Questions answered about tracheostomy timing?

Tracheostomy Update: When and How

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

Tracheostomy after cardiovascular surgery: An assessment of long-term outcome

OBJECTIVE

To ascertain long-term survival, identify risk factors for death, and document complications of tracheostomy after cardiovascular surgery.

METHODS

Between January 1, 1998, and September 1, 2001, 188 (1.4%) of 13,191 patients undergoing cardiovascular surgery had tracheostomy for respiratory failure 5 to 79 days (median, 14 days) after surgery. Factors associated with mortality were identified in the hazard function domain, and mode of death and complications of tracheostomy were determined by follow-up.

RESULTS

Survival was 75%, 50%, and 31% at 30 days, 3 months, and 2 years, respectively. The most important risk factors for death were older age (P = .004) and variables representing deteriorating hemodynamic (P < .0001), respiratory (P < .0001), and renal (P = .0001) function between the index cardiovascular operation and tracheostomy. The mode of death was isolated respiratory failure in only 21 (16%) of 130 patients, but multisystem organ failure in 71 (55%). Follow-up of 58 survivors identified voice complaints in 13 (24%), tracheal stenosis in 5 (9.2%), and permanent tracheostomy in 3 (6%).

CONCLUSIONS

Only one third of patients undergoing tracheostomy after cardiovascular surgery survive, because it is used primarily in those with deteriorating function of multiple organ systems. Although tracheostomy may enhance patient comfort and simplify nursing care, selection algorithms need to be developed if survival is the goal of the intervention.

Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients

OBJECTIVE

Tracheostomy practice in the setting of critical illness is controversial because evidence demonstrating unequivocal benefit is lacking. We undertook this study to determine the relationship between tracheostomy timing and duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay and to evaluate the relative influence of clinical and nonclinical factors on tracheostomy practice.

DESIGN

Analysis of Project Impact, a multi-institutional critical care administrative database.

SETTING

Medical school.

PATIENTS

Data from 43,916 patients were reviewed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Tracheostomy was performed in 2,473 (5.6%) of 43,916 patients analyzed. Tracheostomy patients had a higher survival rate than nontracheostomy patients (78.1 vs. 71.7%, p < .001) and underwent this procedure following a median (25th-75th percentile) of 9.0 (5.0-14.0) days of ventilatory support. Tracheostomy frequency and timing varied significantly comparing patient, intensive care unit, and hospital characteristics (p < .05 for all). Tracheostomy timing correlated significantly with duration of mechanical ventilation (r = .690), intensive care unit (r = .610), and hospital length of stay (r = .341, p < .001 for all). At most, 22% of patients were supported via tracheostomy at any given time. Although a minority, tracheostomy patients accounted for 26.2%, 21.0%, and 13.5% of all ventilator, intensive care unit, and hospital days, respectively.

CONCLUSIONS

Although practice varies substantially, tracheostomy timing appears significantly associated with duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay. These findings emphasize the need for an adequately supported multiple-center trial to better define patient selection for tracheostomy and to test the hypothesis that timing of this procedure influences clinically important outcomes.

A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients

OBJECTIVE

The timing of tracheotomy in patients requiring mechanical ventilation is unknown. The effects of early percutaneous dilational tracheotomy compared with delayed tracheotomy in critically ill medical patients needing prolonged mechanical ventilation were assessed.

DESIGN

Prospective, randomized study.

SETTING

Medical intensive care units.

PATIENTS

One hundred and twenty patients projected to need ventilation >14 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were prospectively randomized to either early percutaneous tracheotomy within 48 hrs or delayed tracheotomy at days 14-16. Time in the intensive care unit and on mechanical ventilation and the cumulative frequency of pneumonia, mortality, and accidental extubation were documented. The airway was assessed for oral, labial, laryngeal, and tracheal damage. Early group showed significantly less mortality (31.7% vs. 61.7%), pneumonia (5% vs. 25%), and accidental extubations compared with the prolonged translaryngeal group (0 vs. 6). The early tracheotomy group spent less time in the intensive care unit (4.8 +/- 1.4 vs. 16.2 +/- 3.8 days) and on mechanical ventilation (7.6 +/- 2.0 vs. 17.4 +/- 5.3 days). There was also significantly more damage to mouth and larynx in the prolonged translaryngeal intubation group.

CONCLUSIONS

This study demonstrates that the benefits of early tracheotomy outweigh the risks of prolonged translaryngeal intubation. It gives credence to the practice of subjecting this group of critically ill medical patients to early tracheotomy rather than delayed tracheotomy.

A structure of care for the chronically critically ill

The chronically critically ill (CCI) are complicated, labor-intensive, and costly patients to care for. A defined structure of care with different focuses at the beginning, middle, and end of a care episode may improve their outcomes and resource utilization. This article reviews the prediction of CCI, outlines some unifying processes of care during an episode of chronic critical illness, and explores some of the difficulties in defining consistent goals of care for this patient population.