Early prediction of hospital outcomes in patients tracheostomized for complex mechanical ventilation weaning

To PEG or not to PEG: Trends in Gastrostomy Tube Needs in Patients Requiring Tracheostomy

INTRODUCTION

Tracheostomy is a commonly performed procedure and often combined with percutaneous endoscopic gastrostomy tube (PEG) placement, a type of gastrostomy tube (GT) utilized to provide durable feeding access. Many patients pass swallow evaluations (SE) prior to discharge, raising the question of optimal timing of GT placement. The purpose of this study was to assess how frequently a GT is required at time of discharge in patients needing a tracheostomy for failure to wean off invasive mechanical ventilation (MV).

METHODS

This was a retrospective, IRB exempt analysis of all patients that received tracheostomy and GT at a Level II trauma center over an 18-mo period. Medical records were reviewed for key patient demographics and clinical course.

RESULTS

159 patients included, median hospital length of stay of 33 d, average time to tracheostomy 17 d, and 17-d median time to oral diet after tracheostomy. PEG was placed at time of tracheostomy in 35% of patients, with 52.8% receiving a GT in the acute care setting. Overall, only 15 patients (9.4%) had continued requirement for a GT at the time of discharge. The remaining 144 patients either died/discharged to hospice (n = 36, 22.6%) or demonstrated the ability to eat prior to discharge from acute care setting (n = 108, 67.9%).

CONCLUSIONS

In patients requiring tracheostomy for failure to wean off invasive MV, only 9.4% actually needed GT placement. Depending on institutional and regional capabilities, this study suggests that waiting to place a GT may be a reasonable approach in patients who need tracheostomy for failure to wean off invasive mechanical ventilation.

Tracheostomy: update on why, when and how

PURPOSE OF REVIEW

The aim of this review is to summarize available data, including the most recent ones, to help develop the best possible strategy regarding the use of tracheostomy in ICU patients requiring prolonged mechanical ventilation or who experience loss of airway-protecting mechanisms.

RECENT FINDINGS

Tracheostomy facilitates the weaning process by reducing the patient's work of breathing and increasing comfort. It thus allows for a reduction in sedation levels. It also helps with secretions clearance, facilitates disconnection from the ventilator, and enables earlier phonation, oral intake, and mobilization. Despite these advantages, tracheostomy does not reduce mortality and is associated with both early and late complications, particularly tracheal stenosis. The timing of tracheostomy remains a subject of debate, and only a personalized approach that considers each patient's specific characteristics can help find the best possible compromise between avoiding unnecessary delays and minimizing the risks of performing a needless invasive procedure. In the absence of contraindications, the percutaneous single dilator technique under fibroscopic guidance should be the first choice, but only if the team is properly trained.

SUMMARY

A step-by-step individualized approach based on the available evidence allows identifying the best strategy regarding the use of tracheostomy in ICU patients.

Geriatric rehabilitation center outcomes after successful weaning from extremely prolonged mechanical ventilation in older adults

AIM

To determine the rate of and predictive factors for postacute in-hospital survival of older adults after successful weaning from extremely prolonged mechanical ventilation (e-PMV).

METHODS

This pilot retrospective study involved patients who were weaned from e-PMV in Bayit Balev Geriatric and Rehabilitation Center, Maccabi Health Services, Bat Yam, Israel between January 2010 and May 2022. In-hospital survival was measured.

RESULTS

Out of 488 patients (of all ages) treated in our geriatric rehabilitation center (GRC) during the study period, only 181 patients aged 65 years and older were conscious and were candidates for weaning from e-PMV. Seventy-three patients (40.3%) were weaned and therefore recruited to this study. Six patients (8.2%) were weaned but died before discharge. Out of the 67 (91.8%) who were alive and weaned, 18 (24.7%) were decanulated and discharged to their homes, and the remaining 49 (75.3%) were weaned and discharged from our GRC with tracheostomy canula to other long-term care institutions. Univariate analysis showed that in-hospital survival was significantly dependent on age and the presence of tracheomalacia, both in a time-independent and time-dependent manner. In a time-dependent (adjusted) multivariate analysis, there were no independent predictive factors for in-hospital mortality.

CONCLUSIONS

A dedicated GRC team can wean a substantial number of patients after e-PMV and return them to their community and even homes.

Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy

Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.