Need for tracheostomy after lung transplant predicts decreased mid- and long-term survival

Impact of Early Tracheostomy After Lung Transplantation: A National Analysis

BACKGROUND

Prolonged mechanical ventilation is common among lung transplant recipients, affecting nearly one-third of patients. Tracheostomy has been shown as a beneficial alternative to endotracheal intubation, but delays in tracheostomy tube placement persist. To date, no large-scale study has investigated the effect of tracheostomy timing on posttransplant outcomes.

METHODS

All adults receiving tracheostomy after primary, isolated lung transplantation were identified in the 2016 to 2020 Nationwide Readmissions Database. Early tracheostomy was defined as placement before postoperative day 8 based on exploratory cohort analysis. Multivariable regression was used to evaluate the association of early tracheostomy with in-hospital mortality, select posttransplant complications, and resource utilization.

RESULTS

Of an estimated 11,048 patients undergoing first-time lung transplantation, 1509 required a tracheostomy in the postoperative period, with 783 (51.9%) comprising the early cohort. After entropy balancing and risk adjustment, early tracheostomy placement was associated with reduced odds of death (adjusted odds ratio, 0.59; 95% CI, 0.36-0.97) and posttransplant infection (adjusted odds ratio, 0.54; 95% CI, 0.35-0.82). Further, tracheostomy within 1 week of transplantation was associated with decreased length of stay (β-coefficient, -16.5 days; 95% CI, -25.3 to -7.6 days) and index hospitalization costs (β-coefficient, -$97,600; 95% CI, -$153,000 to -$42,100).

CONCLUSIONS

The present study supports the safety of early tracheostomy among lung transplant recipients and highlights several potential benefits. Among appropriately selected patients, tracheostomy placement before postoperative day 8 may facilitate early discharge, lower costs, and reduced odds of posttransplant infection.

Risk factors and clinical consequences of early extubation failure in lung transplant recipients

Background

Prolonged intubation following lung transplantation is thought to delay recovery, yet a paucity of data exists regarding risk factors and outcomes related to extubation failure.

Methods

We performed a single-center, retrospective analysis of 238 lung transplant recipients between January 1, 2018, and December 31, 2022, to identify risk factors for extubation failure (intubation greater than 3 days, reintubation, and/or need for tracheostomy). We also assessed short-term outcomes relative to extubation success.

Results

In this cohort, 144 patients (60%) were extubated successfully while 94 patients experienced extubation failure; 10 (11%) were intubated greater than 3 days, 9 (9%) were reintubated, 34 (36%) required tracheostomy after reintubation, and 41 (44%) underwent empiric tracheostomy. Recipient height and female sex, lung allocation score, 6-minute walk distance, donor ischemic time, ex-vivo perfusion, donor smoking history, intraoperative transfused red blood cells (packed red blood cells (PRBCs)), primary graft dysfunction at time zero, and comatose sedation state at day 2 were associated with extubation failure on univariate analysis (all p < 0.01), whereas comatose state [(odds ratio) OR = 84.95 (95%confidence interval (CI) 17-423), p < 0.01], donor smoking [OR = 5.41 (95%CI 1.73-16.92), p < 0.01], primary graft dysfunction at T0 [OR = 2.02 (95%CI 1.22-3.34), p < 0.01], and PRBCs [OR = 1.19 (95%CI 1.06-1.34, p < 0.01] were independently associated with extubation failure on multivariate analysis. Reintubation and empiric tracheostomy were associated with similarly prolonged intensive care unit and hospital length of stay, while tracheostomy was also associated with protracted inpatient rehabilitation, increased functional impairment, and increased 6-month mortality.

Conclusions

Specific baseline donor and recipient demographics and intraoperative variables are associated with greater risk for post-transplant extubation failure. Patients with extubation failure have worse short-term outcomes.

Bacterial genotype and clinical outcomes in solid organ transplant recipients with Staphylococcus aureus bacteremia

INTRODUCTION

Outcomes from Staphylococcus aureus bacteremia (SAB) in solid organ transplant (SOT) recipients are poorly understood.

METHODS

This is a prospective cohort study comparing the bacterial genotype and clinical outcomes of SAB among SOT and non-transplant (non-SOT) recipients from 2005 to 2019. Each subject's initial S. aureus bloodstream isolate was genotyped using spa typing and assigned to a clonal complex.

RESULTS

A total of 103 SOT and 1783 non-SOT recipients with SAB were included. Bacterial genotype did not differ significantly between SOT and non-SOT recipients (p = .4673), including the proportion of SAB caused by USA300 (13.2% vs. 16.0%, p = .2680). Transplant status was not significantly associated with 90-day mortality (18.4% vs. 29.5%; adjusted odds ratio [aOR] 0.74; 95% confidence interval [CI]: 0.44, 1.25), but was associated with increased risk for septic shock (50.0% vs. 21.8%; aOR 2.31; 95% CI: 1.48, 3.61) and acute respiratory distress syndrome (21.4% vs. 13.7%; aOR 2.03; 95% CI: 1.22, 3.37), and a significantly lower risk of metastatic complications (33.0% vs. 45.5%; aOR 0.49; 95% CI: 0.32, 0.76). No association was found between bacterial genotype and 90-day mortality (p = .6222) or septic shock (p = .5080) in SOT recipients with SAB.

CONCLUSIONS

SOT recipients with SAB do not experience greater mortality than non-SOT recipients. The genotype of S. aureus bloodstream isolates in SOT recipients is similar to that of non-SOT recipients, and does not appear to be an important determinant of outcome in SOT recipients with SAB.