35655401 PMCID: PMC9347596 DOI: 10.1111/ans.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/10/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tracheostomy is a commonly performed procedure in patients with coronavirus disease 2019 (COVID-19) receiving mechanical ventilation (MV). This review aims to investigate the occurrence of SARS-CoV-2 transmission from patients to healthcare workers (HCWs) when tracheostomies are performed. METHODS This systematic review used the preferred reporting items for systematic reviews and meta-analysis framework. Studies reporting SARS-CoV-2 infection in HCWs involved in tracheostomy procedures were included. RESULTS Sixty-nine studies (between 01/11/2019 and 16/01/2022) reporting 3117 tracheostomy events were included, 45.9% (1430/3117) were performed surgically. The mean time from MV initiation to tracheostomy was 16.7 ± 7.9 days. Location of tracheostomy, personal protective equipment used, and anaesthesia technique varied between studies. The mean procedure duration was 14.1 ± 7.5 minutes; was statistically longer for percutaneous tracheostomies compared with surgical tracheostomies (mean duration 17.5 ± 7.0 versus 15.5 ± 5.6 minutes, p = 0.02). Across 5 out of 69 studies that reported 311 tracheostomies, 34 HCWs tested positive for SARS-CoV-2 and 23/34 (67.6%) were associated with percutaneous tracheostomies. CONCLUSIONS In this systematic review we found that SARS-CoV-2 transmission to HCWs performing or assisting with a tracheostomy procedure appeared to be low, with all reported transmissions occurring in 2020, prior to vaccinations and more recent strains of SARS-CoV-2. Transmissions may be higher with percutaneous tracheostomies. However, an accurate estimation of infection risk was not possible in the absence of the actual number of HCWs exposed to the risk during the procedure and the inability to control for multiple confounders related to variable timing, technique, and infection control practices.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care MedicinePeninsula HealthMelbourneVictoria
- Monash University, Peninsula Clinical SchoolMelbourneVictoriaAustralia
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Zheng Jie Lim
- Department of AnaesthesiaAustin HospitalHeidelbergVictoriaAustralia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care MedicinePeninsula HealthMelbourneVictoria
- Department of Intensive Care MedicineCalvary HospitalCanberraAustralian Capital TerritoryAustralia
| | - Hayden Mitchell
- Department of MedicinePeninsula HealthFrankstonVictoriaAustralia
| | - Kiran Shekar
- Adult Intensive Care ServicesThe Prince Charles HospitalBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
- Institute of Health and Biomedical innovationUniversity of Technology BrisbaneBrisbaneQueenslandAustralia
- School of MedicineBond UniversityGold CoastQueenslandAustralia
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Klompas M, Branson R, Cawcutt K, Crist M, Eichenwald EC, Greene LR, Lee G, Maragakis LL, Powell K, Priebe GP, Speck K, Yokoe DS, Berenholtz SM. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:687-713. [PMID: 35589091 PMCID: PMC10903147 DOI: 10.1017/ice.2022.88] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Branson
- Department of Surgery, University of Cincinnati Medicine, Cincinnati, Ohio
| | - Kelly Cawcutt
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Crist
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Eric C Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda R Greene
- Highland Hospital, University of Rochester, Rochester, New York
| | - Grace Lee
- Stanford University School of Medicine, Palo Alto, California
| | - Lisa L Maragakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krista Powell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and Harvard Medical School, Boston, Massachusetts
| | - Kathleen Speck
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deborah S Yokoe
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Sean M Berenholtz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Hernandez G, Roca O. Response. Chest 2022; 161:e396. [PMID: 35680328 DOI: 10.1016/j.chest.2022.01.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 01/31/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
| | - Oriol Roca
- Intensive Care Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain; Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
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Eeg-Olofsson M, Pauli N, Hafsten L, Jacobsson J, Lundborg C, Brink M, Larsson H, Lindell E, Löwhagen K, Gisslén M, Bergquist H. TTCOV19: timing of tracheotomy in SARS-CoV-2-infected patients: a multicentre, single-blinded, randomized, controlled trial. Crit Care 2022; 26:142. [PMID: 35585614 PMCID: PMC9115544 DOI: 10.1186/s13054-022-04005-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/01/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Critically ill COVID-19 patients may develop acute respiratory distress syndrome and the need for respiratory support, including mechanical ventilation in the intensive care unit. Previous observational studies have suggested early tracheotomy to be advantageous. The aim of this parallel, multicentre, single-blinded, randomized controlled trial was to evaluate the optimal timing of tracheotomy. METHODS SARS-CoV-2-infected patients within the Region Västra Götaland of Sweden who needed intubation and mechanical respiratory support were included and randomly assigned to early tracheotomy (≤ 7 days after intubation) or late tracheotomy (≥ 10 days after intubation). The primary objective was to compare the total number of mechanical ventilation days between the groups. RESULTS One hundred fifty patients (mean age 65 years, 79% males) were included. Seventy-two patients were assigned to early tracheotomy, and 78 were assigned to late tracheotomy. One hundred two patients (68%) underwent tracheotomy of whom sixty-one underwent tracheotomy according to the protocol. The overall median number of days in mechanical ventilation was 18 (IQR 9; 28), but no significant difference was found between the two treatment regimens in the intention-to-treat analysis (between-group difference: - 1.5 days (95% CI - 5.7 to 2.8); p = 0.5). A significantly reduced number of mechanical ventilation days was found in the early tracheotomy group during the per-protocol analysis (between-group difference: - 8.0 days (95% CI - 13.8 to - 2.27); p = 0.0064). The overall correlation between the timing of tracheotomy and days of mechanical ventilation was significant (Spearman's correlation: 0.39, p < 0.0001). The total death rate during intensive care was 32.7%, but no significant differences were found between the groups regarding survival, complications or adverse events. CONCLUSIONS The potential superiority of early tracheotomy when compared to late tracheotomy in critically ill patients with COVID-19 was not confirmed by the present randomized controlled trial but is a strategy that should be considered in selected cases where the need for MV for more than 14 days cannot be ruled out. Trial registration NCT04412356 , registered 05/24/2020.
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Affiliation(s)
- Måns Eeg-Olofsson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden.
| | - Nina Pauli
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden
| | - Louise Hafsten
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden
| | - Josephine Jacobsson
- Department of Anesthesia and Intensive Care Medicine, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher Lundborg
- Department of Anesthesia and Intensive Care Medicine, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Brink
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Helen Larsson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Region Västra Götaland, NU-Hospital Group, Head and Neck Surgery, Trollhättan, Sweden
| | - Ellen Lindell
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Region Västra Götaland, Södra Älvsborg Hospital, Boras, Sweden
| | - Karin Löwhagen
- Department of Anesthesia and Intensive Care Medicine, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henrik Bergquist
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden
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Bösel J, Niesen WD, Salih F, Morris NA, Ragland JT, Gough B, Schneider H, Neumann JO, Hwang DY, Kantamneni P, James ML, Freeman WD, Rajajee V, Rao CV, Nair D, Benner L, Meis J, Klose C, Kieser M, Suarez JI, Schönenberger S, Seder DB. Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA 2022; 327:1899-1909. [PMID: 35506515 PMCID: PMC9069344 DOI: 10.1001/jama.2022.4798] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Many patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation. OBJECTIVE To test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020. INTERVENTIONS Patients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194). MAIN OUTCOMES AND MEASURES The primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death). RESULTS Among 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, -3.6% [95% CI, -14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy. CONCLUSIONS AND RELEVANCE Among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02377167.
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Affiliation(s)
- Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology, Freiburg University Hospital, Freiburg im Breisgau, Germany
| | - Farid Salih
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Nicholas A. Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Jeremy T. Ragland
- Department of Neurosurgery, University of Texas Health Science Center, Houston
| | - Bryan Gough
- Department of Neurology, Ohio State University, Wexner Medical Center, Columbus
| | - Hauke Schneider
- Department of Neurology, Dresden University Hospital, Dresden, Germany
- Now with the Department of Neurology, Augsburg University Hospital Augsburg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - David Y. Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Phani Kantamneni
- Department of Medicine, Kadlec Regional Medical Center, Richland, Washington
| | - Michael L. James
- Departments of Anesthesiology and Neurology, Duke University Hospital, Durham, North Carolina
| | - William D. Freeman
- Departments of Neurology, Neurologic Surgery, and Critical Care, Mayo Clinic, Jacksonville, Florida
| | | | - Chethan Venkatasubba Rao
- Department of Neurology, Neurosurgery and Center for Space Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Laura Benner
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - José I. Suarez
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David B. Seder
- Department of Critical Care Services, Maine Medical Center, Portland, Maine
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Chong WH, Tan CK. Clinical Outcomes of Early Versus Late Tracheostomy in Coronavirus Disease 2019 Patients: A Systematic Review and Meta-Analysis. J Intensive Care Med 2022; 37:1121-1132. [PMID: 35506907 DOI: 10.1177/08850666221098930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND A significant proportion of Coronavirus Disease 2019 (COVID-19) patients require admission to the intensive care unit (ICU) and invasive mechanical ventilation (IMV). Tracheostomy is increasingly performed when a prolonged course of IMV is anticipated. OBJECTIVES To determine clinical and resource utilization benefits of early versus late tracheostomy among COVID-19 patients. METHODS Pubmed, Cochrane Library, Scopus, and Embase were used to identify relevant studies comparing outcomes of COVID-19 patients undergoing early and late tracheostomy from January 1, 2020, to December 1, 2021. RESULTS Twelve studies were selected, and 2222 critically ill COVID-19 patients hospitalized between January to December 2020 were included. Among the included patients, 34.5% and 65.5% underwent early and late tracheostomy, respectively. Among the included studies, 58.3% and 41.7% defined early tracheostomy using cutoffs of 14 and 10 days, respectively. All-cause in-hospital mortality was not different between the early and late tracheostomy groups (32.9% vs. 33.1%; OR = 1.00; P = 0.98). Sensitivity analysis demonstrated a similar mortality rate in studies using a cutoff of 10 days (34.6% vs. 35.5%; OR = 0.97; P = 0.89) or 14 days (31.2% vs. 27.7%; OR = 1.05; P = 0.78). The early tracheostomy group had shorter ICU length of stay (LOS) (mean: 23.18 vs. 30.51 days; P < 0.001) and IMV duration (mean: 20.49 vs. 28.94 days; P < 0.001) than the late tracheostomy group. The time from tracheostomy to decannulation was longer (mean: 23.36 vs. 16.24 days; P = 0.02) in the early tracheostomy group than in the late tracheostomy group, but the time from tracheostomy to IMV weaning was similar in both groups. Other clinical characteristics, including age, were similar in both groups. CONCLUSIONS Early tracheostomy reduced the ICU LOS and IMV duration among COVID-19 patients compared with late tracheostomy, but the mortality rate was similar in both groups. The findings have important implications for the treatment of COVID-19 patients, especially in a resource-limited setting.
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Affiliation(s)
- Woon Hean Chong
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, 242949Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore
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Hansson A, Sunnergren O, Hammarskjöld A, Alkemark C, Taxbro K. Characteristics, complications, and a comparison between early and late tracheostomy: A retrospective observational study on tracheostomy in patients with COVID‐19‐related acute respiratory distress syndrome. Health Sci Rep 2022; 5:e595. [PMID: 35509382 PMCID: PMC9059198 DOI: 10.1002/hsr2.595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 01/08/2023] Open
Abstract
Background and Aims As the coronavirus disease 2019 (COVID-19) pandemic spread worldwide in 2020, the number of patients requiring intensive care and invasive mechanical ventilation (IMV) has increased rapidly. During the pandemic, early recommendations suggested that tracheostomy should be postponed, as the potential benefits were not certain to exceed the risk of viral transmission to healthcare workers. The aim of this study was to assess the utility of tracheostomy in patients with COVID-19-related acute respiratory distress syndrome, in terms of patient and clinical characteristics, outcomes, and complications, by comparing between early and late tracheostomy. Methods A multicenter, retrospective observational study was conducted in Jönköping County, Sweden. Between 14 March 2020 and 13 March 2021, 117 patients were included. All patients ≥18 years of age with confirmed COVID-19, who underwent tracheostomy were divided into two groups based on the timing of the procedure (≤/>7 days). Outcomes including the time on IMV, intensive care unit (ICU) length of stay, and mortality 30 days after ICU admission, as well as complications due to tracheostomy were compared between the groups. Results Early tracheostomy (<7 days, n = 56) was associated with a shorter median duration of mechanical ventilation (7 [12], p = 0.001) as well as a shorter median ICU stay (8 [14], p = 0.001). The most frequent complication of tracheostomy was minor bleeding. With the exception of a higher rate of obesity in the group receiving late tracheostomy, the patient characteristics were similar between the groups. Conclusion This study showed that early tracheostomy was safe and associated with a shorter time on IMV as well as a shorter ICU length of stay, implicating possible clinical benefits in critically ill COVID-19 patients. However, it is necessary to verify these findings in a randomized controlled trial.
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Affiliation(s)
- Anna Hansson
- Department of Anaesthesiology and Intensive Care Medicine Ryhov County Hospital Jönköping Sweden
- Faculty of Medicine and Health Sciences, School of Medicine Linköping University Linköping Sweden
| | - Ola Sunnergren
- Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
- Department of Otorhinolaryngology Region Jönköping County Jönköping Sweden
| | - Anneli Hammarskjöld
- Department of Anaesthesiology and Intensive Care Medicine Ryhov County Hospital Jönköping Sweden
| | - Catarina Alkemark
- Department of Anaesthesiology and Intensive Care Medicine Ryhov County Hospital Jönköping Sweden
| | - Knut Taxbro
- Department of Anaesthesiology and Intensive Care Medicine Ryhov County Hospital Jönköping Sweden
- Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
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45
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Tanaka A, Uchiyama A, Kitamura T, Sakaguchi R, Komukai S, Matsuyama T, Yoshida T, Tokuhira N, Iguchi N, Fujino Y. Association between early tracheostomy and patient outcomes in critically ill patients on mechanical ventilation: a multicenter cohort study. J Intensive Care 2022; 10:19. [PMID: 35410403 PMCID: PMC8996211 DOI: 10.1186/s40560-022-00610-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/10/2022] [Indexed: 12/04/2022] Open
Abstract
Background Tracheostomy is commonly performed in critically ill patients because of its clinical advantages over prolonged translaryngeal endotracheal intubation. Early tracheostomy has been demonstrated to reduce the duration of mechanical ventilation and length of stay. However, its association with mortality remains ambiguous. This study aimed to evaluate the association between the timing of tracheostomy and mortality in patients receiving mechanical ventilation. Methods We performed a retrospective cohort analysis of adult patients who underwent tracheostomy during their intensive care unit (ICU) admission between April 2015 and March 2019. Patients who underwent tracheostomy before or after 29 days of ICU admission were excluded. Data were collected from the nationwide Japanese Intensive Care Patient Database. The primary outcome was hospital mortality. The timing of tracheostomy was stratified by quartile, and the association between patient outcomes was evaluated using regression analysis. Results Among the 85558 patients admitted to 46 ICUs during the study period, 1538 patients were included in the analysis. The quartiles for tracheostomy were as follows: quartile 1, ≤ 6 days; quartile 2, 7–10 days; quartile 3, 11–14 days; and quartile 4, > 14 days. Hospital mortality was significantly higher in quartile 2 (adjusted odds ratio [aOR]: 1.52, 95% confidence interval [CI]: 1.08–2.13), quartile 3 (aOR: 1.82, 95% CI: 1.28–2.59), and quartile 4 (aOR: 2.26, 95% CI: 1.61–3.16) (p for trend < 0.001) than in quartile 1. A similar trend was observed in the subgroup analyses of patients with impaired consciousness (Glasgow Coma Scale score < 8) and respiratory failure (PaO2:FiO2 ≤ 300) at ICU admission (p for trend = 0.081 and 0.001, respectively). Conclusions This multi-institutional observational study demonstrated that the timing of tracheostomy was significantly and independently associated with hospital mortality in a stepwise manner. Thus, early tracheostomy may be beneficial for patient outcomes, including mortality, and warrants further investigation. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00610-x.
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46
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Craven J, Slaughter A, Potter KF. Early tracheostomy: on the cutting edge, some benefit more than others. Curr Opin Anaesthesiol 2022; 35:236-241. [PMID: 35131970 DOI: 10.1097/aco.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The decision to undergo early tracheostomy in critically ill patients has been the subject of multiple studies in recent years, including several meta-analyses and a large-scale examination of the National in-patient Sampling (NIS) database. The research has focused on different patient populations, and identified common outcomes measures related to ventilation. At the crux of the new research is the decision to undergo an additional invasive procedure, mainly tracheostomy, rather than attempt endotracheal tube ventilation with or without early extubation. Notably, recent research indicates that neurological and SARS-CoV-2 (COVID-19) patients seem to have an exaggerated benefit from early tracheostomy. RECENT FINDINGS Recent studies of patients undergoing early tracheostomy have shown decreases in ventilator associated pneumonia, ventilator duration and duration of ICU stay. However, these studies have shown mixed data with respect to mortality and length of hospitalization. Such advantages only become apparent with large-scale examination. Confounding the overall discussion is that the research has focused on heterogeneous groups, including neurosurgical ICU patients, general ICU patients, and most recently, intubated COVID-19 patients. SUMMARY Specific populations such as neurosurgical and COVID-19 patients have clearly defined benefits following early tracheostomy. Although the benefit is less pronounced, there does seem to be an advantage in general ICU patients with regards to ventilator-free days and lower incidence of ventilator-associated pneumonia. In these patients, large-scale examination points to a clear mortality benefit.
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Affiliation(s)
- Jack Craven
- Virginia Commonwealth University Health System, Department of Anesthesiology
| | - Ashley Slaughter
- Virginia Commonwealth University Health System, Department of Surgery, Richmond, Virginia, USA
| | - Kenneth F Potter
- Virginia Commonwealth University Health System, Department of Anesthesiology - Division of Critical Care Medicine
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47
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Cohen SE, Lopez AR, Ng PK, Friedman OA, Chaux GE. Percutaneous Tracheostomy in Respiratory Failure Due to COVID-19. J Bronchology Interv Pulmonol 2022; 29:125-130. [PMID: 34347696 DOI: 10.1097/lbr.0000000000000800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/30/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) can lead to hypoxemic respiratory failure resulting in prolonged mechanical ventilation. Typically, tracheostomy is considered in patients who remain ventilator dependent beyond 2 weeks. However, in the setting of this novel respiratory virus, the safety and benefits of tracheostomy are not well-defined. Our aim is to describe our experience with percutaneous tracheostomy in patients with COVID-19. MATERIALS AND METHODS This is a single center retrospective descriptive study. We reviewed comorbidities and outcomes in patients with respiratory failure due to COVID-19 who underwent percutaneous tracheostomy at our institution from April 2020 to September 2020. In addition, we provide details of our attempt to minimize aerosolization by using a modified protocol with brief periods of planned apnea. RESULTS A total of 24 patients underwent percutaneous tracheostomy during the study. The average body mass index was 33.0±10.0. At 30 days posttracheostomy 17 (71%) patients still had the tracheostomy tube and 14 (58%) remained ventilator dependent. There were 3 (13%) who died within 30 days. At the time of data analysis in November 2020, 9 (38%) patients had died and 7 (29%) had been decannulated. None of the providers who participated in the procedure experienced signs or symptoms of COVID-19 infection. CONCLUSION Percutaneous tracheostomy in prolonged respiratory failure due to COVID-19 appears to be safe to perform at the bedside for both the patient and health care providers in the appropriate clinical context. Morbid obesity did not limit the ability to perform percutaneous tracheostomy in COVID-19 patients.
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Affiliation(s)
- Samuel E Cohen
- Department of Pulmonary and Critical Care Medicine
- Procedure Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Angelena R Lopez
- Department of Pulmonary and Critical Care Medicine
- Procedure Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Philip K Ng
- Department of Pulmonary and Critical Care Medicine
- Procedure Center, Cedars-Sinai Medical Center, Los Angeles, CA
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The RAISE Score: A Possible Tool to Better Identify Subarachnoid Hemorrhage Patients Who Might Benefit From Early Tracheostomy? Crit Care Med 2022; 50:e329-e330. [PMID: 35191885 DOI: 10.1097/ccm.0000000000005367] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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49
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Ji Y, Fang Y, Cheng B, Li L, Fang X. Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis. Crit Care 2022; 26:40. [PMID: 35135597 PMCID: PMC8822732 DOI: 10.1186/s13054-022-03904-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/26/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients' outcomes. METHODS We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14 days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model. RESULTS Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV (2098 patients; MD - 9.08 days, 95% CI - 10.91 to - 7.26 days, p < 0.01) and duration of ICU stay (1224 patients; MD - 9.41 days, 95% CI - 12.36 to - 6.46 days, p < 0.01). Mortality was reported for 2343 patients and was comparable between groups (OR 1.09, 95% CI 0.79-1.51, p = 0.59). CONCLUSIONS The results of this meta-analysis suggest that, compared with late tracheostomy, early tracheostomy in COVID-19 patients was associated with shorter duration of IMV and ICU stay without modifying the mortality rate. These findings may have important implications to improve ICU availability during the COVID-19 pandemic. Trial registration The protocol was registered at INPLASY (INPLASY202180088).
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Affiliation(s)
- Yun Ji
- Department of Surgical Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Yumin Fang
- Department of Intensive Care Unit, Suichang People's Hospital, Lishui, Zhejiang, China
| | - Baoli Cheng
- Department of Anesthesiology and Intensive Care, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Libin Li
- Department of Surgical Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Xiangming Fang
- Department of Anesthesiology and Intensive Care, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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Hernandez G, Ramos FJ, Añon JM, Ortiz R, Colinas L, Masclans JR, De Haro C, Ortega A, Peñuelas O, Cruz-Delgado MDM, Canabal A, Plans O, Vaquero C, Rialp G, Gordo F, Lesmes A, Martinez M, Figueira JC, Gomez-Carranza A, Corrales R, Castellvi A, Castiñeiras B, Frutos-Vivar F, Prada J, De Pablo R, Naharro A, Montejo JC, Diaz C, Santos-Peral A, Padilla R, Marin-Corral J, Rodriguez-Solis C, Sanchez-Giralt JA, Jimenez J, Cuena R, Perez-Hoyos S, Roca O. Early Tracheostomy for Managing ICU Capacity During the COVID-19 Outbreak: A Propensity-Matched Cohort Study. Chest 2022; 161:121-129. [PMID: 34147502 PMCID: PMC8361308 DOI: 10.1016/j.chest.2021.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND During the first wave of the COVID-19 pandemic, shortages of ventilators and ICU beds overwhelmed health care systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ICU stay is controversial. RESEARCH QUESTION Can failure-free day outcomes focused on ICU resources help to decide the optimal timing of tracheostomy in overburdened health care systems during viral epidemics? STUDY DESIGN AND METHODS This retrospective cohort study included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, when ICU occupancy modified clinician criteria to perform tracheostomy in Patients with COVID-19. We compared ventilator-free days at 28 and 60 days and ICU- and hospital bed-free days at 28 and 60 days in propensity score-matched cohorts who underwent tracheostomy at different timings (≤ 7 days, 8-10 days, and 11-14 days after intubation). RESULTS Of 1,939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (≤ 7 days vs > 7 days [116 patients included in the analysis]: median, 9 days [interquartile range (IQR), 0-15 days] vs 3 days [IQR, 0-7 days]; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs > 10 days [222 patients analyzed]: 6 days [IQR, 0-10 days] vs 0 days [IQR, 0-6 days]; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs > 14 days [318 patients analyzed]: 4 days [IQR, 0-9 days] vs 0 days [IQR, 0-2 days]; difference, 3 days; 95% CI, 2.1-3.9 days). Except hospital bed-free days at 28 days, all other end points were better with early tracheostomy. INTERPRETATION Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on a ventilator in particular may improve ICU availability.
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Affiliation(s)
- Gonzalo Hernandez
- Intensive Care Unit, University Hospital Virgen de la Salud, Toledo, Spain.
| | | | - José Manuel Añon
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain; Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
| | - Ramón Ortiz
- Intensive Care Unit, Ciudad Real University Hospital, Ciudad Real, Sabadell, Spain
| | - Laura Colinas
- Intensive Care Unit, University Hospital Virgen de la Salud, Toledo, Spain
| | - Joan Ramón Masclans
- Intensive Care Unit, Del Mar University Hospital, Barcelona, Spain; Mar Medical Research Institute, UPF, Departament de Ciències Experimentals i de la Salut-DCEXS, Barcelona, Spain
| | | | - Alfonso Ortega
- Intensive Care Unit, Puerta de Hierro University Hospital, Madrid, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Getafe University Hospital, Madrid, Spain
| | | | - Alfonso Canabal
- Intensive Care Unit, La Princesa University Hospital, Madrid, Spain
| | - Oriol Plans
- Intensive Care Unit, Joan XXIII University Hospital, Tarragona, Spain
| | | | - Gemma Rialp
- Intensive Care Unit, Son Llatzer University Hospital, Mallorca, Spain
| | - Federico Gordo
- Intensive Care Unit, Henares University Hospital, Madrid, Spain; Universidad Francisco de Vitoria, Madrid, Spain
| | - Amanda Lesmes
- Intensive Care Unit, 12 de Octubre University Hospital, Madrid, Spain
| | - María Martinez
- Intensive Care Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | - Rocio Corrales
- Department of Otolaryngology-Head and Neck Surgery, University Hospital Virgen de la Salud, Toledo, Spain
| | - Andrea Castellvi
- Intensive Care Unit, Del Mar University Hospital, Barcelona, Spain
| | | | | | - Jorge Prada
- Department of Otolaryngology-Head and Neck Surgery, La Princesa University Hospital, Madrid, Spain
| | - Raul De Pablo
- Intensive Care Unit, Ramón y Cajal University Hospital, Madrid, Spain; Critical Care Department, Alcala de Henares University, Alcala de Henares, Spain
| | - Antonio Naharro
- Intensive Care Unit, Henares University Hospital, Madrid, Spain
| | | | - Claudia Diaz
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
| | - Alfonso Santos-Peral
- Intensive Care Unit, Ciudad Real University Hospital, Ciudad Real, Sabadell, Spain
| | - Rebeca Padilla
- Intensive Care Unit, University Hospital Virgen de la Salud, Toledo, Spain
| | | | | | | | - Jorge Jimenez
- Intensive Care Unit, Getafe University Hospital, Madrid, Spain
| | | | - Santiago Perez-Hoyos
- Statistics and Bioinformatics Unit, Vall d'Hebron Research Institute, Barcelona, Spain; IDIBAPS, the Genetics, Microbiology and Statistics Department, University of Barcelona, Barcelona, Spain
| | - Oriol Roca
- Intensive Care Unit, Vall d'Hebron University Hospital, Barcelona, Spain; Ciber Enfermedades Respiratorias (CIBERES), Health Institute Carlos III, Madrid, Spain
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