The effect of tracheostomy delay time on outcome of patients with prolonged mechanical ventilation: A STROBE-compliant retrospective cohort study

Association of early versus late tracheostomy with prognosis in hypoxic-ischaemic encephalopathy patients: A propensity-matched cohort study

BACKGROUND

The optimal timing for exchanging an endotracheal tube for a tracheostomy cannula in patients with hypoxic-ischaemic encephalopathy is controversial.

AIM

This study aimed to evaluate the effects of early versus late tracheostomy on the prognosis of patients with hypoxic-ischaemic encephalopathy.

STUDY DESIGN

The study was an observational retrospective study that followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. We included adults with hypoxic-ischaemic encephalopathy who underwent tracheostomy between January 2012 and September 2020. The patients were classified into early or late tracheostomy groups. To eliminate differences in baseline characteristics, propensity score matching was conducted, and the outcomes between the two groups were compared.

RESULTS

A total of 132 patients were included, and through propensity score matching, 54 pairs of patients were matched. The early tracheostomy group showed a significant reduction in the duration of mechanical ventilation (median, 12 days; interquartile range 7-20 vs. median, 28 days; interquartile range, 15.75-58.25, p < .001), intensive care unit length of stay (median, 14.5 days; interquartile range, 6.75-26 vs. median, 35 days; interquartile range, 20-59, p < .001) and hospital length of stay (median, 19.5 days; interquartile range, 10.87-36.5 vs. median, 39.5 days; interquartile range, 22-66, p < .001). Over a 1-year follow-up period, there were no significant differences between the two groups regarding inhospital mortality (57.4% vs. 46.3%, p = .248), 30-day mortality (59.3% vs. 46.3%, p = .177) and 1-year mortality (61.1% vs. 48.1%, p = .176).

CONCLUSIONS

In patients with hypoxic-ischaemic encephalopathy undergoing mechanical ventilation, early tracheostomy is associated with a reduction in the duration of mechanical ventilation and decreased intensive care unit and hospital length of stay.

RELEVANCE TO CLINICAL PRACTICE

For patients with hypoxic-ischaemic encephalopathy who are at a high risk of requiring prolonged mechanical ventilation, the benefits of early tracheostomy suggest considering it a viable treatment option.

Impact of Obesity on Timing of Tracheotomy: A Multi-institutional Retrospective Study

OBJECTIVE

To examine the impact of increased body mass index (BMI) on (1) tracheotomy timing and (2) short-term surgical complications requiring a return to the operating room and 30-day mortality utilizing data from the Multi-Institutional Study on Tracheotomy (MIST).

METHODS

A retrospective analysis of patients from the MIST database who underwent surgical or percutaneous tracheotomy between 2013 and 2016 at eight institutions was completed. Unadjusted and adjusted logistic regression analyses were used to assess the impact of obesity on tracheotomy timing and complications.

RESULTS

Among the 3369 patients who underwent tracheotomy, 41.0% were obese and 21.6% were morbidly obese. BMI was associated with higher rates of prolonged intubation prior to tracheotomy accounting for comorbidities, indication for tracheotomy, institution, and type of tracheostomy (p = 0.001). Morbidly obese patients (BMI ≥35 kg/m2) experienced a longer duration of intubation compared with patients with a normal BMI (median days intubated [IQR 25%-75%]: 11.0 days [7-17 days] versus 9.0 days [5-14 days]; p < 0.001) but did not have statistically higher rates of return to the operating room within 30 days (p = 0.12) or mortality (p = 0.90) on multivariable analysis. This same finding of prolonged intubation was not seen in overweight, nonobese patients when compared with normal BMI patients (median days intubated [IQR 25%-75%]: 10.0 days [6-15 days] versus 10.0 days [6-15 days]; p = 0.36).

CONCLUSION

BMI was associated with increased duration of intubation prior to tracheotomy. Although morbidly obese patients had a longer duration of intubation, there were no differences in return to the operating room or mortality within 30 days.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:4674-4681, 2024.

Weaning-associated interventions for ventilated intensive care patients: A scoping review

BACKGROUND

Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing.

AIM

To provide an overview of interventions associated with ventilator weaning.

STUDY DESIGN

We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered.

RESULTS

Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies).

CONCLUSIONS

Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion).

RELEVANCE TO CLINICAL PRACTICE

This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.

A Simulated Tracheostomy Tube Change Educational Intervention to Promote Competency Among Novice Healthcare Professionals: A Repeated Measures Study

Objective

To evaluate an educational intervention to promote confidence, knowledge, and skills in tracheostomy tube change among nursing students.

Methods

The study, conducted at the at the Johns Hopkins Center for Immersive Learning and Digital Innovation, enrolled nursing students without prior experience in tracheostomy tube change. The intervention included a pre-recorded presentation, faculty demonstrations with a Tracheostomy Care Training Simulation Model, and participant practice demonstrating skills. Primary outcomes included confidence, knowledge, and competency with tracheostomy tube changes. Secondary outcomes included number of attempts required to achieve competency and time required per attempt. The study followed STROBE guidelines with repeated measure design.

Results

Participants in the study (n=50) had a mean age of 30 years, were predominantly female (83%) with a bachelor's degree (76%), most often in the third semester of nursing school (45%). Participants showed a mean improvement of 3.58 points out of five (SD: 0.56, P<0.001) across 11 pre- and post-test items. Every confidence assessment improved, with the largest increase in assessing tube placement. Knowledge assessments improved across all eight test items in the first test-retest interval, showing an improvement of 1.14 points out of five (SD: 0.89, P<0.001). Competency assessment improved in the first test-retest interval of 1.01 points out of five (SD: 0.65, P<0.001). On serial assessments, time to complete tracheostomy tube change decreased from 2.39 to 0.60 minutes. Faculty deemed 95% of participants competent after only one skill testing iteration.

Conclusion

An educational intervention, combining digital presentations with interactive faculty-led simulations and practical skill assessments, successfully elevated nursing students' confidence, knowledge, and competency in tracheostomy tube changes.

Optimal methodology for percutaneous dilatational tracheostomy: a comparative analysis between conventional and multidisciplinary approaches utilizing ultrasound, flexible bronchoscopy, and microcatheter puncture in critically ill individuals of diminutive stature-a longitudinal single-institutional experience and retrospective analysis

Background

Percutaneous dilatational tracheostomy (PDT), a bedside procedure in intensive care, enhances respiratory support for critically ill patients with benefits over traditional tracheostomy, such as improved safety, ease of use, cost-effectiveness, and operational efficiency by eliminating patient transfers to the operating room. It also minimizes complications including bleeding, infection, and inflammation. Despite decades of PDT evolution and device diversification, adaptations primarily cater to larger Western patients rather than smaller-statured Korean populations. This study assesses the efficacy and appropriateness of the Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IN, USA), augmented with ultrasound, flexible bronchoscopy, and microcatheter techniques, for Korean patients with short stature.

Methods

We conducted PDT on 183 intubated adults (128 male/55 female) with severe respiratory issues at a single medical center from January 2010 to December 2022. Patients were divided into two groups for retrospective analysis: a modified group (n=133) underwent PDT with ultrasound-guided flexible bronchoscopy and microcatheter puncture, and a conventional group (n=50) received PDT using only the Ciaglia Blue Rhino device. We assessed clinical and demographic characteristics, outcomes, and complications such as pneumothorax and emphysema. The study also evaluated the suitability and effectiveness of the devices for Korean patients with short stature.

Results

Demographic characteristics including sex, body weight, height, body mass index, obesity status, and underlying diseases showed no significant differences between the two groups. However, the modified group was older (69.5±14.2 vs. 63.5±14.1 years; P=0.01). The sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS) II score was slightly higher in the modified groups, but no statistically significant differences were observed (7.1±2.3 vs. 6.7±2.3, P=0.31 and 46.7±9.0 vs. 44.0±9.1, P=0.08, respectively). The duration of hospital and ICU stays, as well as days post-PDT, were longer in the conventional group, yet these differences were not statistically significant (P=0.20, P=0.44, P=0.06). Total surgical time, including preparation, ultrasound, bronchoscopy, and microcatheter puncture, was significantly longer in the modified group (25.6±7.5 vs. 19.9±6.5 minutes; P<0.001), and the success rate of the first tracheal puncture was also higher (100.0% vs. 92.0%; P=0.006). Intra-operative bleeding was less frequent in the modified group (P=0.02 for tracheostomy site bleeding and P=0.002 for minor bleeding).

Conclusions

PDT, performed at the bedside in intensive care settings, proves to be a swift and dependable method. Utilizing the Ciaglia Blue Rhino device, combined with ultrasound guidance, flexible bronchoscopy, and 4.0-Fr microcatheter puncture, PDT is especially effective for intubated patients who cannot be weaned from ventilation. This technique results in fewer complications than traditional tracheostomy and is particularly beneficial for patients with respiratory issues and smaller-statured Koreans, potentially reducing morbidity and mortality.

Increasing the precision of simulated percutaneous dilatational tracheostomy-a pilot prototype device development study

Percutaneous dilatational tracheostomy (PDT) is a bedside medical procedure which sites a new tracheostomy tube in the front of the neck. The critical first step is accurate placement of a needle through the neck tissues into the trachea. Misplacement occurs in around 5% of insertions, causing morbidity, mortality, and delays to recovery. We aimed to develop and evaluate a prototype medical device to improve precision of initial PDT-needle insertion. The Guidance for Tracheostomy (GiFT) system communicates the relative locations of intra-tracheal target sensor and PDT-needle sensor to the operator. In simulated "difficult neck" models, GiFT significantly improved accuracy (mean difference 10.0 mm, ANOVA p < 0.001) with ten untrained laboratory-based participants and ten experienced medical participants. GiFT resulted in slower time-to-target (mean difference 56.1 s, p < 0.001) than unguided attempts, considered clinically insignificant. Our proof-of-concept study highlights GiFT's potential to significantly improve PDT accuracy, reduce procedural complications and offer bedside PDT to more patients.

A retrospective analysis of COVID-19 tracheostomies: Early versus late tracheostomy

Objectives

To assess the impact of early tracheostomy (ET) versus late tracheostomy (LT) placement on mortality and decannulation rates of COVID patients.

Methods

A retrospective chart review was performed of all patients infected with COVID-19 who underwent tracheostomy tube placement in an Ochsner-affiliated hospital from March 2020 to May 2022. Patients were identified using the electronic medical record and data was collated using the "Epic SlicerDicer" tool. Descriptive statistics were gathered and compared between patients who underwent ET placement and those who underwent LT placement. Patient demographics, previous medical history, tracheostomy procedural details, arterial blood gases, complications, and outcomes including time to wean from the ventilator, and time to decannulation were recorded.

Results

Two-hundred nineteen patients were included in the study. There were no statistically significant differences in liberation from mechanical ventilation rates between early and LT (62% vs. 55%, p = .19), or in decannulation rates (40% vs. 32%, p = .14). The mean duration of time to liberation from mechanical ventilation for early trach was 13.88 versus 18.17 days for late trach, however, no statistically significant difference was found (p = .12). Similarly, mean duration of time to decannulation was 41.17 days for early versus 47.72 for late trach (p = .15).

Conclusion

Contrary to some studies in the literature, the results presented here suggest ETs are not associated with hastened liberation from mechanical ventilation or increased decannulation rates. Further prospective studies may be warranted in assessing the impact of early versus LT in the COVID patient population.

Level of Evidence

III.

Early Tracheostomy and Outcomes in Ventilated Pediatric Trauma Patients

INTRODUCTION

The purpose of the study was to evaluate the outcomes of pediatric ventilated patients who underwent early tracheostomy. Our hypothesis is early tracheostomy will be associated with less ventilator days, Intensive care (ICU) days and hospital days.

METHODS

The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017 through 2019 was used for the study. All pediatric trauma patients ≤17 years who were admitted to the hospital and were placed on mechanical ventilation were included in the study. Other variables included patients' demography, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, types of procedure that were performed for hemorrhage control. Propensity score matching analysis was performed between the early (≤7 days) and late tracheostomy (>7 days) groups. The primary outcome of the study was total hospital length of stay. Other outcomes were ICU days, ventilator days.

RESULTS

Propensity score matching created 643 pairs of patients. The median age (years [interquartile range]) of the patient was 14 [8-16]. Most patients suffered from severe injuries with a median ISS 29 [22-38] and GCS score was 3 [3-8]. There was no significant difference identified between the early and the late groups, in hospital stay (24 [23, 26] vs. 24 [23, 26], P = 0.5), ICU days (14 [9-22] vs. 16 [9-23], P = 0.073) and ventilator days (10 [6-17] vs. 11 [7-18], P = 0.068). The incidence of pneumonia between the groups was (8.7% vs. 9.2%, P = 0.347).

CONCLUSION

Early tracheostomy failed to show any outcomes benefit in ventilated pediatric trauma patients.

Percutaneous tracheostomy: Comparison of three different methods with respect to tracheal cartilage injury in cadavers—Randomized controlled study

Background: Performing tracheostomy improves patient comfort and success rate of weaning from prolonged invasive mechanical ventilation. Data suggest that patients have more benefit of percutaneous technique than the surgical procedure, however, there is no consensus on the percutaneous method of choice regarding severe complications such as late tracheal stenosis. Aim of this study was comparing incidences of cartilage injury caused by different percutaneous dilatation techniques (PDT), including Single Dilator, Griggs’ and modified (bidirectional) Griggs’ method.

Materials and methods: Randomized observational study was conducted on 150 cadavers underwent post-mortem percutaneous tracheostomy. Data of cadavers including age, gender and time elapsed from death until the intervention (more or less than 72 h) were collected and recorded. Primary and secondary outcomes were: rate of cartilage injury and cannula malposition respectively.

Results: Statistical analysis revealed that method of intervention was significantly associated with occurrence of cartilage injury, as comparing either standard Griggs’ with Single Dilator (p = 0.002; OR: 4.903; 95% CI: 1.834–13.105) or modified Griggs’ with Single Dilator (p &lt; 0.001; OR: 6.559; 95% CI: 2.472–17.404), however, no statistical difference was observed between standard and modified Griggs’ techniques (p = 0.583; OR: 0.748; 95% CI: 0.347–1.610). We found no statistical difference in the occurrence of cartilage injury between the early- and late post-mortem group (p = 0.630). Neither gender (p = 0.913), nor age (p = 0.529) influenced the rate of cartilage fracture. There was no statistical difference between the applied PDT techniques regarding the cannula misplacement/malposition.

Conclusion: In this cadaver study both standard and modified Griggs’ forceps dilatational methods were safer than Single dilator in respect of cartilage injury.

The impact of tracheostomy delay in intensive care unit patients: a two-year retrospective cohort study

Aims

This study was undertaken to evaluate our tracheostomy service and identify reasons for any delays.

Methods

A retrospective study in an academic tertiary-care hospital in Jeddah, Saudi Arabia. Inclusion criteria were any patients in ICU who required a surgical tracheostomy over a 2-year period (January 2014 to December 2015). The primary outcome was delayed tracheostomy referral and secondary outcomes included the number of days between referral and consultation, days between consultation and tracheostomy placement, and mortality rates.

Results

Ninety-nine patients had a tracheostomy between January 2014 to December 2015 and could be analysed, mean age of 52.7 years, 44.5% females. The average duration from referral to tracheostomy was 5.12 days (SD 6.52). Eighteen patients (18.2%) had delayed tracheostomy (> 7 days from referral). The main reasons for the delay were the patient’s medical condition (50%, n = 9), followed by low haemoglobin (38.9%, n = 7). Administrative reasons were recorded in 5 cases only (28%); 2 due to operating room lack of time, 2 due to multidisciplinary issues, and 1 due to family refusal. Laboratory-confirmed low haemoglobin, a prescription of anti-platelets, or a prescription of anti-coagulation were not associated with a longer duration between referral and tracheostomy placement. An increase of 1 day in the time between referral and tracheostomy corresponded to an increase in delay in discharge from ICU of 1.24 days (95% CI 0.306 to 2.18).

Conclusion

Although most delays related to the clinical condition of the patient, administrative and multidisciplinary factors also play a role. Early tracheostomy (less than 14 days) from intubation increases the survival rates of patients and improves their clinical outcomes. Further prospective evaluation is needed to confirm the impact of delay in performing surgical tracheostomy among ICU patients whose bedside percutaneous tracheostomy is contraindicated.

Early tracheostomy: on the cutting edge, some benefit more than others

PURPOSE OF REVIEW

The decision to undergo early tracheostomy in critically ill patients has been the subject of multiple studies in recent years, including several meta-analyses and a large-scale examination of the National in-patient Sampling (NIS) database. The research has focused on different patient populations, and identified common outcomes measures related to ventilation. At the crux of the new research is the decision to undergo an additional invasive procedure, mainly tracheostomy, rather than attempt endotracheal tube ventilation with or without early extubation. Notably, recent research indicates that neurological and SARS-CoV-2 (COVID-19) patients seem to have an exaggerated benefit from early tracheostomy.

RECENT FINDINGS

Recent studies of patients undergoing early tracheostomy have shown decreases in ventilator associated pneumonia, ventilator duration and duration of ICU stay. However, these studies have shown mixed data with respect to mortality and length of hospitalization. Such advantages only become apparent with large-scale examination. Confounding the overall discussion is that the research has focused on heterogeneous groups, including neurosurgical ICU patients, general ICU patients, and most recently, intubated COVID-19 patients.

SUMMARY

Specific populations such as neurosurgical and COVID-19 patients have clearly defined benefits following early tracheostomy. Although the benefit is less pronounced, there does seem to be an advantage in general ICU patients with regards to ventilator-free days and lower incidence of ventilator-associated pneumonia. In these patients, large-scale examination points to a clear mortality benefit.

Factors influencing the length of stay among patients admitted to a tertiary pediatric intensive care unit in Saudi Arabia

This study aimed to assess the variables contributing to the length of stay in the pediatric intensive care unit. This study utilized a retrospective design by analyzing data from the Virtual Pediatric Systems web-based database. The study was conducted in a tertiary hospital-King Fahad Medical City in Riyadh, Saudi Arabia-from January 1, 2014 to December 31, 2019. The patients were admitted to intensive care with complex medical and surgical diseases. The variables were divided into quantitative and qualitative parameters, including patient data, Pediatric Risk of Mortality III score, and complications. Data from 3,396 admissions were analyzed. In this cohort, the median and mean length of stay were 2.8 (interquartile range, 1.08-7.04) and 7.43 (standard deviation, 14.34) days, respectively. The majority of long-stay patients-defined as those staying longer than 30 days-were less than 12 months of age (44.79%), had lower growth parameters (p < 0.001), and had a history of admission to pediatric intensive care units. Moreover, the majority of long-stay patients primarily suffered from respiratory diseases (51.53%) and had comorbidities and complications during their stay (p < 0.001). Multivariate analysis of all variables revealed that central line-associated bloodstream infections (p < 0.001), external ventricular drain insertion (p < 0.005), tracheostomy (p < 0.001), and use of mechanical ventilation (p < 0.001) had the most significant associations with a longer stay in the pediatric intensive care unit. The factors associated with longer stays included the admission source, central nervous system disease comorbidity, and procedures performed during the stay. Factors such as respiratory support were also associated with prolonged intensive care unit stays.

Impact of Tracheostomy Timing on Outcomes After Cardiovascular Surgery

OBJECTIVES

This study aimed to investigate whether tracheostomy timing in patients undergoing cardiac surgery had an impact on outcomes.

DESIGN

Retrospective, observational study.

SETTING

Single-center university hospital.

PARTICIPANTS

Patients requiring tracheostomy among a total of 961 patients who underwent cardiovascular surgery via a median sternotomy from January 2014 to March 2021.

INTERVENTIONS

Early versus late tracheostomy.

MEASUREMENTS AND MAIN RESULTS

During the study period, tracheostomy was performed in 28 patients (2.9%). According to tracheostomy timing, postoperative day seven was chosen as the cutoff to define early (≤seven days) and late (>seven days) tracheostomy. Patients in the early-tracheostomy group had a significantly shorter ventilation time after tracheostomy compared with the late-tracheostomy group (p = 0.039), and early tracheostomy resulted in a reduction in total ventilation time (p = 0.001). The incidence of pressure ulcers was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group. There was a higher tracheal tube removal rate in the early-tracheostomy group compared with the late-tracheostomy group (p = 0.0007). The one-year survival rate in the early- and late-tracheostomy groups was 65% and 31%, respectively. The long-term mortality rate was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group (p = 0.04).

CONCLUSIONS

Early tracheostomy (<seven days) may provide better clinical outcomes, with lower mortality and morbidity rates, when patients are judged to require at least seven days of ventilation after cardiovascular surgery.

Identification of ferroptosis-associated genes exhibiting altered expression in response to cardiopulmonary bypass during corrective surgery for pediatric tetralogy of fallot

BACKGROUND

Tetralogy of Fallot (ToF) is a life-threatening congenital cardiovascular disorder. Currently, the most effective therapeutic intervention for pediatric ToF remains corrective surgery with cardiopulmonary bypass (CPB). Ferroptosis is an iron-dependent form of regulated cell death, driven by an accumulation of lipid peroxides to levels sufficient to trigger cell death. Ferroptosis was recently linked to cardiac ischemia and reperfusion injury. However, few studies have examined CPB-associated ferroptosis.

METHOD

In the current study, pediatric ToF patient pre- and post-CPB atrial biopsy gene expression profiles were downloaded from a public database, and 117 differentially expressed genes (DEGs) were identified using the Wilcoxon rank-sum test and weighted gene correlation network analysis. These were screened for ferroptosis-associated genes using the FerrDb database, thereby identifying ten genes. Finally, the construction of gene-microRNA (miRNA) and gene-transcription factor (TF) networks, in conjunction with gene ontology and biological pathway enrichment analysis, were used to inform hypotheses regarding the molecular mechanisms underlying CPB-associated ferroptosis.

RESULTS

Ten genes involved in CPB-associated ferroptosis(ATF3,TNFAIP3，CDKN1A, ZFP36, JUN，SLC2A3, IL6, CXCL2, PTGS2, and DDIT3). Ferroptosis-associated genes were largely involved in myocardial inflammatory responses and may be regulated by a number of identified miRNAs and TFs, thereby suggesting modulatable pathways potentially involved in CPB-associated ferroptosis.

CONCLUSIONS

Results suggest that CPB precipitates ferroptosis within cardiac tissue during corrective Surgery for Pediatric Tetralogy of Fallot. These findings may ultimately help improve outcomes of corrective surgery for pediatric ToF.

Tracheostomy for Coronavirus Disease 2019 Patients: Maintaining the Standard of Care

Objectives:

To respond to the new recommendations for delaying tracheostomy for coronavirus disease 2019 patients to day 21 post-intubation to ensure viral clearance.

Design:

Prospective observational cohort from April 1, 2020, to April 30, 2020, with 60 days follow-up.

Setting:

Academic medical center with nine adult ICUs dedicated to caring for coronavirus disease 2019 patients requiring mechanical ventilation.

Patients:

Mechanically ventilated patients with coronavirus disease 2019 pneumonia requiring tracheostomy for prolonged ventilatory support.

Interventions:

Adherence to the standard of care for timing of tracheostomy as deemed necessary by the intensivist without delay and utilizing the existing tracheostomy team in performing the needed procedures within 1 day of the request.

Measurements and Main Results:

One hundred eleven patients with coronavirus disease 2019 received tracheostomy in the month of April 2020. Median time to tracheostomy was 11 days. All procedures were performed percutaneously at bedside under bronchoscopic guidance. Sixty-three percent of patients who received tracheostomy either weaned or discharged alive within 60 days of the procedure. Performing tracheostomy on these patients without delay did not lead to coronavirus disease 2019 viral transmission to the tracheostomy team as evident by lack of symptoms and negative antibody testing.

Conclusions:

Adherence to standard of care in timing of tracheostomy is safe. Recommending delaying the procedure may lead to harmful consequences from prolonging mechanical ventilation and sedation without apparent benefit.

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.