Evidence-based guidelines for the use of tracheostomy in critically ill patients

A nomogram for predicting the necessity of tracheostomy after severe acute brain injury in patients within the neurosurgery intensive care unit: A retrospective cohort study

Objective

This retrospective study was aimed to develop a predictive model for assessing the necessity of tracheostomy (TT) in patients admitted to the neurosurgery intensive care unit (NSICU).

Method

We analyzed data from 1626 NSICU patients with severe acute brain injury (SABI) who were admitted to the Department of NSICU at the Affiliated People's Hospital of Jiangsu University between January 2021 and December 2022. Data of the patients were retrospectively obtained from the clinical research data platform. The patients were randomly divided into training (70%) and testing (30%) cohorts. The least absolute shrinkage and selection operator (LASSO) regression identified the optimal predictive features. A multivariate logistic regression model was then constructed and represented by a nomogram. The efficacy of the model was evaluated based on discrimination, calibration, and clinical utility.

Results

The model highlighted six predictive variables, including the duration of NSICU stay, neurosurgery, orotracheal intubation time, Glasgow Coma Scale (GCS) score, systolic pressure, and respiration rate. Receiver operating characteristic (ROC) analysis of the nomogram yielded area under the curve (AUC) values of 0.854 (95% confidence interval [CI]: 0.822-0.886) for the training cohort and 0.865 (95% CI: 0.817-0.913) for the testing cohort, suggesting commendable differential performance. The predictions closely aligned with actual observations in both cohorts. Decision curve analysis demonstrated that the numerical model offered a favorable net clinical benefit.

Conclusion

We developed a novel predictive model to identify risk factors for TT in SABI patients within the NSICU. This model holds the potential to assist clinicians in making timely surgical decisions concerning TT.

Perceptions of critically ill individuals with acute and chronic spinal cord injury requiring a tracheostomy tube

STUDY DESIGN

Observational study.

OBJECTIVES

To evaluate the perceptions of patients requiring a tracheostomy tube and to identify possible different perceptions in critically ill patients with tracheostomy tubes who have acute (ASCI) or chronic spinal cord injuries (CSCI).

SETTING

Medical and surgical intensive care units (ICU) and intermediate care unit of the BG University Hospital Bergmannsheil Bochum, Germany.

METHODS

Patients who met the inclusion criteria completed a 25-item questionnaire on two consecutive days regarding their experiences and perceptions in breathing, coughing, pain, speaking, swallowing, and comfort of the tracheostomy tube.

RESULTS

A total of 51 persons with ASCI (n = 31) and CSCI (n = 20) were included with a mean age of 53 years. Individuals with ASCI reported significantly more frequent pain and swallowing problems as compared to individuals with CSCI (p ≤ 0.014) at initial assessment. There were no differences between ASCI and CSCI reported with respect to speaking and overall comfort.

CONCLUSIONS

It is necessary to regularly assess the perceptions of critically ill patients with tracheostomy tubes with ASCI or CSCI in the daily ICU care routine. We were able to assess these perceptions in different categories. For the future, evaluating the perception of individuals with SCI and a tracheostomy should be implemented to their daily routine care.

TRIAL REGISTRATION

DRKS00022073.

Impact of radiological surveillance for major blood vessels on complications of percutaneous dilatational tracheostomy: A retrospective cohort study

PURPOSE

Percutaneous dilatational tracheostomy (PDT) is the preferred method for managing long-term ventilator-dependent patients in ICUs. This study aimed to evaluate the association between preprocedural screening (ultrasound Doppler [USD] or computed tomography [CT]) for major neck blood vessels and complications in ICU patients undergoing PDT.

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent PDT between 2012 and 2023 at a tertiary referral center. We performed a multivariable analysis and created a propensity-matched cohort. The primary outcome was bleeding within the first seven days after PDT. Secondary outcomes included early and late PDT complications and PTD-related mortality.

RESULTS

A total of 1766 consecutive critically ill patients hospitalized at a tertiary academic hospital were evaluated for PDT. Of these, 881 (49.9 %) underwent only physical examination before PDT, while 885 (50.1 %) underwent additional imaging (CT/USD). A higher proportion of patients in the imaging group were referred to open surgery due to suspected major blood vessels interfering with the procedure (6.2 % vs. 3.0 %, p = 0.001). Among the 1685 patients who underwent PDT, there was no significant difference in the rate of early bleeding between the physical examination group and the imaging group (4.6 % vs. 6.3 %, p = 0.12). Similarly, the overall early complication rates (5.5 % vs. 7.6 %, p = 0.08), late complication rates (1.6 % vs. 2.2 %, p = 0.42), and PDT-related mortality rates (0.7 % vs. 0.6 %, p = 0.73) did not exhibit significant differences between the two groups. In a propensity score-matched cohort, results remained consistent.

CONCLUSIONS

Physical examination can effectively identify major neck blood vessels without increasing the risk of bleeding during and after PDT.

Liberation from mechanical ventilation in critically ill patients: Korean Society of Critical Care Medicine Clinical Practice Guidelines

BACKGROUND

Successful liberation from mechanical ventilation is one of the most crucial processes in critical care because it is the first step by which a respiratory failure patient begins to transition out of the intensive care unit and return to their own life. Therefore, when devising appropriate strategies for removing mechanical ventilation, it is essential to consider not only the individual experiences of healthcare professionals, but also scientific and systematic approaches. Recently, numerous studies have investigated methods and tools for identifying when mechanically ventilated patients are ready to breathe on their own. The Korean Society of Critical Care Medicine therefore provides these recommendations to clinicians about liberation from the ventilator.

METHODS

Meta-analyses and comprehensive syntheses were used to thoroughly review, compile, and summarize the complete body of relevant evidence. All studies were meticulously assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) method, and the outcomes were presented succinctly as evidence profiles. Those evidence syntheses were discussed by a multidisciplinary committee of experts in mechanical ventilation, who then developed and approved recommendations.

RESULTS

Recommendations for nine PICO (population, intervention, comparator, and outcome) questions about ventilator liberation are presented in this document. This guideline includes seven conditional recommendations, one expert consensus recommendation, and one conditional deferred recommendation.

CONCLUSIONS

We developed these clinical guidelines for mechanical ventilation liberation to provide meaningful recommendations. These guidelines reflect the best treatment for patients seeking liberation from mechanical ventilation.

Early risk factors for prolonged mechanical ventilation in patients with severe blunt thoracic trauma: A retrospective cohort study

BACKGROUND

A significant proportion of patients with severe chest trauma require mechanical ventilation (MV). Early prediction of the duration of MV may influence clinical decisions. We aimed to determine early risk factors for prolonged MV among adults suffering from severe blunt thoracic trauma.

METHODS

This retrospective, single-center, cohort study included all patients admitted between January 2014 and December 2020 due to severe blunt chest trauma. The primary outcome was prolonged MV, defined as invasive MV lasting more than 14 days. Multivariable logistic regression was performed to identify independent risk factors for prolonged MV.

RESULTS

The final analysis included 378 patients. The median duration of MV was 9.7 (IQR 3.0-18.0) days. 221 (58.5 %) patients required MV for more than 7 days and 143 (37.8 %) for more than 14 days. Male gender (aOR 3.01, 95 % CI 1.63-5.58, p < 0.001), age (aOR 1.40, 95 % CI 1.21-1.63, p < 0.001, for each category above 30 years), presence of severe head trauma (aOR 3.77, 95 % CI 2.23-6.38, p < 0.001), and transfusion of >5 blood units on admission (aOR 2.85, 95 % CI 1.62-5.02, p < 0.001) were independently associated with prolonged MV. The number of fractured ribs and the extent of lung contusions were associated with MV for more than 7 days, but not for 14 days. In the subgroup of 134 patients without concomitant head trauma, age (aOR 1.63, 95 % CI 1.18-2.27, p = 0.004, for each category above 30 years), respiratory comorbidities (aOR 9.70, 95 % CI 1.49-63.01, p = 0.017), worse p/f ratio during the first 24 h (aOR 1.55, 95 % CI 1.15-2.09, p = 0.004), and transfusion of >5 blood units on admission (aOR 5.71 95 % CI 1.84-17.68, p = 0.003) were independently associated with MV for more than 14 days.

CONCLUSIONS

Several predictors have been identified as independently associated with prolonged MV. Patients who meet these criteria are at high risk for prolonged MV and should be considered for interventions that could potentially shorten MV duration and reduce associated complications. Hemodynamically stable, healthy young patients suffering from severe thoracic trauma but no head injury, including those with extensive lung contusions and rib fractures, have a low risk of prolonged MV.

Audit of Tracheostomy Care Practices in a Nigerian Tertiary Neurosurgical Intensive Care Unit According to Published Guidelines

INTRODUCTION

Chest infections are a frequently encountered problem in patients admitted to the intensive care unit (ICU), more so in tracheostomised patients. This study aimed to audit the tracheostomy care practices in patients with neurosurgical pathologies in the ICU of Wellington Clinics Abuja, a tertiary neurosurgical hospital in Nigeria.

METHODS

We conducted a closed-loop audit with mixed methods involving analysis of 24 patients who had tracheostomy within the first two weeks of neurosurgical pathology at a tertiary neurosurgical hospital and semi-structured interviews to determine tracheostomy care practices among the primary caregivers - nurses, intensivists, and doctors.

RESULTS

Of the 161 ICU admissions in the first cycle, 22 patients received tracheostomy, 16 met the eligibility criteria. At re-audit (second cycle), eight of 40 patients met the criteria. All the patients received open suctioning through a dual cannula-cuffed tracheostomy tube and had independent portable suction units. In the baseline audit (first cycle), suction catheters were reused for 12-24 hours in each patient and were stored in varying combinations of normal saline and Savlon antiseptic (5 mg of cetrimide (0.5% w/w) and 1 mg of chlorhexidine digluconate (0.1% w/w)). The frequency, technique, and assessment of the need for airway suctioning were inconsistent among caregivers interviewed. All 16 patients had at least one episode of pneumonia, 10 patients had a second episode, and two patients had > two episodes. One mortality was recorded directly attributable to the complications of pneumonia. While in the re-audit, with adherence to recommendations, three patients suffered one episode of pneumonia and only one had a second episode. No mortality was recorded.

CONCLUSION

A standard practice guideline was necessary for tracheostomy care in our ICU. In low-resource settings, stated recommendations such as single-use suction catheters and improved hygienic practices can reduce rates of pneumonia in tracheostomised patients.

Risk Factors for Pulmonary Infection and Nursing Interventions Post-Tracheostomy in Patients with Spinal Cord Injury

Objective

We analyzed the characteristics and risk factors for pulmonary infection in patients with spinal cord injury who underwent tracheostomy and propose measures to help in early detection and intervention to reduce mortality and improve prognosis.

Methods

We collected data retrospectively from January 1, 2018, to December 31, 2022. The inclusion criteria were: Patients aged 18 years or more with a spinal cord injury who underwent tracheostomy, were treated with mechanical ventilation for over 48 hours, and were diagnosed as having a pulmonary infection. Sputum samples were cultured and analyzed.

Results

101 cases of pulmonary infection were analyzed, and the incidence was 32.17%. Diabetes (OR 2.302, 95% CI 1.285-3.972), hypoproteinemia (OR 1.992, 95% CI 1.125-3.101), administration of glucocorticoids (OR 2.934, 95% CI 1.412-4.661), ASIA grade A (OR 3.672, 95% CI 1.988-5.046), mechanical ventilation for ≥ 6 days (OR 2.108, 95% CI 1.385-4.751), and length of hospital stay for ≥ 20 days (OR 2.137, 95% CI 1.092-3.842) were risk factors for pulmonary infection in patients with spinal cord injury post-tracheostomy. Among 213 pathogenic bacteria, 52 (51.48%) were Gram-negative and 24 (23.76%) were Gram-positive. Klebsiella pneumoniae (15.84%) and Staphylococcus aureus (8.91%) were the most common pathogenic bacteria. The mortality rate of patients with gram-positive infection was higher than that of patients with gram-negative infection. K. pneumoniae and S. aureus were sensitive to cefoperazone, meropenem, and levofloxacin.

Conclusion

Pulmonary infection is a complication post-tracheostomy in patients with spinal cord injury. Diabetes, hypoproteinemia, administration of glucocorticoids, mechanical ventilation for ≥ 6 days, length of hospital stay for ≥ 20 days were risk factors for pulmonary infection. Pulmonary infection was mainly caused by gram-negative bacteria. Timely and effective measures for managing risk factors are essential for improving the prognosis of pulmonary infection post-tracheostomy in patients with spinal cord injuries.

Fatal Acute Airway Obstruction During Bronchoscopy-Guided Percutaneous Tracheostomy: An Analysis of a New Complication

Percutaneous tracheostomy (PT) is a commonly performed procedure in ICUs as a safe and cost-effective alternative to surgical tracheostomy (ST). Bronchoscopy is frequently used during PT for real-time confirmation of needle placement and tube positioning. We present a case of a 42-year-old female with a complex medical history who underwent PT and experienced acute airway loss due to endotracheal tube obstruction caused by accumulated secretions. To prevent such complications, vigilance regarding airway obstruction, cautious bronchoscope advancement, avoiding endotracheal tube puncture, and readiness to abort the procedure and replace the tube are crucial.

Effects of tracheostomy timing in adult patients receiving mechanical ventilation: A systematic review and network meta-analysis

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.

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

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.

Multi-institutional search for patient factors associated with adverse events following tracheotomy

BACKGROUND

Tracheotomy is a common procedure for otolaryngologists. The risk of complications is difficult to predict. This study aims to identify measurable preoperative indicators associated with adverse events following tracheotomy.

METHODS

The charts of adults undergoing tracheotomy for respiratory failure at one of four university-affiliated hospitals between 1/2012 and 8/2018 were reviewed. Complications were analyzed in the context of demographics, physiologic parameters, and comorbidities.

RESULTS

Among 507 tracheotomies performed, the most common complications included infection, bleeding, and cardiac arrest. Mortality was 39 % in patients with pulmonary hypertension, 42 % in those with ejection fraction ≤ 40 and 32 % in those with abnormal right ventricular function, double the rates in patients without each of these findings.

CONCLUSION

Many critically ill tracheotomy patients experience significant rates of adverse events. Risk factors for mortality include ejection fraction ≤ 40, pulmonary hypertension, and abnormal ventricular function. These should be considered for use in preoperative counseling.

LEVEL OF EVIDENCE: 4

A prospective comparative study of the functional results associated with the use of Björk flap tracheostomy versus standard tracheostomy

BACKGROUND

Placement of a tracheostomy for patients requiring prolonged mechanical ventilation (PMV) improves patients' comfort, decreases dead space ventilation, allows superior airway hygiene, and reduces the incidence of ventilator-associated pneumonia. Controversy still exists regarding the role of standard tracheostomy (ST) as opposed to the less frequently done Björk flap tracheostomy (BFT). This study compares the functional outcomes of these two techniques.

STUDY DESIGN

Seventy-nine patients receiving tracheostomy in a 12-month period: 38 BFT vs. 41 ST. Data included demographics, indications for PMV, ventilator days before tracheostomy, time to and a number of patients who passed the fiberoptic endoscopic evaluation of swallowing (FEES), time to and a number of patients decannulated.

RESULTS

Indications in both groups were PMV from trauma (18/38 vs 15/41), pneumonia (13/38 vs 13/41), and ARDS (7/38 vs 11/4), respectively (p > 0.05). Patients in both groups did not differ with regard to age, sex, GCS, duration of PMV before tracheostomy, the time to and a number of patients who passed the 1st FEES. However, the number of days and the number of FEES required before the next successful FEES in the 20 BFT and 21 ST patients who failed the 1st was 9 (4) vs. 16 (5), and 2 (1) vs. 4 (1), respectively (p < 0.05). Additionally, the number of intraoperative complications in aggregate were 0/38 in the BFT as opposed to 6/41 in the ST group (p < 0.05).

CONCLUSION

We conclude that BFT may be associated with an overall shorter time to restoration of normal swallowing when compared to ST.

[Risk factors at admission associated with intubation in patients with COVID-19]

Background

Intubation rates up to 33% have been found in patients diagnosed with COVID-19. Some cohorts have reported the presence of dyspnea in 84.1% of intubated patients, being this the only symptom associated with intubation. Oxygen saturation < 90% and increased respiratory rate have also been described as predictors of intubation.

Objective

To analyze the risk factors associated with intubation in patients hospitalized for COVID-19 at their admission.

Material and methods

An observational, retrospective, analytical, cross-sectional study was carried out. The universe of study consisted of patients over 18 years of age hospitalized due to a diagnosis of SARS-CoV-2 virus infection from April 1, 2020 to April 31, 2021 in the Hospital de Especialidades (Specialties Hospital) "Dr. Bernardo Sepúlveda Gutiérrez" at the National Medical Center.

Results

The mean age of intubated patients was 59.17 years (95% confidence interval [95% CI] -9.994 to -3.299, p < 0.001). Overall, 76.7% (230) of patients had a history of one or more preexisting comorbidities, including hypertension in 42.3% (127), obesity in 36.7% (110), and diabetes mellitus in 34.3% (103).

Conclusions

The main clinical characteristics of patients hospitalized for COVID-19 in our center who required intubation are very similar to those observed in different centers, including male sex, age over 50 years and obesity, which were the most common.

Percutaneous tracheostomy in the ICU: a review of the literature and recent updates

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.

Reducing Tracheostomy Medical Device-Related Pressure Injury: A Quality Improvement Project

OBJECTIVE

To reduce the incidence of medical device-related pressure injuries associated with tracheostomies performed with the percutaneous dilation technique using a standardized multidisciplinary intervention.

METHODS

The intervention was developed using the Agency for Healthcare Research and Quality Preventing Pressure Injuries Toolkit. A fenestrated polyurethane foam dressing was sutured in place under the tracheostomy flange during insertion to reduce the risk of medical device-related pressure injuries. The sutures were removed in pairs over a period of 7 to 10 days.

RESULTS

Comparison of data from 2018 to 2021 demonstrated a decrease in the incidence of tracheostomy medical device-related pressure injuries from 13% to 0% in the first year, which was maintained for the following 3 years. This improvement was supported by electronic medical record audits, daily interdisciplinary rounds, weekly practice assessments, and primary nurse evaluations.

CONCLUSION

Implementation of a standardized process, supported by an interdisciplinary clinical team, can reduce medical device-related pressure injuries among patients undergoing percutaneous dilation tracheostomy.

Development of the Tracheostomy Well-Being Score in critically ill patients

PURPOSE

Little attention has been given to understanding the experiences and perceptions of tracheostomized patients. This study aimed to measure the impact of tracheostomy on well-being in critically ill patients with the development of the Tracheostomy Well-Being Score (TWBS).

METHODS

This is a prospective, monocentric, observational study including critically ill patients with a tracheostomy without delirium. A 25-item questionnaire with items from six categories (respiration, coughing, pain, speaking, swallowing, and comfort) was used to select the 12 best items (two per category) to form the TWBS score after testing on two consecutive days. Item selection secured (1) that there were no skewed response distributions, (2) high stability from day 1 to day 2, and (3) high prototypicality for the category in terms of item-total correlation.

RESULTS

A total of 63 patients with a mean age of 56 years were included. The 12 items of the TWBS were characterized by a high retest reliability (τ = 0.67-0.93) and acceptable internal consistency. The overlap with the clinician rating was low, suggesting that acquiring self-report data is strongly warranted.

CONCLUSION

With the TWBS, an instrument is available for the assessment of the subjective effects a tracheostomy has on in critically ill patients. The score potentially offers a chance to increase well-being of these patients. Additionally, this score could also increase their quality of life by improving tracheostomy and weaning management.

CLINICAL TRIAL REGISTRATION

German Clinical Trials Register Identifier DRKS00022073 (2020/06/02).

Debunk the Myth: Percutaneous Tracheostomy in Cervical Spine Injury

How to cite this article: Govil D, Pachisia AV. Debunk the Myth: Percutaneous Tracheostomy in Cervical Spine Injury. Indian J Crit Care Med 2022;26(10):1067-1068.

Prediction of factors influencing the timing and prognosis of early tracheostomy in patients with multiple rib fractures: A propensity score matching analysis

Objective

To investigate the factors affecting the timing and prognosis of early tracheostomy in multiple rib fracture patients.

Methods

A retrospective case-control study was used to analyze the clinical data of 222 patients with multiple rib fractures who underwent tracheotomy in the Affiliated Hospital of Yangzhou University from February 2015 to October 2021. According to the time from tracheal intubation to tracheostomy after admission, the patients were divided into two groups: the early tracheostomy group (within 7 days after tracheal intubation, ET) and late tracheostomy group (after the 7th day, LT). Propensity score matching (PSM) was used to eliminate the differences in baseline characteristics Logistic regression was used to predict the independent risk factors for early tracheostomy. Kaplan–Meier and Cox survival analyses were used to analyze the influencing factors of the 28-day survival.

Results

According to the propensity score matching analysis, a total of 174 patients were finally included in the study. Among them, there were 87 patients in the ET group and 87 patients in the LT group. After propensity score matching, Number of total rib fractures (NTRF) (P < 0.001), Acute respiratory distress syndrome (ARDS) (P < 0.001) and Volume of pulmonary contusion(VPC) (P < 0.000) in the ET group were higher than those in the LT group. Univariate analysis showed that the patients who underwent ET had a higher survival rate than those who underwent LT (P = 0.021). Pearson's analysis showed that there was a significant correlation between NTRF and VPC (r = 0.369, P = 0.001). A receiver operating characteristic(ROC)curve analysis showed that the areas under the curves were 0.832 and 0.804. The best cutoff-value values of the VPC and NTRF were 23.9 and 8.5, respectively. The Cox survival analysis showed that the timing of tracheostomy (HR = 2.51 95% CI, 1.12–5.57, P = 0.004) and age (HR = 1.53 95% CI, 1.00–2.05, P = 0.042) of the patients had a significant impact on the 28-day survival of patients with multiple rib fractures. In addition, The Kaplan–Meier survival analysis showed that the 28-day survival of patients in the ET group was significantly better than that of the LT group, P = 0.01.

Conclusions

NTRF, ADRS and VPC are independent risk factors for the timing and prognosis of early tracheotomy. A VPC ≥ 23.9% and/or an NTRF ≥ 8.5 could be used as predictors of ET in patients with multiple rib fractures. Predicting the timing of early tracheostomy also need prediction models in the future.

A novel ZC4H2 variant in a female with severe respiratory complications

INTRODUCTION

An X-linked ZC4H2 variant is associated with a variety of phenotypes that have abnormalities related to external malformation and neurodevelopment. There have been no reports on severe respiratory dysfunction resulting in surgical treatments not being possible due to the deformity resulting from in this disease. Here we report a female with arthrogryposis multiplex congenita with a severe respiratory complication.

CASE

A two-year-old girl had arthrogryposis multiplex congenita at delivery and subsequently had hypotonia and feeding difficulty. A novel ZC4H2 frameshift variant was identified by whole-exome sequencing in her genome. At eight months, she had recurrent aspiration pneumonia. A tracheostomy and gastrostomy were required; however, surgical intervention was not possible because of her short neck and complicated airway.

CONCLUSION

We compared this case with previous reports. The truncation group had more described phenotypes than the non-truncation group. The patient had the most severe respiratory dysfunction in truncating variant.

Utilization and outcomes of tracheostomies in the intensive care unit in Iceland in 2007-2020: A descriptive study

BACKGROUND

Tracheostomies are commonly utilized in ICU patients due to prolonged mechanical ventilation, upper airway obstruction, or surgery in the face/neck region. However, practices regarding the timing of placement and utilization vary. This study provides a nationwide overview of tracheostomy utilization and outcomes in the ICU over a 14-year period.

METHODS

A retrospective study including all patients that received a tracheostomy during their ICU stay in Iceland between 2007 and 2020. Data were retrieved from hospital records on admission cause, comorbidities, indication for tracheostomy insertion, duration of mechanical ventilation before and after tracheostomy placement, extubation attempts, complications, length of ICU and hospital stay and survival. Descriptive statistics were provided, and survival analysis was performed using Cox regression.

RESULTS

A total of 336 patients (median age 64 years, 33% females) received a tracheostomy during the study period. The most common indication for tracheostomy insertion was respiratory failure, followed by neurological disorders. The median duration of mechanical ventilation prior to tracheostomy insertion was 9 days and at least one extubation had been attempted in 35% of the cases. Percutaneous tracheostomies were 32%. The overall rate of complications was 25% and the most common short-term complication was bleeding (5%). In-hospital mortality was 33%. The one- and five-year survival rate was 60% and 44%, respectively.

CONCLUSIONS

We describe a whole-nation practice of tracheostomies. A notable finding is the relatively low rate of extubation attempts prior to tracheostomy insertion. Future work should focus on standardization of assessing the need for tracheostomy and the role of extubation attempts prior to tracheostomy placement.

Percutaneous dilatational tracheostomy: evaluation of YouTube videos

BACKGROUND AND OBJECTIVE

In today's rapidly changing world, the technology of social media is widely used for educational purposes. Our aim in this study was to investigate the accuracy and efficacy of video presentations of percutaneous dilatational tracheostomy procedures available on the international video sharing website YouTube.

METHODS

On 1 December 2020, the terms "percutaneous dilatational tracheostomy" and "percutaneous tracheostomy" were entered into the search feature of YouTube ( www.youtube.com ). The evaluation was made in three categories; general information about percutaneous tracheostomy, performing percutaneous tracheostomy steps and demographic features of videos.

RESULTS

The median number of viewings of the videos on the date our data were collected was 1342 (IQR, 237-8052), and the most watched video had been viewed 325,170 times. Surgical site cleaning was explained in 46 (65.7%) videos and incision site detection in 55 (78.6%) videos. Needle aspiration into the trachea, insertion of the Seldinger guidewire, dilatation, and tracheal tube placement were covered in all videos (70; 100%). Confirmation of the location of the tracheal tube with end tidal capnography, the last step of the procedure, is available in 34 videos (48.6%).

CONCLUSION

The use of inexpensive or freely available teaching materials is possible but should always be checked before use with respect to the completeness and correctness of the content conveyed. The unreflected adoption of such content can lead to serious treatment errors.

Association between early tracheostomy and patient outcomes in critically ill patients on mechanical ventilation: a multicenter cohort study

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.

Pulmonary infection in traumatic brain injury patients undergoing tracheostomy: predicators and nursing care

Background

Pulmonary infection is common yet serious complication in patients with severe traumatic brain injury (STBI). We aimed to evaluate the predicators of pulmonary infection in STBI patients undergoing tracheostomy, to provide evidence for the clinical nursing care of STBI patients.

Methods

This study was a retrospective cohort design. STBI patients undergoing tracheostomy treatment from January 1, 2019 to August 31, 2021 in our hospital were included. The characteristics of pulmonary infection and no pulmonary infection patients were analyzed.

Results

A total 216 STBI patients undergoing tracheostomy were included, the incidence of pulmonary infection was 26.85%. Diabetes (r = 0.782), hypoproteinemia (r = 0.804), duration of coma(r = 0.672), duration of mechanical ventilation(r = 0.724) and length of hospital stay (r = 0.655), length of hospital stay post tracheostomy (r = 0.554), mortality (r = 0.598) were all correlated with pulmonary infection (all p < 0.05). Klebsiella pneumoniae (33.87%) and Staphylococcus aureus (29.03%) were the most commonly seen pathogens in the pulmonary infection of TBI patients. Logistic regression analyses indicated that diabetes (OR 2.232, 95% CI 1.215–3.904), hypoproteinemia with plasma total protein < 60 g/L (OR 1.922, 95% CI 1.083–3.031), duration of coma ≥ 22 h (OR 2.864, 95% CI 1.344–5.012), duration of mechanical ventilation ≥ 5 days (OR 3.602, 95% CI 1.297–5.626), length of hospital stay ≥ 21 days (OR 2.048, 95% CI 1.022–3.859) were the risk factors of pulmonary infection in TBI patients undergoing tracheostomy (all p < 0.05).

Conclusions

Further investigations on the early preventions and treatments targeted on those risk factors are needed to reduce the pulmonary infection in clinical practice.

The application of ambroxol hydrochloride combined with fiberoptic bronchoscopy in elderly patients with severe pneumonia: A meta-analysis and systematic review

BACKGROUND

The role of ambroxol hydrochloride combined with fiberoptic bronchoscopy in elderly patients with severe pneumonia remains unclear, we aimed to analyze this issue to provide evidences into the management of clinical pneumonia.

METHODS

We searched PubMed et al databases up to October 20, 2021 for the randomized controlled trials on the application of ambroxol hydrochloride combined with fiberoptic bronchoscopy in elderly patients with severe pneumonia. Related outcomes were extracted and analyzed. Review Manager 5.3 software was used for data analysis.

RESULTS

A total of 13 randomized controlled trials involving 1317 elderly patients (559 cases in the ambroxol hydrochloride + fiberoptic bronchoscopy group and 658 cases in the fiberoptic bronchoscopy group) with pneumonia were included. Meta-analyses indicated that the blood oxygen partial pressure [mean difference (MD) = 5.75, 95% confidence interval (CI) (3.80, 7.70)], blood oxygen saturation [MD = 6.43, 95% CI (4.39, 8.48)], oxygenation index [MD = 26.75, 95% CI (14.61, 38.89)] of experimental group was significantly higher than that of control group (all P < .001), the incidence of multiple organ failure [odds ratio = 0.42, 95% CI (0.31, 0.56), P < .001], mortality on day 28 [odds ratio = 0.44, 95% CI (0.33, 0.59)] of experimental group was significantly less than that of control group (all P < .001).

CONCLUSIONS

The high-dose ambroxol hydrochloride combined with fiberoptic bronchoscopy is beneficial to improve the patient's blood gas indicators, and reduce mortality in elderly patients with severe pneumonia.

Diagnostic Developments in Differentiating Unresponsive Wakefulness Syndrome and the Minimally Conscious State

When treating patients with a disorder of consciousness (DOC), it is essential to obtain an accurate diagnosis as soon as possible to generate individualized treatment programs. However, accurately diagnosing patients with DOCs is challenging and prone to errors when differentiating patients in a Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) from those in a Minimally Conscious State (MCS). Upwards of ~40% of patients with a DOC can be misdiagnosed when specifically designed behavioral scales are not employed or improperly administered. To improve diagnostic accuracy for these patients, several important neuroimaging and electrophysiological technologies have been proposed. These include Positron Emission Tomography (PET), functional Magnetic Resonance Imaging (fMRI), Electroencephalography (EEG), and Transcranial Magnetic Stimulation (TMS). Here, we review the different ways in which these techniques can improve diagnostic differentiation between VS/UWS and MCS patients. We do so by referring to studies that were conducted within the last 10 years, which were extracted from the PubMed database. In total, 55 studies met our criteria (clinical diagnoses of VS/UWS from MCS as made by PET, fMRI, EEG and TMS- EEG tools) and were included in this review. By summarizing the promising results achieved in understanding and diagnosing these conditions, we aim to emphasize the need for more such tools to be incorporated in standard clinical practice, as well as the importance of data sharing to incentivize the community to meet these goals.

Development of an institutional protocol for percutaneous dilatational tracheostomy in critically ill COVID-19 patients: Initial experience

Background and Aims:

Percutaneous dilatational tracheostomy (PDT) may improve the outcome in critically ill COVID-19 patients on mechanical ventilation. However, the timing of performing tracheostomy may be controversial, and it is an aerosol-generating procedure with a potential risk of viral exposure to healthcare workers.

Material and Methods:

An operational protocol for performing PDT was made and subsequently followed in a designated COVID-19 ICU. Critically ill adult patients on mechanical ventilators who underwent PDT were included in this retrospective cohort study. Case files were retrospectively reviewed and patient characteristics, clinical outcome, and procedure-related details were noted.

Results:

Forty-one patients were included in the analysis. The median age was 49 (39–67) years, and 41.5% of patients were females. The median duration of mechanical ventilation before tracheostomy was 10 (8–16) days, and the median (IQR) PaO₂/FiO₂ ratio on the day of PDT was 155 (125–180) mm Hg. Further, 48.8% of patients had transient desaturation to SpO2 <90%, and 41.5% survived to ICU discharge. None of the health care providers involved in PDT developed any symptoms of COVID 19.

Conclusion:

This descriptive study demonstrates the feasibility, implementation, and apparent safety of the PDT protocol developed at our institution.

Traumatic xylophagia leading to foreign body removal and tracheostomy in the setting of postpartum psychosis

Postpartum psychosis (PPP) is a severe mood disorder following childbirth that rarely leads to injurious or suicidal behavior. This report illustrates otolaryngologic intervention for pharyngeal laceration and airway instability following traumatic foreign body ingestion in the setting of PPP.

A 25-year-old woman with PPP presented with hemoptysis after attempting suicide by traumatically forcing tree branches into her oropharynx. Imaging revealed pneumomediastinum, and flexible laryngoscopy and esophagoscopy showed a large foreign body (tree branch) extending from the hypopharynx to the gastroesophageal junction. She was taken to the operating room for direct microlaryngoscopy, bronchoscopy and esophagoscopy with removal of the 25-cm tree branch. Panendoscopy revealed a mucosal laceration at the cricopharyngeus with supraglottic and hypopharyngeal edema but no injury to the larynx. Due to airway concerns, a cuffed tracheostomy was placed along with a gastrostomy tube for feeding access. She tolerated her postoperative course with successful decannulation and oral feeding prior to discharge.

Long-term laryngotracheal complications following cardiac surgery

BACKGROUND AND AIM OF THE STUDY

Long-term laryngotracheal complications have not been described in adult patients undergoing cardiac surgery. The purpose of this study was to determine the incidence of and risk factors for laryngotracheal complications following cardiac surgery.

METHODS

A retrospective chart review of patients at high risk for laryngotracheal complications following cardiac surgery between 2006 and 2016 was performed. High-risk patients were reviewed to determine the presence of laryngotracheal complications including laryngotracheal stenosis, keyhole deformity, or vocal cord immobility. Logistic regression was used to identify predictors of long-term laryngotracheal complications.

RESULTS

Of 11,417 patients who underwent cardiac surgery, 1099 were identified as at high risk. Of these, 24 (2.2%) developed laryngotracheal complications following their surgery and intensive care unit (ICU) stay. Laryngotracheal stenosis and keyhole deformity were present in 13 (1.2%) and 6 (0.5%) patients, respectively. Logistic regression demonstrated older age (age ≥ 70 odds ratio [OR] 0.31, 95% confidence interval [CI] 0.12-0.83) was protective, while readmission to ICU for ventilation (OR 3.11, 95% CI 1.17-8.25) and receiving a tracheostomy (OR 7.83, 95% CI 2.22-27.6) were associated with laryngotracheal complications.

CONCLUSIONS

The incidence of long-term laryngotracheal complications following cardiac surgery was 2.2%. Readmission to ICU for ventilation and having a tracheostomy performed were associated with laryngotracheal complications.

Wound care management: tracheostomy and gastrostomy

Percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) tube placements are routine procedures performed in the intensive care units (ICUs). They are performed to facilitate care and promote healing. They also help prevent complications from prolonged endotracheal intubation and malnutrition. In most cases, both are performed simultaneously. Physicians performing them require knowledge of local anatomy, tissue and vascular relationships, along with advance bronchoscopy and endoscopy skills. Although PDTs and PEGs are considered relatively low-risk procedures, operators need to have the knowledge and skill to recognize and prevent adverse outcomes. Current published literature on post-procedural care and stoma wound management was reviewed. Available recommendations for the routine care of tracheostomy and PEG tubes are included in this review. Signs and symptoms of early PDT- and PEG-related complications and their management are discussed in detail. These include hemorrhage, infection, accidental decannulation, tube obstruction, clogging, and dislodgement. Rare, life-threatening complications are also discussed. Multidisciplinary teams are needed for improved patient care, and members should be aware of all pertinent care aspects and potential complications related to PDT and PEG placement. Each institute is strongly encouraged to have detailed protocols to standardize care. This review provides a state-of-the-art guidance on the care of patients with tracheostomies and gastrostomies specifically in the ICU setting.

Equipment and procedural setup for interventional pulmonology procedures in the intensive care unit

Procedural setup is an important aspect of any procedure. Interventional pulmonologists provide a procedural practice and have additional expertise in performing high-risk procedures needed in the critically ill patients in intensive care. Taking the time to plan the procedure setup in advance and having all necessary equipment readily available at the patient's bedside is imperative for procedural services. This is especially essential to ensure patient safety, minimize risk of complications, and improve success for specialized procedures performed by interventional pulmonary in the intensive care unit. In this review we describe the equipment and procedural setup ideal for both pleural and airway procedures. These include flexible diagnostic and therapeutic bronchoscopy, ultrasound guided thoracentesis, chest tube insertion, difficult airway management, and bedside percutaneous dilatation tracheostomy. We provide a guide checklist for these procedures emphasizing the practical aspects of each procedure from selecting the appropriate size endotracheal tube to operator positioning to ensure efficiency and best access. The components of procedural setup are discussed in relation to patient factors that include patient positioning and anesthesia, personnel in the procedure team and the equipment itself. We further briefly describe the additional equipment needed for specialized techniques in therapeutic bronchoscopy used by interventional pulmonologists.

Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis

Introduction. Tracheostomy can help weaning in long-term ventilated patients, reducing the duration of mechanical ventilation and intensive care unit length of stay, and decreasing complications from prolonged tracheal intubation. In traumatic brain injury (TBI), ideal timing for tracheostomy is still debated. We performed a systematic review and meta-analysis to evaluate the effects of timing (early vs. late) of tracheostomy on mortality and incidence of VAP in traumatic brain-injured patients. Methods. This study was conducted in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a search in PubMed, using an association between heading terms: early, tracheostomy, TBI, prognosis, recovery, impact, mortality, morbidity, and brain trauma OR brain injury. Two reviewers independently assessed the methodological quality of eligible studies using the Newcastle–Ottawa Scale (NOS). Comparative analyses were made among Early Tracheostomy (ET) and late tracheostomy (LT) groups. Our primary outcome was the odds ratio of mortality and incidence of VAP between the ET and LT groups in acute brain injury patients. Secondary outcomes included the standardized mean difference (MD) of the duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS. Results. We included two randomized controlled trials, three observational trials, one cross-sectional study, and three retrospective cohort studies. The total number of participants in the ET group was 2509, while in the LT group it was 2597. Early tracheostomy reduced risk for incidence of pneumonia, ICU length of stay, hospital length of stay and duration of mechanical ventilation, but not mortality. Conclusions. In TBI patients, early tracheostomy compared with late tracheostomy might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, but increase the risk of mortality.

The role of routine FIBERoptic bronchoscopy monitoring during percutaneous dilatational TRACHeostomy (FIBERTRACH): a study protocol for a randomized, controlled clinical trial

Background

Tracheostomy is one of the most frequent techniques in intensive care units (ICU). Fiberoptic bronchoscopy (FB) is a safety measure when performing a percutaneous dilatational tracheostomy (PDT), but the controversy surrounding the routine use of FB as part of the procedure remains open. National surveys in some European countries showed that the use of FB is non-standardized. Retrospective studies have not shown a significant difference in complications between procedures performed with or without a bronchoscope. International guidelines have not been able to establish recommendations regarding the use of FB in PDT due to lack of evidence.

Design

This is a multicenter (three centers at the time of  publishing this paper) randomized controlled clinical trial to examine the safety of percutaneous tracheostomy using FB. We will include all consecutive adult patients admitted to the ICU in whom percutaneous tracheostomy for prolonged mechanical ventilation is indicated and with no exclusion criteria for using FB. Eligible patients will be randomly assigned to receive blind PDT or PDT under endoscopic guidance. All procedures will be performed by experienced intensivists in PDT and FB. A Data Safety and Monitoring Board (DSMB) will monitor the trial. The primary outcome is the incidence of perioperative complications.

Discussion

FB is a safe technique when performing PDT although its use is not universally accepted in all ICUs as a routine practice. Should PDT be monitored routinely with endoscopic guidance? This study will assess the role of FB monitoring during PDT.

Trial registration

ClinicalTrials.gov NCT04265625. Registered on February 11, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05370-x.

Life-threatening oral mucositis following chemotherapy in a pediatric patient

Severe oral mucositis as a complication of chemotherapy may lead to airway obstruction and require prolonged intubation. As its course is consistent with the course of neutropenia, airway management strategies should be determined individually.

Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol

Background

Coronavirus disease-2019 (COVID-19) pandemic has inundated healthcare systems globally especially resources in intensive care units (ICUs). Tracheostomy may be required in critically ill COVID-19 patients to facilitate weaning and to optimize resources like ventilator and ICU beds. Percutaneous tracheostomy (PCT) has become the standard of care globally in ICUs; however, it is considered a high-risk procedure in COVID-19 patients because of the inherent risk of aerosol generation.

Materials and methods

Patients with severe COVID-19 who were on mechanical ventilation because of respiratory failure for ≥10 days were evaluated for PCT. We developed a four-step approach from patient selection and timing, preparation, performance, and postprocedure for PCT in these patients.

Results

We evaluated our four-step protocol in four patients. One of them was non-COVID patient and rest three were COVID patients. The procedure was uneventful in all of the patients with median time of procedure and apnea is 10 minutes 30 seconds and 2 minutes 20 seconds, respectively. The tracheostomy was decannulated in two of these patients and one patient is still on ventilator.

Conclusion

We believe our four-step protocol for PCT in critically ill COVID-19 patient is simple, safe, and easily adapted in any setting with limited training and available resources. We recommend further studies to evaluate this approach in selected critically ill COVID-19 patients who need tracheostomy.

How to cite this article

Nasa P, Singh A, Ali A, Patidar S, Georgian A. Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol. Indian J Crit Care Med 2020;24(9):832-834.

Short-term Outcomes for Patients and Providers After Elective Tracheostomy in COVID-19-Positive Patients

Background

Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit.

Methods

This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications.

Results

From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19.

Conclusions

and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.

Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol

BACKGROUND

Coronavirus disease-2019 (COVID-19) pandemic has inundated healthcare systems globally especially resources in intensive care units (ICUs). Tracheostomy may be required in critically ill COVID-19 patients to facilitate weaning and to optimize resources like ventilator and ICU beds. Percutaneous tracheostomy (PCT) has become the standard of care globally in ICUs; however, it is considered a high-risk procedure in COVID-19 patients because of the inherent risk of aerosol generation.

MATERIALS AND METHODS

Patients with severe COVID-19 who were on mechanical ventilation because of respiratory failure for ≥10 days were evaluated for PCT. We developed a four-step approach from patient selection and timing, preparation, performance, and postprocedure for PCT in these patients.

RESULTS

We evaluated our four-step protocol in four patients. One of them was non-COVID patient and rest three were COVID patients. The procedure was uneventful in all of the patients with median time of procedure and apnea is 10 minutes 30 seconds and 2 minutes 20 seconds, respectively. The tracheostomy was decannulated in two of these patients and one patient is still on ventilator.

CONCLUSION

We believe our four-step protocol for PCT in critically ill COVID-19 patient is simple, safe, and easily adapted in any setting with limited training and available resources. We recommend further studies to evaluate this approach in selected critically ill COVID-19 patients who need tracheostomy.

HOW TO CITE THIS ARTICLE

Nasa P, Singh A, Ali A, Patidar S, Georgian A. Percutaneous Tracheostomy in COVID-19 Patients: A Four-step Safe Protocol. Indian J Crit Care Med 2020;24(9):832-834.

Intensive care management of patients with COVID-19

The COVID-19 pandemic originated in China in December 2019 and has since then, swept across the world. The last Influenza pandemic of 1918 happened before the advent of modern medicine. We have come a long way since then. But the pandemic has still caught us unprepared in many quarters. The review focuses on the management of critically ill COVID-19 patients and the various challenges faced by intensivists.

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.

Quality improvement in tracheostomy care: A multidisciplinary approach to standardizing tracheostomy care to reduce complications

PURPOSE

Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications.

METHODS

This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters.

RESULTS

Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04).

CONCLUSIONS

An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.

Tracheostomy practice and timing in traumatic brain-injured patients: a CENTER-TBI study

Purpose

Indications and optimal timing for tracheostomy in traumatic brain-injured (TBI) patients are uncertain. This study aims to describe the patients’ characteristics, timing, and factors related to the decision to perform a tracheostomy and differences in strategies among different countries and assess the effect of the timing of tracheostomy on patients’ outcomes.

Methods

We selected TBI patients from CENTER-TBI, a prospective observational longitudinal cohort study, with an intensive care unit stay ≥ 72 h. Tracheostomy was defined as early (≤ 7 days from admission) or late (> 7 days). We used a Cox regression model to identify critical factors that affected the timing of tracheostomy. The outcome was assessed at 6 months using the extended Glasgow Outcome Score.

Results

Of the 1358 included patients, 433 (31.8%) had a tracheostomy. Age (hazard rate, HR = 1.04, 95% CI = 1.01–1.07, p = 0.003), Glasgow coma scale ≤ 8 (HR = 1.70, 95% CI = 1.22–2.36 at 7; p < 0.001), thoracic trauma (HR = 1.24, 95% CI = 1.01–1.52, p = 0.020), hypoxemia (HR = 1.37, 95% CI = 1.05–1.79, p = 0.048), unreactive pupil (HR = 1.76, 95% CI = 1.27–2.45 at 7; p < 0.001) were predictors for tracheostomy. Considerable heterogeneity among countries was found in tracheostomy frequency (7.9–50.2%) and timing (early 0–17.6%). Patients with a late tracheostomy were more likely to have a worse neurological outcome, i.e., mortality and poor neurological sequels (OR = 1.69, 95% CI = 1.07–2.67, p = 0.018), and longer length of stay (LOS) (38.5 vs. 49.4 days, p = 0.003).

Conclusions

Tracheostomy after TBI is routinely performed in severe neurological damaged patients. Early tracheostomy is associated with a better neurological outcome and reduced LOS, but the causality of this relationship remains unproven.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-05935-5) contains supplementary material, which is available to authorized users.

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.

Tracheotomy When and Where?

The time for elective tracheotomies has been discussed for years in what has become very comprehensive literature by now. In this chapter, studies with high levels of evidence are taken into account and recommendations are given for the timing of tracheotomies in long-term ventilated patients, with the individual decision being at the center of consideration.

Tracheotomies can be performed both in the operating room and in an intensive care unit. The criteria for such choice are presented under interdisciplinary medical and organizational aspects.

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

BACKGROUND AND AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

HOW TO CITE THIS ARTICLE

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

Effect of Early Tracheostomy on Clinical Outcomes in Patients with Prolonged Acute Mechanical Ventilation: A Single-Center Study

Background

The purpose of this study was to investigate the effect of early tracheostomy on clinical outcomes in patients requiring prolonged acute mechanical ventilation (≥96 hours).

Methods

Data from 575 patients (69.4% male; median age, 68 years), hospitalized in the medical intensive care unit (ICU) of a university-affiliated tertiary care hospital March 2008–February 2017, were retrospectively evaluated. Early and late tracheostomy were designated as 2–10 days and >10 days after translaryngeal intubation, respectively.

Results

The 90-day cumulative mortality rate was 47.5% (n=273) and 258 patients (44.9%) underwent tracheostomy. In comparison with the late group (n=115), the early group (n=125) had lower 90-day mortality (31.2% vs. 47.8%, p=0.012), shorter stays in hospital and ICU, shorter ventilator length of stay (median, 43 vs. 54; 24 vs. 33; 23 vs. 28 days; all p<0.001), and a higher rate of transfer to secondary care hospitals with post-intensive care settings (67.2% vs. 43.5% p<0.001). Also, the total medical costs of the early group were lower during hospital stays than those of the late group (26,609 vs. 36,973 USD, p<0.001).

Conclusion

Early tracheostomy was associated with lower 90-day mortality, shorter ventilator length of stay and shorter lengths of stays in hospital and ICU, as well as lower hospital costs than late tracheostomy.

A Modified Translaryngeal Tracheostomy Technique in the Neurointensive Care Unit. Rationale and Single-center Experience on 199 Acute Brain-damaged Patients

BACKGROUND

Brain-injured patients frequently require tracheostomy, but no technique has been shown to be the gold standard for these patients. We developed and introduced into standard clinical practice an innovative bedside translaryngeal tracheostomy (TLT) technique aided by suspension laryngoscopy (modified TLT). During this procedure, the endotracheal tube is left in place until the airway is secured with the new tracheostomy. This study assessed the clinical impact of this technique in brain-injured patients.

MATERIALS AND METHODS

This is a retrospective analysis of prospectively collected data from adult brain-injured patients who had undergone modified TLT during the period spanning from January 2010 to December 2016 at the Neurointensive care unit, San Gerardo Hospital (Monza, Italy). The incidence of intraprocedural complications, including episodes of intracranial hypertension (intracranial pressure [ICP] >20 mm Hg), was documented. Neurological, ventilatory, and hemodynamic parameters were retrieved before, during, and after the procedure. Risk factors for complications and intracranial hypertension were assessed by univariate logistic analysis. Data are presented as n (%) and median (interquartile range) for categorical and continuous variables, respectively.

RESULTS

A total of 199 consecutive brain-injured patients receiving modified TLT were included. An overall 52% male individuals who were 66 (54 to 74) years old and who had an admission Glasgow Coma Scale of 7 (6 to 10) were included in the cohort. Intracerebral hemorrhage (30%) was the most frequent diagnosis. Neurointensivists performed 130 (65%) of the procedures. Patients underwent tracheostomy 10 (7 to 13) days after intensive care unit admission. Short (ie, <2 min) and clinically uneventful increases in ICP>20 mm Hg were observed in 11 cases. Overall, the procedure was associated with an increase in ICP from 7 (4 to 10) to 12 (7 to 18) mm Hg (P<0.001). Compared with baseline, cerebral perfusion pressure (CPP), respiratory variables, and hemodynamics were unchanged during the procedure (P-value, not significant). Higher baseline ICP and core temperature were associated with an increased risk of complications and intracranial hypertension. Complication rates were low: 1 procedure had to be converted to a surgical tracheostomy, and 1 (0.5%) episode of minor bleeding and 5 (2.5%) of minor non-neurological complications were recorded. Procedures performed by intensivists did not have a higher risk of complications compared with those performed by ear, nose, and throat specialists.

CONCLUSIONS

A modified TLT (by means of suspension laryngoscopy) performed by neurointensivists is feasible in brain-injured patients and does not adversely impact ICP and CPP.