Timing of tracheostomy and patient outcomes in critically ill patients requiring extracorporeal membrane oxygenation: a single-center retrospective observational study

[Liberation of mechanical ventilation in tracheostomized pediatric patients during their stay in the intensive care unit]

Introduction

Tracheostomy in pediatric intensive care has a prevalence between 5% and 10% of patients on mechanical ventilation.

Objective

The objective of this study was to determine the duration and outcome of the weaning process from mechanical ventilation (MV) and the behavior according to the reason for the tracheostomy.

Methodology

Data from 59 patients under 18 years of age who received MV and underwent tracheostomy between January 2018 and March 2023 at the Juan P. Garrahan National Pediatric Hospital, Argentina, were retrospectively examined. Demographic variables, reasons for admission to the unit, days on MV, tracheostomy characteristics, and the weaning process from MV were recorded.

Results

The main reasons for tracheostomy were airway disorders (50.8%) and prolonged MV (30.5%). Notable variability was observed in the duration and success of the weaning process among different groups of patients. Patients with airway disorders showed a faster weaning (median: 1.5 days) and higher success in this process, while those with prolonged MV and neurological disorders experienced longer processes (medians: 25.5 and 28 days, respectively) and more patients required partial or total mechanical ventilation at the end of this process. The presence of diaphragmatic dysfunction was more common in those who took longer to wean.

Conclusion

The weaning from MV is a complex process, and the reason for the tracheostomy influences its progression.

Characteristics of patients requiring tracheostomy following extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Aim

This study aimed to describe the characteristics of patients requiring tracheostomy following extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) using real-world data from a multicenter registry.

Methods

This was a secondary analysis of the SAVE-J II study, a retrospective multicenter registry study in Japan. Patients with OHCA aged ≥18 years who underwent ECPR between January 2013 and December 2018 were included. Participants were classified into the tracheostomy and non-tracheostomy groups, with the tracheostomy group further categorized into early (≤10 days) and late (>10 days) subgroups. Survival and favorable neurological outcome at hospital discharge were the primary outcomes.

Results

Overall, this study included 1,910 patients with a median age of 61 (interquartile range [IQR], 49-69) years, of whom 1,610 (82.6%) were male. Of the participants, 276 (14.5%) underwent tracheostomy, with 224 (81.2%) and 44 (15.9%) surviving to discharge and achieving favorable neurological outcomes at hospital discharge, respectively. The median duration to tracheostomy was 10 (IQR, 8-14) days, with 98% of tracheostomies performed following extracorporeal membrane oxygenation (ECMO) weaning. The early tracheostomy group accounted for 145 patients (54.7%). The early and late tracheostomy subgroups showed no significant differences in survival or favorable neurological outcomes at discharge.

Conclusions

Following ECPR, 14.5% of the patients underwent tracheostomy, with the majority performed following ECMO weaning. Although the survival rate at discharge among these patients was 81.2%, only 15.9% exhibited favorable neurological outcomes. To explore the long-term outcomes of patients treated with ECPR for OHCA, future studies are needed.

Risk factors for nosocomial infection in patients undergoing extracorporeal membrane oxygenation support treatment: A systematic review and meta-analysis

OBJECTIVE

To evaluate the risk factors of nosocomial infection during Extracorporeal membrane oxygenation (ECMO) treatment through systematic evaluation and meta-analysis, in order to provide evidence-based basis for clinical treatment and prevention of nosocomial infection during ECMO treatment.

METHOD

Computer search of Cochrane Library, PubMed, Embase, and Web of Science databases was conducted to establish a database of relevant literature published in March 2023. Two researchers independently screened literature, extracted data, and evaluated quality based on inclusion and exclusion criteria, and then analyzed the data using STATA 14.0 software. This plan is registered with PROSPERO as CRD42021271083.

RESULT

A total of 2955 ECMO patients, including 933 nosocomial infected patients, were included in 23 articles. Meta analysis showed that immunosuppression, Heart transplantation, VA-ECMO, CRRT, red blood cell input, ECMO support time, mechanical ventilation time, ICU hospitalization time, and total hospitalization time were the risk factors for nosocomial infection in patients supported by ECMO.

CONCLUSION

ECMO treatment for nosocomial infections in patients is related to multiple factors. In clinical work, medical staff should identify high-risk groups of ECMO nosocomial infections, actively take preventive measures, and reduce the incidence and mortality of nosocomial infections.

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.

Development of a Prognostic Scoring System for Tracheostomized Patients Requiring Prolonged Ventilator Care: A Ten-Year Experience in a University-Affiliated Tertiary Hospital

Background and Objectives: This study aimed to assess the value of a novel prognostic model, based on clinical variables, comorbidities, and demographic characteristics, to predict long-term prognosis in patients who received mechanical ventilation (MV) for over 14 days and who underwent a tracheostomy during the first 14 days of MV. Materials and Methods: Data were obtained from 278 patients (66.2% male; median age: 71 years) who underwent a tracheostomy within the first 14 days of MV from February 2011 to February 2021. Factors predicting 1-year mortality after the initiation of MV were identified by binary logistic regression analysis. The resulting prognostic model, known as the tracheostomy-ProVent score, was computed by assigning points to variables based on their respective ß-coefficients. Results: The overall 1-year mortality rate was 64.7%. Six factors were identified as prognostic indicators: platelet count < 150 × 103/μL, PaO2/FiO2 < 200 mmHg, body mass index (BMI) < 23.0 kg/m2, albumin concentration < 2.8 g/dL on day 14 of MV, chronic cardiovascular diseases, and immunocompromised status at admission. The tracheostomy-ProVent score exhibited acceptable discrimination, with an area under the receiver operating characteristic curve (AUC) of 0.786 (95% confidence interval: 0.733-0.833, p < 0.001) and acceptable calibration (Hosmer-Lemeshow chi-square: 2.753, df: 8, p = 0.949). Based on the maximum Youden index, the cut-off value for predicting mortality was set at ≥2, with a sensitivity of 67.4% and a specificity of 76.3%. Conclusions: The tracheostomy-ProVent score is a good predictive tool for estimating 1-year mortality in tracheostomized patients undergoing MV for >14 days. This comprehensive model integrates clinical variables and comorbidities, enhancing the precision of long-term prognosis in these patients.

Extracorporeal Membrane Oxygenation Without Invasive Ventilation for Respiratory Failure in Adults: A Systematic Review

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is an advanced treatment for acute severe respiratory failure. Patients on ECMO are frequently maintained sedated and immobilized until weaning from ECMO, first, and then from mechanical ventilation. Avoidance of sedation and invasive ventilation during ECMO may have potential advantages. We performed a systematic literature review to assess efficacy and safety of awake ECMO without invasive ventilation in patients with respiratory failure.

DATA SOURCES

PubMed, Web of Science, and Scopus were searched for studies reporting outcome of awake ECMO for adult patients with respiratory failure.

STUDY SELECTION

We included all studies reporting outcome of awake ECMO in patients with respiratory failure. Studies on ECMO for cardiovascular failure, cardiac arrest, or perioperative support and studies on pediatric patients were excluded. Two investigators independently screened and selected studies for inclusion.

DATA EXTRACTION

Two investigators abstracted data on study characteristics, rate of awake ECMO failure, and mortality. Primary outcome was rate of awake ECMO failure (need for intubation). Pooled estimates with corresponding 95% CIs were calculated. Subgroup analyses by setting were performed.

DATA SYNTHESIS

A total of 57 studies (28 case reports) included data from 467 awake ECMO patients. The subgroup of patients with acute respiratory distress syndrome showed a pooled estimate for awake ECMO failure of 39.3% (95% CI, 24.0-54.7%), while in patients bridged to lung transplantation, pooled estimate was 23.4% (95% CI, 13.3-33.5%). Longest follow-up mortality was 121 of 439 (pooled estimate, 28%; 95% CI, 22.3-33.6%). Mortality in patients who failed awake ECMO strategy was 43 of 74 (pooled estimate, 57.2%; 95% CI, 40.2-74.3%). Two cases of cannula self-removal were reported.

CONCLUSIONS

Awake ECMO is feasible in selected patients, although the effect on outcome remains to be demonstrated. Mortality is almost 60% in patients who failed awake ECMO strategy.

Successful management of temporary veno-venous extracorporeal membrane oxygenation for a pediatric lung transplant recipient with bronchiolitis obliterans syndrome awaiting lung re-transplantation: a case report

BACKGROUND

The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation is an uncommon strategy in Japan owing to the severe donor shortage and absence of urgent allocation policy. Moreover, the use of veno-venous (VV) ECMO for immunosuppressed patients is controversial; thus, applying ECMO to patients who await lung re-transplantation is challenging.

CASE PRESENTATION

A 16-year-old lung transplant recipient with grade 3 bronchiolitis obliterans syndrome was waitlisted for lung re-transplantation. Eleven months later, he fell into severe respiratory acidosis with hypercapnia, which were not resolved with mechanical ventilation. VV ECMO was introduced to minimize lung stress and strain. Tracheostomy was additionally performed on day 5 after the start of ECMO, and respiratory condition swiftly improved; hence, the weaning process from VV ECMO began on day 9. Rehabilitation became implementable, and bilateral re-lung transplantation was successfully performed 6 months after the ECMO treatment. No critical complication related to the precedent use of ECMO was noted.

CONCLUSIONS

VV ECMO can be a feasible treatment option even for lung transplant candidates awaiting re-transplantation for a prolonged period. Introduction of ECMO and tracheostomy in the early deterioration stage may be crucial to successful subsequent patient management.