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

Comparison of Outcomes of Early Versus Late Tracheostomy in the Treatment of Mechanically Ventilated Critically ill Patients

Comparative evaluation of early and late tracheostomy outcomes in mechanically ventilated patients. The present retrospective study was conducted in Government medical college Jammu from April 2021 to November 2022 on 111 tracheotomised patient in intensive care unit. All tracheostomies with in 10 days of intubation were grouped as early tracheostomy (ET) group and all those done after 10 days were grouped as LATE TRACHEOSTOMY (LT) group. APACHE II score at the time of intensive care unit admission of all included tracheotomised patients was noted. Data regarding mortality, duration of mechanical ventilation and length of stay in intensive care unit (ICU) was studied. Mean age of presentation was 41.5 ± 15.7 yrs, with male preponderance. Out of 111 patients, 57 patients underwent early tracheostomy and 54 underwent late TRACHEOSTOMY. In APACHE II, < 25 category-short term mortality was 4 in ET and 5 in LT; long term mortality in ET was 4 and 10 in LT; average days of mechanical ventilation were 11.2 in ET and 3 in LT; average stay in ICU was 18 days in ET and 61 days in LT. in APACHE II > 25-short term mortality was 4 in ET and 5 in LT; long term mortality in ET was 3 and 9 in LT. Average days of mechanical ventilation were 10.8 in ET and 57 in LT; average stay in ICU was 24 days in ET and 79 days in LT. Early tracheostomy is superior to late Tracheostomy in terms of mortality, number of days of mechanical ventilation and the duration of intensive care unit stay.

Comparison of the Outcomes of Early Versus Late Tracheostomy in the Treatment of Critically Ill Patients: A Retrospective Multicenter Measurement Study Done in Two Hospital Centers in Lebanon

Background 

Benefits of early tracheostomy (ET) versus late tracheostomy (LT) while treating critically ill patients have been a matter of big debate in the last few years. Several meta-analyses tried to prove the benefits of ET in decreasing the duration of mechanical ventilation (MV), the length of intensive care unit (ICU) stay, and the mortality rates. However, no clear guidelines are available yet. This study will focus on comparing the outcomes of early tracheostomy versus late one.

Methods

This is a retrospective study done in two medical and surgical ICUs at “Sacre-Coeur Hospital” and “Rafik Hariri University Hospital” at Beirut, where we reviewed various files of patients who underwent elective tracheostomy for prolonged MV from January 2015 to June 2016. ET and LT were assumed to be procedures performed respectively before and after 10 days of MV. These two groups were subdivided based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) score calculated in the first 24 hours of ICU admission. Data about short- and long-term mortality, the duration of MV, and the length of ICU stay were collected and compared.

Results

From a total of 45 patients, only 25 patients met the inclusion and exclusion criteria of whom 12 (48%) underwent ET and 13 (52%) patients underwent LT. In patients with APACHE II <25 (6 ET and 6 LT), ET was associated with 50% long-term mortality, 9.6 days mean duration of MV and 23 days mean length of ICU stay compared to 57% (P-value=0.05), 78 days (P-value=0.04) and 79 days (P-value=0.012) of respective parameters in LT groups. In patients with APACHE II >25 (6 ET and 7 LT), ET was associated with 50% long-term mortality, 8.6 days mean duration of MV and 24 days mean length of ICU stay compared to 84%, 105 days, 84 days of respective parameter in LT groups.

Conclusions

Our results are suggestive of the superiority of ET because it was associated with a reduced duration of MV, a decrease in the length of ICU stay, and, most importantly, a lower long-term mortality rate.

Influence of prolonged translaryngeal intubation on airway complications: a retrospective comparative analysis

PURPOSE

Tracheostomy is usually suggested to facilitate airway management of intensive care unit (ICU) patients requiring prolonged translaryngeal intubation (PTLI). While it is not uncommon for physicians to hesitate and delay to perform it for more than 2 weeks, clinically recognizable airway adverse effects following PTLI are rarely discussed. Therefore, we compared retrospectively the PTLI group with control to assess them in adult patients.

METHODS

During a period of 1991-2012, patients aged older than 15 years that were admitted to University of Tsukuba Hospital ICU, underwent translaryngeal intubation (TLI) for 14 days or longer, were retrospectively studied as Group P. Patients whose tracheas were intubated for 13 days or less were set up as a control group (Group C). Patients were excluded if they had undergone any procedures that might have affected recurrent laryngeal nerves.

RESULTS

Ninety-eight patients (M:F = 58:40) (group P) and 88 patients (M:F = 58:30) (group C) were included. There were no differences in patients' characteristics. Durations of TLI were 20.8 ± 6.8 days in group P and 3.8 ± 3.0 days in group C. There were no differences in the occurrence rates of severe airway adverse events. Although we found higher incidence rates of dysphagia and dysphonia/hoarseness in group P, the symptoms were mild and they were not prolonged. There were no differences in other signs and symptoms.

CONCLUSIONS

We found no difference in the occurrence rates of severe airway adverse events in both groups. Translaryngeal intubation may be tolerable in adults even if the duration exceeds 2 weeks.

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.