Outcomes of early versus late tracheostomy: 2008-2010

A U-shaped association of tracheostomy timing with all-cause mortality in mechanically ventilated patients admitted to the intensive care unit: A retrospective cohort study

Objectives

To evaluate the association of tracheostomy timing with all-cause mortality in patients with mechanical ventilation (MV).

Method

It's a retrospective cohort study. Adult patients undergoing invasive MV who received tracheostomy during the same hospitalization based on the Medical Information Mart for Intensive Care-III (MIMIC-III) database, were selected. The primary outcome was the relationship between tracheostomy timing and 90-day all-cause mortality. A restricted cubic spline was used to analyze the potential non-linear correlation between tracheostomy timing and 90-day all-cause mortality. The secondary outcomes included free days of MV, incidence of ventilator-associated pneumonia (VAP), free days of analgesia/sedation in the intensive care unit (ICU), length of stay (LOS) in the ICU, LOS in hospital, in-ICU mortality, and 30-day all-cause mortality.

Results

A total of 1,209 patients were included in this study, of these, 163 (13.5%) patients underwent tracheostomy within 4 days after intubation, while 647 (53.5%) patients underwent tracheostomy more than 11 days after intubation. The tracheotomy timing showed a U-shaped relationship with all-cause mortality, patients who underwent tracheostomy between 5 and 10 days had the lowest 90-day mortality rate compared with patients who underwent tracheostomy within 4 days and after 11 days [84 (21.1%) vs. 40 (24.5%) and 206 (31.8%), P < 0.001].

Conclusion

The tracheotomy timing showed a U-shaped relationship with all-cause mortality, and the risk of mortality was lowest on day 8, but a causal relationship has not been demonstrated.

Early versus standard tracheostomy in ventilated patients in neurosurgical intensive care unit: A randomized controlled trial

INTRODUCTION

Tracheostomy is performed in patients with prolonged mechanical ventilation, who suffered catastrophic neurologic insult or upper airway obstruction. Thus far, there is no consensus on the optimal timing in performing a tracheostomy. This study aims to test whether early tracheostomy in mechanically ventilated patients in a neurosurgical setting would be associated with a shorter time of mechanical ventilation as compared to standard tracheostomy.

METHODS

This single-center prospective randomized controlled trial was conducted at University Malaya Medical Centre from July 2019 to July 2021. The likelihood of prolonged ventilation was determined objectively using the TRACH score and the patient's clinical presentation. The outcomes measured were days of mechanical ventilation post-tracheostomy, days of neuro-intensive care unit stay, and days of hospital stay. Tracheostomy-related complications were collected. The data collected were analyzed using Statistical Package for the Social Sciences version 25 for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS

In all, 39 patients were randomly assigned. Of these, 20 were allocated to the early tracheostomy group (ET) and 19 were allocated to the standard tracheostomy group (ST). The demographic characteristics were similar between the groups. The primary outcome, mean (SD) days of mechanical ventilation post-tracheostomy, was statistically different in the 2 groups- early 11.9 (9.3) days, standard 18.9 (32.5) days; p = 0.014. There were comparable tracheostomy-related complications in both groups.

CONCLUSION

Early tracheostomy is associated with a shorter duration of mechanical ventilation in a neurosurgical intensive care unit setting.

Guidelines for Tracheostomy From the Korean Bronchoesophagological Society

The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.

Otolaryngology during COVID-19: Preventive care and precautionary measures

Since the outbreak of novel coronavirus disease (COVID-19) in December 2019, it has spread to various regions and countries, forming a global pandemic. Reducing nosocomial infection is a new issue and challenge for all healthcare systems. Otolaryngology is a high-risk specialty as it close contact with upper respiratory tract mucous, secretions, droplets and aerosols during procedures and surgery. Therefore, infection prevention and control measures for this specialty are essential. Literatures on the epidemiology, clinical characteristics and infection control measures of COVID-19 were reviewed, practical knowledge from first-line otolaryngologists in China, the United States, and Brazil were reviewed and collated. It was recommended that otolaryngology professionals should improve screening in suspected patients with relevant nasal and pharyngeal symptoms and signs, suspend non-emergency consultations and examinations in clinics, and rearrange the working procedures in operating rooms. The guidelines of personal protective equipment for swab sampling, endoscopy and surgery were listed. Indications for tracheotomy during the pandemic should be carefully considered to avoid unnecessary airway opening and aerosol-generation; precautions during surgery to reduce the risk of exposure and infection were illustrated. This review aimed to provide recommendations for otolaryngologists to enhance personal protection against COVID-19 and reduce the risk of nosocomial infection.

Use of Tracheostomy During the COVID-19 Pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/Association of Interventional Pulmonology Program Directors Expert Panel Report

Background

The role of tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic remains unknown. The goal of this consensus statement is to examine the current evidence for performing tracheostomy in patients with respiratory failure from COVID-19 and offer guidance to physicians on the preparation, timing, and technique while minimizing the risk of infection to health care workers (HCWs).

Methods

A panel including intensivists and interventional pulmonologists from three professional societies representing 13 institutions with experience in managing patients with COVID-19 across a spectrum of health-care environments developed key clinical questions addressing specific topics on tracheostomy in COVID-19. A systematic review of the literature and an established modified Delphi consensus methodology were applied to provide a reliable evidence-based consensus statement and expert panel report.

Results

Eight key questions, corresponding to 14 decision points, were rated by the panel. The results were aggregated, resulting in eight main recommendations and five additional remarks intended to guide health-care providers in the decision-making process pertinent to tracheostomy in patients with COVID-19-related respiratory failure.

Conclusion

This panel suggests performing tracheostomy in patients expected to require prolonged mechanical ventilation. A specific timing of tracheostomy cannot be recommended. There is no evidence for routine repeat reverse transcription polymerase chain reaction testing in patients with confirmed COVID-19 evaluated for tracheostomy. To reduce the risk of infection in HCWs, we recommend performing the procedure using techniques that minimize aerosolization while wearing enhanced personal protective equipment. The recommendations presented in this statement may change as more experience is gained during this pandemic.

Development of clinical tracheostomy score to identify cervical spinal cord injury patients requiring prolonged ventilator support

BACKGROUND

Cervical spinal cord injuries often necessitate ventilator support (VS). Prolonged endotracheal tube use has conveyed substantial morbidity in prospective study. Tracheostomy is recommended if VS is anticipated to be 7 days or longer, which defines prolonged ventilation (PV). Identifying these patients on arrival and before tracheostomy need is readily evident could prevent morbidity while lowering hospital costs. We aimed to create a tracheostomy score (trach score) to identify patients requiring PV and who could benefit from immediate tracheostomy.

METHODS

A review of patients with cervical spine fractures and cervical spinal cord injuries from 2005 to 2017 from the Pennsylvania Trauma Outcome Study database was performed. Patients were excluded for missing data, no use of VS or death in less than 7 days. Patients were selected for a training set or validation set by state identification number. We used automated forward stepwise selection to select a logistic model. Significant continuous variables were dichotomized to create a simplified screening score (trach score) and this was applied to the validation set.

RESULTS

Needing ventilation for 7 or more days was positively associated with higher Injury Severity Scores having a complete or anterior injury, and having a motor cord injury from C1 to C4. Application of the logistic model to the validation data produced a receiver operating characteristic curve with area under the curve of 0.7712, with 95% confidence limit (CL) of 0.6943 to 0.8481. The validation receiver operating characteristic curve was statistically better than chance using a contrast test with χ with p value less than 0.01. In the validation set, a trach score of 0 correlated to 33% needing PV, a score of 1 with 67% needing PV, 2 with 85%, and 3 with 98%.

CONCLUSION

Use of the trach score identified the majority of patients requiring prolonged VS in our study. An early tracheostomy protocol using predictive modeling could aid in reduction of intensive care unit length of stay and improving ventilator weaning in these patients. External verification of this predictive tool and of an early tracheostomy protocol is needed.

LEVEL OF EVIDENCE

This work is a retrospective prognostic cohort study and meets evidence Level III criteria.

Utilization of tracheostomy among geriatric trauma patients and association with mortality

BACKGROUND

The purpose of this study was to investigate trends in tracheostomy (TR) utilization among trauma patients over the last decade and explore its impact on mortality among elderly trauma patients.

METHODS

Patients 18 years or older with at least 72 h on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Patients were divided into three groups based on age: 18-60, 61-80, and > 80 years and proportions of patients undergoing a TR were depicted. Elderly (> 80 years) were divided into two groups, based on whether they underwent a TR. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to account for survival bias.

RESULTS

Over the 9-year study period 284,774 patients met inclusion criteria. Of those, 21,465 (7.5%) were older than 80 years. Elderly patients were significantly less likely to undergo a TR (13.1% vs. 21.5% in the 18-60 years and 20.4% in the 61-80 years group, p < 0.01) and this trend continued throughout the study period. Among the elderly patients, those who underwent TR were more likely to have a severe (AIS ≥ 3) thoracic, abdominal, and/or spinal injury, but not head injury and were less likely to have a history of cerebrovascular accident (5.9% vs. 7.7%, p < 0.01). The overall mortality was significantly higher in elderly patients who did not undergo a TR (46.9% vs. 17.6%, p < 0.01). The adjusted hazard ratio for elderly patients undergoing a TR was 0.36 (adjusted p < 0.01).

CONCLUSION

In ventilated trauma patients, tracheostomy is less likely to be utilized in the elderly population compared to younger age groups. Amongst the elderly patients, performance of tracheostomy was associated with a significantly higher overall survival. Delaying or avoiding this procedure in the elderly trauma patient predominantly based on age might not be justified.

STUDY TYPE

Prognostic/epidemiological.

LEVEL OF EVIDENCE

III or IV.

Healthcare costs and outcomes for patients undergoing tracheostomy in an Australian tertiary level referral hospital

OBJECTIVE

Patients undergoing tracheostomy represent a unique cohort, as often they have prolonged hospital stay, require multi-disciplinary, resource-intensive care, and may have poor outcomes. Currently, there is a lack of data around overall healthcare cost for these patients and their outcomes in terms of morbidity and mortality. The objective of the study was to estimate healthcare costs and outcomes associated in tracheostomy patients at a tertiary level hospital in South Australia.

DESIGN

Retrospective review of prospectively collected data in patients who underwent tracheostomy between July 2009 and May 2015.

METHODS

Overall healthcare-associated costs, length of mechanical ventilation, length of intensive care unit stay, and mortality rates were assessed.

RESULTS

A total of 454 patients with tracheostomies were examined. Majority of the tracheostomies (n = 386 (85%)) were performed in intensive care unit patients, predominantly using bedside percutaneous approach (85%). The median length of hospital stay was 44 (29-63) days and the in-hospital mortality rate was 20%. Overall total cost of managing a patient with tracheostomy was median $192,184 (inter-quartile range $122560-$295553); mean 225,200 (range $5942-$1046675) Australian dollars. There were no statistically significant differences in any of the measured outcomes, including costs, between patients who underwent percutaneous versus surgical tracheostomy and patients who underwent early versus late tracheostomy in their intensive care unit stay. Factors that predicted (adjusted R 2 = 0.53) the cost per patient were intensive care unit length of stay and hospital length of stay.

CONCLUSION

Hospitalised patients undergoing tracheostomy experience high morbidity and mortality and typically experience highly resource-intensive and costly healthcare.

Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review

The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.

Outcomes of Tracheostomy With Concomitant and Delayed Percutaneous Endoscopic Gastrostomy in the Neuroscience Critical Care Unit

BACKGROUND

In patients with severe neurologic conditions, percutaneous endoscopic gastrostomy (PEG) is typically performed either alone or with a tracheostomy. The characteristics and outcomes of patients receiving PEG concomitantly with a tracheostomy (CTPEG) and those receiving delayed PEG (DPEG) after a tracheostomy were compared.

METHODS

Retrospective cohort study in a 24-bed neuroscience critical care unit (NCCU) at a tertiary care hospital. Consecutive patients admitted to the NCCU from April 2007 to July 2013 who underwent percutaneous tracheostomy and gastrostomy by the percutaneous tracheostomy team were included and grouped according to the timing of PEG placement: CTPEG versus DPEG.

RESULTS

Of the 290 patients, 234 (81%) received CTPEG. Demographic and clinical characteristics were similar among the 2 groups except for a lower median (interquartile range [IQR]) body mass index (BMI; 27 [22.67-31.60] versus 30.8 [24.55-40.06], P = .017) and lower rate of acute respiratory distress syndrome (3.85% vs 10.71%, P = .048) in the CTPEG cohort. Furthermore, 59% of CTPEG cohort were neurology patients while 63% of DPEG were neurosurgery patients, P = .004. Primary outcomes showed shorter mean NCCU length of stay (LOS; 25 [12] vs 33 [17] days, P < .001) and median hospital LOS (32 [25-43] vs 37 [31-56] days, P = .002) for the CTPEG cohort. Secondary outcomes showed higher predischarge prealbumin levels (15.6 [7.75] vs 11.58 [5.41], P = .021) and lower median overall hospital cost (US$123 860.20 [US$99 024-US$168 713.40] vs US$159 633.50 [US$121 312-US$240 213.10], P = .0003) in the CTPEG group. Anatomic contraindications were the most common reason for DPEG (30%).

CONCLUSIONS

Among institutions with a tracheostomy team, the practice of tracheostomy with concomitant PEG placement may be considered as feasible as delayed PEG in carefully selected neurocritically ill patients with possible advantages of overall shorter NCCU and hospital LOS, higher predischarge prealbumin, and lower hospital costs. These findings may aid in decisions regarding the timing of PEG placement in the NCCU. Further prospective studies are warranted.

Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study

OBJECTIVE

Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.

DESIGN

In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. "Early tracheostomy" was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression.

SETTING

2012 National Inpatient Sample.

PATIENTS

A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01-1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98-1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9-81.9%) compared with pneumonia/sepsis (14.9-38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home.

CONCLUSION

Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.

A Survey of Mechanical Ventilator Practices Across Burn Centers in North America

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The χ, Fisher's exact, and Cochran-Mantel-Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association-supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

Inpatient Complications After Transsphenoidal Surgery in Cushing’s Versus Non-Cushing’s Disease Patients

Objective:

Transsphenoidal surgery (TSS) harbors a potential for hypopituitarism, cerebrospinal fluid (CSF) leaks, and other complications. We utilized the Nationwide Inpatient Sample Database (NIS) to compare inpatient complication rates between Cushing’s disease (CD) and non-Cushing’s disease (NCD) patients undergoing TSS.

Methods:

Inpatient hospitalization data for 960 CD and 12 110 NCD patients who underwent TSS between 2002 and 2010 were accessed. Demographic information, outcomes, and complication rates were evaluated.

Results:

Patients with CD had a female predilection (81.7%) and were younger (40.5 ± 14.4 years) than NCD patients (47.8% female; 52.1 ± 16.3 years) ( P < .001). Length of stay and total charges did not differ between groups. Patients with CD had significantly greater postoperative diabetes insipidus rates (14.0% vs 9.6%, P < .001) and urinary/renal complications (1.7% vs 0.9%, P = .027). After adjusting for possible confounders, the relationship between urinary/renal complications and CD status strengthened. There was no difference in rates of CSF leak and iatrogenic pituitary disorders overall.

Conclusion:

No differences were noted in the rate of early CSF leaks between postoperative TSS CD and NCD patients. Postoperative diabetes insipidus did not significantly differ between groups after adjusting for confounders. Only odds of urinary/renal complications in CD patients was significant after adjustment.

Transsphenoidal surgery for malignant pituitary lesions: an analysis of inpatient complications

BACKGROUND

Fewer than 4% of pituitary tumors are malignant lesions. These tumors predominantly represent metastatic disease from elsewhere. This study evaluates inpatient complications, demographics, and hospitalization characteristics of patients who underwent transsphenoidal surgery (TSS) for malignant pituitary lesions.

METHODS

The Nationwide Inpatient Sample was evaluated for TSS patients from 1998 to 2010. Demographics, hospitalization characteristics, and complications were evaluated among patients with malignant lesions and compared to those with benign tumors.

RESULTS

There were 17,425 inpatient records, 1.0% of which involved malignant pituitary tumors. There was no difference in age between these cohorts (p = 0.378). Patients with malignant tumors had greater length of stay (6.7 days vs 4.5 days, p = 0.003) and higher trending charges ($55,371 vs $40,550 p = 0.091). The most common postoperative complications among patients with malignant lesions included diabetes insipidus (DI) (17.9%), fluid/electrolyte abnormalities (14.0%), neurological complications (5.6%), cerebrospinal fluid (CSF) rhinorrhea (2.2%), and iatrogenic pituitary disorders (2.2%). Patients with malignant lesions had a significantly greater rates of postoperative DI and fluid/electrolyte abnormalities (odds ratio = 2.0 and 1.7, respectively), whereas no statistical difference was noted in the rates of CSF rhinorrhea (p = 0.372).

CONCLUSION

In this analysis of inpatient hospitalizations for TSS patients, malignant pituitary disease was associated with a greater rate of postoperative DI and fluid/electrolyte abnormalities, but no differences in the rates of postoperative CSF rhinorrhea and other complications were found. Patients with malignant pituitary lesions undergoing TSS had significantly longer hospitalizations and higher trending charges than those with benign lesions. This analysis is, however, subject to the limitations of the database.

Transsphenoidal surgery and diabetes mellitus: An analysis of inpatient data and complications

OBJECTIVES/HYPOTHESIS

Transsphenoidal surgery (TSS) has emerged as the standard approach for pituitary resection due to its minimally invasive nature. There has been little analysis examining the impact of diabetes mellitus (DM) on patients undergoing TSS. In this study, we characterize DM's association with postoperative TSS complications. In addition to analysis of associated charges and patient demographics, we performed comparison of complication rates between DM and non-DM patients who have undergone TSS in recent years.

METHODS

The Nationwide Inpatient Sample, a database encompassing nearly 8 million inpatient hospitalizations, was evaluated for patients undergoing TSS from 2002 to 2010.

RESULTS

Of 12,938 TSS patients, 2,173 (16.8%) had a DM diagnosis. The non-DM cohort was younger (50.1 y ± 16.6SD vs. 56.8 y ± 14.1; P < 0.001) and had shorter hospitalizations and lesser charges. DM patients had a greater incidence of pulmonary, cardiac, urinary/renal, and fluid/electrolyte complications, and had a lesser incidence of diabetes insipidus (P < 0.05). Upon controlling for age, the greater incidence of pulmonary and fluid/electrolyte complications was present only among patients < 60 years of age. Higher occurrence of cerebrospinal fluid rhinorrhea was noted among black diabetics when compared to non-DM blacks.

CONCLUSIONS

DM is associated with greater length of stay and hospital charges among TSS patients. DM patients undergoing TSS have a significantly greater incidence of pulmonary and fluid/electrolyte complications among patients under the age of 60, and greater risk for urinary/renal complications across all ages. Despite a theoretical concern due to an impaired wound-healing in DM patients, association with cerebrospinal fluid rhinorrhea was only noted among black diabetics.

LEVEL OF EVIDENCE

2C.