Tracheostomy protocol: experience with development and potential utility

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.

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.

Fiber optic bronchoscopy-assisted percutaneous tracheostomy: a decade of experience at a university hospital

Objective

To evaluate the efficacy and safety of percutaneous tracheostomy by means of single-step dilation with fiber optic bronchoscopy assistance in critical care patients under mechanical ventilation.

Methods

Between the years 2004 and 2014, 512 patients with indication of tracheostomy according to clinical criteria, were prospectively and consecutively included in our study. One-third of them were high-risk patients. Demographic variables, APACHE II score, and days on mechanical ventilation prior to percutaneous tracheostomy were recorded. The efficacy of the procedure was evaluated according to an execution success rate and based on the necessity of switching to an open surgical technique. Safety was evaluated according to post-operative and operative complication rates.

Results

The mean age of the group was 64 ± 18 years (203 women and 309 males). The mean APACHE II score was 21 ± 3. Patients remained an average of 11 ± 3 days on mechanical ventilation before percutaneous tracheostomy was performed. All procedures were successfully completed without the need to switch to an open surgical technique. Eighteen patients (3.5%) presented procedure complications. Five patients experienced transient desaturation, 4 presented low blood pressure related to sedation, and 9 presented minor bleeding, but none required a transfusion. No serious complications or deaths associated with the procedure were recorded. Eleven patients (2.1%) presented post-operative complications. Seven presented minor and transitory bleeding of the percutaneous tracheostomy stoma, 2 suffered displacement of the tracheostomy cannula, and 2 developed a superficial infection of the stoma.

Conclusion

Percutaneous tracheostomy using the single-step dilation technique with fiber optic bronchoscopy assistance seems to be effective and safe in critically ill patients under mechanical ventilation when performed by experienced intensive care specialists using a standardized procedure.

Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation

Background

Weaning from tracheostomy has implications in management, quality of life, and costs of ventilated patients. Furthermore, endotracheal cannula removing needs further studies. Aim of this study was the validation of a protocol for weaning from tracheostomy and evaluation of predictor factors of decannulation.

Methods

Medical records of 48 patients were retrospectively evaluated. Patients were decannulated in agreement with a decannulation protocol based on the evaluation of clinical stability, expiratory muscle strength, presence of tracheal stenosis/granulomas, deglutition function, partial pressure of CO₂, and PaO₂/FiO2 ratio. These variables, together with underlying disease, blood gas analysis parameters, time elapsed with cannula, comordibity, Barthel index, and the condition of ventilation, were evaluated in a logistic model as predictors of decannulation.

Results

63 % of patients were successfully decannulated in agreement with our protocol and no one needed to be re-cannulated. Three variables were significantly associated with the decannulation: no pulmonary underlying diseases (OR = 7.12; 95 % CI 1.2–42.2), no mechanical ventilation (OR = 9.55; 95 % CI 2.1–44.2) and period of tracheostomy ≤10 weeks (OR = 6.5; 95 % CI 1.6–27.5).

Conclusions

The positive course of decannulated patients supports the suitability of the weaning protocol we propose here. The strong predictive role of three clinical variables gives premise for new studies testing simpler decannulation protocols.

Medical economic impact of tracheotomy patients on a hospital system

BACKGROUND

Tracheotomy patients are a small portion of hospitalizations, but account for disproportionately high risk and costs. There are many complex decisions that go into the care of these patients, and practice variation is expected to be compounded in a health system. This study sought to characterize the medical economic impact of tracheotomy patients on the hospital system.

METHODS

A retrospective review of the health system's hospital billing software was performed for 2013, and pertinent outcomes measures were tabulated.

RESULTS

There were 829 tracheotomies performed in the health system of seven hospitals, with total costs of $128,883,865. Average length of stay was 36.74 days for principal procedures, and 43.36 days for tracheotomy as secondary procedures. Mortality was ∼ 18% overall, and re-admissions were 10.93% for primary, and 14.36% for secondary procedures. A fairly wide variation in each category among the different hospitals was observed.

CONCLUSIONS

There are potentially many factors that impact variations of care and outcomes in patients with tracheotomy. Due to their large economic impact and risks for morbidity and mortality, a formalized care pathway is warranted. Goals of the pathway should include understanding medical decisions surrounding these complex patients, monitoring pertinent outcomes, reducing practice variation, and improving the efficiency of compassionate care.

Early versus late tracheostomy for critically ill patients

BACKGROUND

Long-term mechanical ventilation is the most common situation for which tracheostomy is indicated for patients in intensive care units (ICUs). 'Early' and 'late' tracheostomies are two categories of the timing of tracheostomy. Evidence on the advantages attributed to early versus late tracheostomy is somewhat conflicting but includes shorter hospital stays and lower mortality rates.

OBJECTIVES

To evaluate the effectiveness and safety of early (≤ 10 days after tracheal intubation) versus late tracheostomy (> 10 days after tracheal intubation) in critically ill adults predicted to be on prolonged mechanical ventilation with different clinical conditions.

SEARCH METHODS

This is an update of a review last published in 2012 (Issue 3, The Cochrane Library) with previous searches run in December 2010. In this version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 8); MEDLINE (via PubMed) (1966 to August 2013); EMBASE (via Ovid) (1974 to August 2013); LILACS (1986 to August 2013); PEDro (Physiotherapy Evidence Database) at www.pedro.fhs.usyd.edu.au (1999 to August 2013) and CINAHL (1982 to August 2013). We reran the search in October 2014 and will deal with any studies of interest when we update the review.

SELECTION CRITERIA

We included all randomized and quasi-randomized controlled trials (RCTs or QRCTs) comparing early tracheostomy (two to 10 days after intubation) against late tracheostomy (> 10 days after intubation) for critically ill adult patients expected to be on prolonged mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and conducted a quality assessment. Meta-analyses with random-effects models were conducted for mortality, time spent on mechanical ventilation and time spent in the ICU.

MAIN RESULTS

We included eight RCTs (N = 1977 participants). At the longest follow-up time available in these studies, evidence of moderate quality from seven RCTs (n = 1903) showed lower mortality rates in the early as compared with the late tracheostomy group (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70 to 0.98; P value 0.03; number needed to treat for an additional beneficial outcome (NNTB) ≅ 11). Divergent results were reported on the time spent on mechanical ventilation and no differences were noted for pneumonia, but the probability of discharge from the ICU was higher at day 28 in the early tracheostomy group (RR 1.29, 95% CI 1.08 to 1.55; P value 0.006; NNTB ≅ 8).

AUTHORS' CONCLUSIONS

The whole findings of this systematic review are no more than suggestive of the superiority of early over late tracheostomy because no information of high quality is available for specific subgroups with particular characteristics.

Factors determining the timing of tracheostomy in medical ICU of a tertiary referral hospital

BACKGROUND

Tracheostomy is a common procedure for patients requiring prolonged mechanical ventilation. However, the timing of tracheostomy is quite variable. This study was performed to find out the factors determining the timing of tracheostomy in medical intensive care unit (ICU).

METHODS

Patients who were underwent tracheostomy between January 2008 and December 2009 in the medical ICU of Seoul National University Hospital were included in this retrospective study.

RESULTS

Among the 59 patients, 36 (61.0%) were male. Median Acute Physiology And Chronic Health Evaluation (APACHE) II scores and Sequential Organ Failure Assessment scores on the admission day were 28 and 7, respectively. The decision of tracheostomy was made on 13 days, and tracheostomy was performed on 15 days after endotracheal intubation. Of the 59 patients, 21 patients received tracheostomy before 2 weeks (group I) and 38 were underwent after 2 weeks (group II). In univariate analysis, days until the decision to perform tracheostomy (8 vs. 14.5, p<0.001), days before tracheostomy (10 vs. 18, p<0.001), time delay for tracheostomy (2.1 vs. 3.0, p<0.001), cardiopulmonary resuscitation (19.0% vs. 2.6%, p=0.049), existence of neurologic problem (38.1% vs. 7.9%, p=0.042), APACHE II scores (24 vs. 30, p=0.002), and PaO(2)/FiO(2)<300 mm Hg (61.9% vs. 91.1%, p=0.011) were different between the two groups. In multivariate analysis, APACHE II scores≥20 (odds ratio [OR], 12.44; 95% confidence interval [CI], 1.14~136.19; p=0.039) and time delay for tracheostomy (OR, 1.97; 95% CI, 1.11~3.55; p=0.020) were significantly associated with tracheostomy after 2 weeks.

CONCLUSION

APACHE II scores≥20 and time delay for tracheostomy were associated with tracheostomy after 2 weeks.

Early versus late tracheostomy for critically ill patients

BACKGROUND

Long-term mechanical ventilation is the most common situation where tracheostomy is indicated for patients in intensive care units (ICU). 'Early' and 'late' tracheostomies are two categories of the timing of tracheostomy. The evidence on the advantages attributed to early over late tracheostomy is somewhat conflicting but includes shorter hospital stays and lower mortality rates.

OBJECTIVES

To evaluate the effectiveness and safety of early (≤ 10 days after intubation) versus late tracheostomy (> 10 days after intubation) in critically ill adult patients predicted to be on prolonged mechanical ventilation and with different clinical conditions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 12); MEDLINE (via PubMed) (1966 to December 2010); EMBASE (via Ovid) (from 1974 to December 2010); LILACS (1986 to December 2010); PEDro (Physiotherapy Evidence Database) at www.pedro.fhs.usyd.edu.au (1999 to December 2010) and CINAHL (1982 to December 2010).

SELECTION CRITERIA

We included all randomized or quasi-randomized controlled trials which compared early tracheostomy (two to10 days after intubation) against late tracheostomy (> 10 days after intubation) for critically ill adult patients expected to be on prolonged mechanical ventilation. There was no language restriction.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and conducted a quality assessment. Meta-analyses using the random-effects model were conducted for mortality and pneumonia.

MAIN RESULTS

We included four studies, with a high risk of bias, in which a total of 673 patients were randomized to either early or late tracheostomy. We could not pool data in a meta-analysis because of clinical, methodological and statistical heterogeneity between the included studies. There is no strong evidence for real differences between early and late tracheostomy in the primary outcome of mortality. In one study a statistically significant result favouring early tracheostomy was observed in the outcome measuring time spent on ventilatory support (mean difference (MD) -9.80 days, 95% CI -11.48 to -8.12, P < 0.001).

AUTHORS' CONCLUSIONS

Updated evidence is of low quality, and potential differences between early and late tracheostomy need to be better investigated by means of randomized controlled trials. At present there is no specific information about any subgroup or individual characteristics potentially associated with better outcomes with either early or late tracheostomy.

Evaluation of a novel closed-loop fluid-administration system based on dynamic predictors of fluid responsiveness: an in silico simulation study

Introduction

Dynamic predictors of fluid responsiveness have made automated management of fluid resuscitation more practical. We present initial simulation data for a novel closed-loop fluid-management algorithm (LIR, Learning Intravenous Resuscitator).

Methods

The performance of the closed-loop algorithm was tested in three phases by using a patient simulator including a pulse-pressure variation output. In the first phase, LIR was tested in three different hemorrhage scenarios and compared with no management. In the second phase, we compared LIR with 20 practicing anesthesiologists for the management of a simulated hemorrhage scenario. In the third phase, LIR was tested under conditions of noise and artifact in the dynamic predictor.

Results

In the first phase, we observed a significant difference between the unmanaged and the LIR groups in moderate to large hemorrhages in heart rate (76 ± 8 versus 141 ± 29 beats/min), mean arterial pressure (91 ± 6 versus 59 ± 26 mm Hg), and cardiac output (CO; (6.4 ± 0.9 versus 3.2 ± 1.8 L/min) (P < 0.005 for all comparisons). In the second phase, LIR intervened significantly earlier than the practitioners (16.0 ± 1.3 minutes versus 21.5 ± 5.6 minutes; P < 0.05) and gave more total fluid (2,675 ± 244 ml versus 1,968 ± 644 ml; P < 0.05). The mean CO was higher in the LIR group than in the practitioner group (5.9 ± 0.2 versus 5.2 ± 0.6 L/min; P < 0.05). Finally, in the third phase, despite the addition of noise to the pulse-pressure variation value, no significant difference was found across conditions in mean, final, or minimum CO.

Conclusion

These data demonstrate that LIR is an effective volumetric resuscitator in simulated hemorrhage scenarios and improved physician management of the simulated hemorrhages.

Should tracheostomy practice in the setting of trauma be standardized?

PURPOSE OF REVIEW

Trauma is a common predisposing condition in patients developing acute respiratory failure. Selection criteria for tracheostomy use in trauma remain poorly defined. The purpose of this review is to discuss contemporary knowledge regarding the benefits and risks of tracheostomy and to highlight potential strategies to standardize practice.

RECENT FINDINGS

A number of studies have examined the effects of tracheostomy timing on clinically important end points. In general, these studies have produced conflicting findings, and are difficult to apply clinically. As a result, tracheostomy practice varies considerably. An approach to standardizing tracheostomy practice is presented, whereby decision for tracheostomy is based, in part, on a patient's clinical trajectory. The attractiveness of such an approach is that it attempts to match use of tracheostomy to patients with a need for continued ventilatory support.

SUMMARY

Variation in clinical practice is costly. To the extent that variation in tracheostomy practice reflects suboptimal use of this procedure, greater understanding of tracheostomy utility has the potential to enhance the quality of care and more effectively target resources.

The difficult-to-wean patient

Up to 20% of patients requiring mechanical ventilation will suffer from difficult weaning (the need of more than 7 days of weaning after the first spontaneous breathing trial), which may depend on several reversible causes: respiratory and/or cardiac load, neuromuscular and neuropsychological factors, and metabolic and endocrine disorders. Clinical consequences (and/or often causes) of prolonged mechanical ventilation comprise features such as myopathy, neuropathy, and body composition alterations and depression, which increase the costs, morbidity and mortality of this. These difficult-to-wean patients may be managed in two type of units: respiratory intermediate-care units and specialized regional weaning centers. Two weaning protocols are normally used: progressive reduction of ventilator support (which we usually use), or progressively longer periods of spontaneous breathing trials. Physiotherapy is an important component of weaning protocols. Weaning success depends strongly on patients&#x2019; complexity and comorbidities, hospital organization and personnel expertise, availability of early physiotherapy, use of weaning protocols, patients&#x2019; autonomy and families&#x2019; preparation for home discharge with mechanical ventilation.

Examination of non-clinical factors affecting tracheostomy practice in an academic surgical intensive care unit

OBJECTIVES

To gain insight into nonclinical factors potentially influencing tracheostomy practice and determine whether a specialized consultation form impacts tracheostomy utilization.

DESIGN

Prospective, observational.

SETTING

Surgical intensive care unit (SICU).

PATIENTS

Patients requiring mechanical ventilatory support. Data abstracted from the Project Impact administrative database served as a practice benchmark.

INTERVENTIONS

Prospective data collection, completion of online survey, and implementation of specialized tracheostomy consultation form.

MEASUREMENTS AND MAIN RESULTS

Data were prospectively collected on 539 patients and 13 attending intensivists. Our SICU tracheostomy rate (54.2%) exceeded that of 18 comparable ICUs participating in Project Impact (13.9%, p < .001). We attempted to identify factors that might account for liberal tracheostomy use. In 41.5% (+/-0.6%) of patients undergoing tracheostomy, extubation had not occurred despite successful completion of spontaneous breathing trial on >or=1 occasion, a rate that varied significantly among attending intensivists responsible for decision making for this procedure (p < .001). Attending intensivists and postgraduate surgical trainees with SICU experience were surveyed to better understand perceptions of tracheostomy practice. Most respondents (96.1%) reported relying on spontaneous breathing trial to guide decision for extubation, 72.6% estimated that <or=25% of patients successfully completed spontaneous breathing trial but did not proceed to immediate extubation, 86.3% estimated that <or=25% of such patients undergo tracheostomy, and 58.8% felt an acceptable benchmark for this practice was <or=10%. In most survey domains, respondents' perceptions underestimated actual practice. Implementation of a specialized tracheostomy consultation form did not impact tracheostomy utilization.

CONCLUSIONS

We identified variation among clinicians with respect to tracheostomy practice as well as discrepancies between perceptions of this practice and actual utilization. These factors may underlie the liberal use of this procedure in our SICU. Processes for providing accurate physician feedback may assist in optimizing tracheostomy use.

The impact of time to tracheostomy on mechanical ventilation duration, length of stay, and mortality in intensive care unit patients

INTRODUCTION

This study examined the potential effects of time to tracheostomy on mechanical ventilation duration, intensive care unit (ICU), and hospital length of stay (LOS), and ICU and hospital mortality.

METHODS

Cohort observational study was conducted in a tertiary care medical-surgical ICU based on a prospectively collected ICU database. We included 531 consecutive patients who were admitted between March 1999 and February 2005, and underwent tracheostomy during their ICU stay. The effect of time to tracheostomy on the different outcomes assessed was estimated using multivariate regression analyses (linear or logistic, based on the type of variables). Other independent variables that were included in the analyses included selected admission characteristics.

RESULTS

Mean +/- SD was 12.0 +/- 7.3 days for time to tracheostomy, and 23.1 +/- 18.9 days for ICU LOS. Time to tracheostomy was associated with an increased duration of mechanical ventilation (beta-coefficient = 1.31 for each day; 95% confidence interval [CI], 1.14-1.48), ICU LOS (beta-coefficient = 1.31 for each day; 95% CI, 1.13-1.48), and hospital LOS (beta-coefficient = 1.80 for each day; 95% CI, 0.65-2.94). On the other hand, time to tracheostomy was not associated with increased ICU or hospital mortality.

CONCLUSIONS

Time to tracheostomy was independently associated with increased mechanical ventilation duration, ICU LOS, and hospital LOS, but was not associated with increased mortality. Performing tracheostomy earlier in the course of ICU stay may have an effect on ICU resources and could entail significant cost-savings without adversely affecting patient mortality.