Tracheotomy timing and outcomes in the critically ill

Sociodemographic Disparities in Tracheostomy Timing and Outcomes

OBJECTIVE

Tracheostomies are commonly performed in critically ill patients requiring prolonged mechanical ventilation. Although early tracheostomy has been associated with improved outcomes, the reasons for delayed tracheostomy are complex. We examined the impact of sociodemographic factors on tracheostomy timing and outcomes.

METHODS

Medical records were retrospectively reviewed of ventilator-dependent adult patients who underwent tracheostomy from 2021 to 2022. Tracheostomy timing was defined as routine (<21 days) versus late (21 days or more). Sociodemographic variables were compared between cohorts using univariate and multivariate models. Secondary outcomes included hospital length of stay (LOS), decannulation, tracheostomy-related complications, and inhospital mortality.

RESULTS

One hundred forty-two patients underwent tracheostomy after initial intubation: 74.7% routine (n = 106) and 25.4% late (n = 36). In a multivariate model adjusted for age, race, surgical service, tracheostomy technique, and time between consultation and surgery, non-English speaking patients and women were more likely to receive a late tracheostomy compared with English speaking patients and men, respectively (odds ratio [OR] 3.18, 95% confidence interval [CI] 1.03, 9.81, p < 0.05), (OR 3.15, 95% CI 1.18, 8.41, p < 0.05). Late tracheostomy was associated with longer median hospital LOS (62 vs. 52 days, p < 0.05). Tracheostomy timing did not significantly impact mortality, decannulation or tracheostomy-related complications.

CONCLUSION

Despite an association between earlier tracheostomy and shorter LOS, non-English speaking patients and female patients are more likely to receive a late tracheostomy. Standardized protocols for tracheostomy timing may address bias in the referral and execution of tracheostomy and reduce unnecessary hospital days.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:582-587, 2024.

Tracheostomy versus prolonged intubation in moderate to severe traumatic brain injury: a multicentre retrospective cohort study

PURPOSE

Tracheostomy is a surgical procedure that is commonly performed in patients admitted to the intensive care unit (ICU). It is frequently required in patients with moderate to severe traumatic brain injury (TBI), a subset of patients with prolonged altered state of consciousness that may require a long period of mechanical respiratory assistance. While many clinicians favour the use of early tracheostomy in TBI patients, the evidence in favour of this practice remains scarce. The aims of our study were to evaluate the potential clinical benefits of tracheostomy versus prolonged endotracheal intubation, as well as whether the timing of the procedure may influence outcome in patients with moderate to severe TBI.

METHODS

We conducted a retrospective multicentre cohort study based on data from the provincial integrated trauma system of Quebec (Québec Trauma Registry). The study population was selected from adult trauma patients hospitalized between 2013 and 2019. We included patients 16 yr and older with moderate to severe TBI (Glasgow Coma Scale score < 13) who required mechanical ventilation for 96 hr or longer. Our primary outcome was 30-day mortality. Secondary outcomes included hospital and ICU mortality, six-month mortality, duration of mechanical ventilation, ventilator-associated pneumonia, ICU and hospital length of stay as well as orientation of patients upon discharge from the hospital. We used propensity score covariate adjustment. To overcome the effect of immortal time bias, an extended Cox shared frailty model was used to compare mortality between groups.

RESULTS

From 2013 to 2019, 26,923 patients with TBI were registered in the Québec Trauma Registry. A total of 983 patients who required prolonged endotracheal intubation for 96 hr or more were included in the study, 374 of whom underwent a tracheostomy and 609 of whom remained intubated. We observed a reduction in 30-day mortality (adjusted hazard ratio, 0.33; 95% confidence interval, 0.21 to 0.53) associated with tracheostomy compared with prolonged endotracheal intubation. This effect was also seen in the ICU as well as at six months. Tracheostomy, when compared with prolonged endotracheal intubation, was associated with an increase in the duration of mechanical respiratory assistance without any increase in the length of stay. No effect on mortality was observed when comparing early vs late tracheostomy procedures. An early procedure was associated with a reduction in the duration of mechanical respiratory support as well as hospital and ICU length of stay.

CONCLUSION

In this multicentre cohort study, tracheostomy was associated with decreased mortality when compared with prolonged endotracheal intubation in patients with moderate to severe TBI. This effect does not appear to be modified by the timing of the procedure. Nevertheless, the generalization and application of these results remains limited by potential residual time-dependent indication bias.

Impact of Early Tracheostomy Versus Late or No Tracheostomy in Nonneurologically Injured Adult Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

The optimal timing of tracheostomy in nonneurologically injured mechanically ventilated critically ill adult patients is uncertain. We conducted a systematic review of randomized controlled trials to evaluate the effect of early versus late tracheostomy or prolonged intubation in this population.

DATA SOURCES

We searched MEDLINE, Embase, CENTRAL, CINAHL, and Web of science databases for randomized controlled trials comparing early tracheostomy (<10 d of intubation) with late tracheostomy or prolonged intubation in adults.

DATA SELECTION

We selected trials comparing early tracheostomy (defined as being performed less than 10 d after intubation) with late tracheostomy (performed on or after the 10th day of intubation) or prolonged intubation and no tracheostomy in nonneurologically injured patients. The primary outcome was overall mortality. Secondary outcomes included ventilator-associated pneumonia, duration of mechanical ventilation, ICU, and hospital length of stay.

DATA EXTRACTION

Two reviewers screened citations, extracted data, assessed the risk of bias, and classification of Grading of Recommendations, Assessment, Development, and Evaluation independently.

DATA SYNTHESIS

Our search strategy yielded 8,275 citations, from which nine trials (n = 2,457) were included. We did not observe an effect on the overall mortality of early tracheostomy compared with late tracheostomy or prolonged intubation (risk ratio, 0.91, 95% CI, 0.82-1.01; I2 = 18%). Our results were consistent in all subgroup analyses. No differences were observed in ICU and hospital length of stay, duration of mechanical ventilation, incidence of ventilator-acquired pneumonia, and complications. Our trial sequential analysis showed that our primary analysis on mortality was likely underpowered.

CONCLUSION

In our systematic review, we observed that early tracheostomy, as compared with late tracheostomy or prolonged intubation, was not associated with a reduction in overall mortality. However, we cannot exclude a clinically relevant reduction in mortality considering the level of certainty of the evidence. A well-designed trial is needed to answer this important clinical question.

A U-shaped association of tracheostomy timing with all-cause mortality in mechanically ventilated patients admitted to the intensive care unit: A retrospective cohort study

Objectives

To evaluate the association of tracheostomy timing with all-cause mortality in patients with mechanical ventilation (MV).

Method

It's a retrospective cohort study. Adult patients undergoing invasive MV who received tracheostomy during the same hospitalization based on the Medical Information Mart for Intensive Care-III (MIMIC-III) database, were selected. The primary outcome was the relationship between tracheostomy timing and 90-day all-cause mortality. A restricted cubic spline was used to analyze the potential non-linear correlation between tracheostomy timing and 90-day all-cause mortality. The secondary outcomes included free days of MV, incidence of ventilator-associated pneumonia (VAP), free days of analgesia/sedation in the intensive care unit (ICU), length of stay (LOS) in the ICU, LOS in hospital, in-ICU mortality, and 30-day all-cause mortality.

Results

A total of 1,209 patients were included in this study, of these, 163 (13.5%) patients underwent tracheostomy within 4 days after intubation, while 647 (53.5%) patients underwent tracheostomy more than 11 days after intubation. The tracheotomy timing showed a U-shaped relationship with all-cause mortality, patients who underwent tracheostomy between 5 and 10 days had the lowest 90-day mortality rate compared with patients who underwent tracheostomy within 4 days and after 11 days [84 (21.1%) vs. 40 (24.5%) and 206 (31.8%), P < 0.001].

Conclusion

The tracheotomy timing showed a U-shaped relationship with all-cause mortality, and the risk of mortality was lowest on day 8, but a causal relationship has not been demonstrated.

Acute Complications of COVID-19 With Lasting Damages: A Case of Severe Long-Term Sequelae in a Middle-Aged Female Post COVID-19

Following coronavirus disease-2019 (COVID-19), many patients experience acute complications and long-term sequelae. Acute complications include respiratory failure, myocardial injury, and neurological complications. Respiratory and thromboembolic complications prove to be acute changes that cause detrimental long-term outcomes. A continued exploration of the COVID-19 hospital course will allow for effective management and treatment of the virus. We report the case of a 48-year-old Hispanic woman who experienced a pulmonary embolism, deep vein thrombosis in all four extremities, and a brain embolus following a COVID-19 infection in 2021. Despite hospital care and prompt treatment, she developed long-term sequelae, specifically post-intubation tracheal stenosis. The critical factor promoting this inflammatory state is the overproduction of cytokines in what is coined a “cytokine storm.” The lasting complications have multiple facets that need to be explored beyond the virus itself. Treatment modalities have their own risks and side effects. Comparing effective and ineffective treatment outcomes for this patient may lead to improvements in COVID-19 management. For this reason, exploring the treatment and complications in the acute setting is necessary for the prevention of the long-term sequelae accompanying cases of COVID-19. While literature exists detailing the unique thrombotic and respiratory complications that can present as a result of COVID-19 coagulopathies, this field is continuously evolving and warrants further research. 

Otolaryngology Consult Protocols in the Setting of COVID-19: The University of Pittsburgh Approach

Objective:

To analyze trends in otolaryngology consultations and provide algorithms to guide management during the COVID-19 pandemic.

Methods:

A retrospective cohort study at a single institution tertiary care hospital. A total of 95 otolaryngology consultations were performed from March 1, 2020 to April 26, 2020 (COVID-era) and 363 were performed from September 1, 2019 to February 29, 2020 (pre-COVID-era) at the UPMC Oakland campus. Data collected included patient demographics, COVID-19 status, reason for consult, location of consult, type of consult, procedures performed, need for surgical intervention, length of hospital stay and recommended follow up.

Results:

Patient populations in the pre-COVID-era and COVID-era were similar in terms of their distribution of demographics and chief complaints. Craniofacial trauma was the most common reason for consultation in both periods, followed by vocal fold and airway-related consults. We saw a 21.5% decrease in the rate of consults seen per month during the COVID-era compared to the 6 months prior. Review of trends in the consult workflow allowed for development of several algorithms to safely approach otolaryngology consults during the COVID-19 pandemic.

Conclusions:

Otolaryngology consultations provide valuable services to inpatients and patients in the emergency department ranging from evaluation of routine symptoms to critical airways. Systematic otolaryngology consult service modifications are required in order to reduce risk of exposure to healthcare providers while providing comprehensive patient care.

Safety and Feasibility of a Novel Protocol for Percutaneous Dilatational Tracheostomy in Patients with Respiratory Failure due to COVID-19 Infection: A Single Center Experience

Introduction

The rapidly spreading Novel Coronavirus 2019 (COVID-19) appeared to be a highly transmissible pathogen in healthcare environments and had resulted in a significant number of patients with respiratory failure requiring tracheostomy, an aerosol-generating procedure that places healthcare workers at high risk of contracting the infection. Instead of deferring or delaying the procedure, we developed and implemented a novel percutaneous dilatational tracheostomy (PDT) protocol aimed at minimizing the risk of transmission while maintaining favorable procedural outcome. Patients and Methods. All patients who underwent PDT per novel protocol were included in the study. The key element of the protocol was the use of apnea during the critical part of the insertion and upon any opening of the ventilator circuit. This was coupled with the use of enhanced personnel protection equipment (PPE) with a powered air-purifying respirator (PAPR). The operators underwent antibody serology testing and were evaluated for COVID-19 symptoms two weeks from the last procedure included in the study.

Results

Between March 12th and June 30th, 2020, a total of 32 patients underwent PDT per novel protocol. The majority (80%) were positive for COVID-19 at the time of the procedure. The success rate was 94%. Only one patient developed minor self-limited bleeding. None of the proceduralists developed positive serology or any symptoms compatible with COVID-19 infection.

Conclusion

A novel protocol that uses periods of apnea during opening of the ventilator circuit along with PAPR-enhanced PPE for PDT on COVID-19 patients appears to be effective and safe for patients and healthcare providers.

Modified percutaneous tracheostomy in patients with COVID-19

Background

Patients hospitalized with COVID-19 are at risk of developing hypoxic respiratory failure and often require prolonged mechanical ventilation. Indication and timing to perform tracheostomy is controversial in patients with COVID-19.

Methods

This was a single-institution retrospective review of tracheostomies performed on patients admitted for COVID-19 between April 8, 2020 and August 1, 2020 using a modified percutaneous tracheostomy technique to minimize hypoxia and aerosolization.

Results

Twelve tracheostomies were performed for COVID-related respiratory failure. Median patient age was 54 years (range: 36–76) and 9 (75%) were male. Median time to tracheostomy was 17 days (range: 10–27), and 5 (42%) patients had failed attempts at extubation prior to tracheostomy. There were no intraprocedural complications, including hypoxia. Post-tracheostomy bleeding was noted in two patients. Eight (67%) patients have been discharged at the time of this study, and there were four patient deaths unrelated to tracheostomy placement. No healthcare worker transmissions resulted from participating in the tracheostomy procedure.

Conclusions

A modified percutaneous tracheostomy is feasible and can be safely performed in patients infected with COVID-19.

Level of evidence

Level V, case series.

Percutaneous tracheostomy in COVID-19 patients: The Miami model

The surge in critically ill patients requiring mechanical ventilation fueled by the COVID-19 pandemic has strained healthcare systems globally. With the increasing need for critical care resources, tracheostomy can facilitate weaning from mechanical ventilation and potentially increase availability of critical care resources. In this case series of three patients, we describe our technique for performing bedside percutaneous tracheostomy on patients with persistently positive SARS-CoV-2 real time polymerase chain reaction (RT-PCR). We hope to provide proceduralists with a specific method for percutaneous tracheostomies that is both safe for the patient and provider.

Tracheostomy in the intensive care unit: Guidelines during COVID-19 worldwide pandemic

PURPOSE

COVID-19 has become a pandemic with significant consequences worldwide. About 3.2% of patients with COVID-19 will require intubation and invasive ventilation. Moreover, there will be an increase in the number of critically ill patients, hospitalized and intubated due to unrelated acute pathology, who will present underlying asymptomatic or mild forms of COVID-19. Tracheostomy is one of the procedures associated with an increased production of aerosols and higher risk of transmission of the virus to the health personnel. The aim of this paper is to describe indications and recommended technique of tracheostomy in COVID-19 patients, emphasizing the safety of the patient but also the medical team involved.

MATERIALS AND METHODS

A multidisciplinary group made up of surgeons with privileges to perform tracheostomies, intensive care physicians, infectious diseases specialists and intensive pulmonologists was created to update previous knowledge on performing a tracheostomy in critically ill adult patients (>18 years) amidst the SARS-CoV-2 pandemic in a high-volume referral center. Published evidence was collected using a systematic search and review of published studies.

RESULTS

A guideline comprising indications, surgical technique, ventilator settings, personal protective equipment and timing of tracheostomy in COVID-19 patients was developed.

CONCLUSIONS

A safe approach to performing percutaneous dilational bedside tracheostomy with bronchoscopic guidance is feasible in COVID-19 patients of appropriate security measures are taken and a strict protocol is followed. Instruction of all the health care personnel involves is key to ensure their safety and the patient's favorable recovery.

Outcomes after percutaneous dilatation tracheostomy: Patients view 6 years after the procedure

BACKGROUND

Percutaneous dilatational tracheostomy have been performed increasingly since its introduction in 1985, and is today one of the most commonly performed operative procedures in intensive care units. The aim of this study was to document patient-reported outcomes from percutaneous dilatational tracheostomy after hospital discharge.

METHODS

This study is based on retrospective extraction of data from the databases in the ICU at Haukeland University Hospital from 2004 to 2016. Patients alive by April 2018 and with a code for dilatation tracheostomy were sent a questionnaire about their experiences with having a tracheostomy performed. The occurrence of problems and their relations were registered.

RESULTS

Of 5769 admitted patients, 900 patients ≥ 15 years (15.7%) had a percutaneous dilatation tracheostomy performed. The median time from admission to follow-up was 6.1 years, and the 30 days mortality in those who received a tracheostomy was 315/900 (35%). Of the 441 survivors contacted, 181 answered the questionnaire and a total of 293 problems were reported. The majority of these problems were reported as no or moderate in 115 patients (78.3%). The presence of any problem was significantly associated with occurrence for other problems; however, there were no significant differences related to the elapsed time since the ICU stay. Pain and difficulties with breathing were the two single factors most often related to occurrence of other problems.

CONCLUSION

Although self-reported problems after percutaneous tracheostomy occurring after hospital discharge were often reported, most (78.3%) were considered by the patients to be moderate.

Early Data From Case Series of Tracheostomy in Patients With SARS-CoV-2

Thirty-eight tracheostomies were performed on patients with respiratory failure secondary to SARS-CoV-2 infection over the month of April at North Shore University Hospital and Lenox Hill Hospital (members of Northwell Health System in Long Island and New York City). Follow-up by May 14 revealed that 21 (55.2%) had been weaned from ventilators and 7 (18.4%) underwent decannulation. Two patients (5.3%) expired in the weeks following tracheostomy. Between the 2 institutions, 10 attending surgeons performed all of the tracheostomies using appropriate personal protective equipment, and none demonstrated seroconversion within 1 to 2 weeks of this article.

Delayed Tracheostomy in a Patient With Prolonged Invasive Mechanical Ventilation due to COVID-19

Coronavirus disease 2019 (COVID-19) can cause acute respiratory distress syndrome (ARDS) that is associated with high mortality among patients requiring invasive mechanical ventilation. We present a case of a 56-year-old male with hypertension and obesity who presented with chest pain from COVID-19. The patient required endotracheal intubation due to worsening hypoxia and remained intubated for 33 days. Tracheostomy placement was delayed in part due to persistent COVID-19 positive testing until hospital day 37. The patient required a total of 52 days in the ICU prior to discharge to a rehabilitation facility. This case highlights the extensive resources needed for critically ill patients with COVID-19 and the long duration that patients may test positive for the virus after onset of symptoms. It also raises questions about the timing and safety of tracheostomy placement among those patients requiring mechanical ventilation from COVID-19.

Novel Percutaneous Tracheostomy for Critically Ill Patients With COVID-19

Background

Coronavirus 2019 (COVID-19) is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy is not recommended by current guidelines as it is considered a superspreading event owing to aerosolization that unduly risks health care workers.

Methods

Patients with severe COVID-19 who were on mechanical ventilation for 5 days or longer were evaluated for percutaneous dilational tracheostomy. We developed a novel percutaneous tracheostomy technique that placed the bronchoscope alongside the endotracheal tube, not inside it. That improved visualization during the procedure and continued standard mechanical ventilation after positioning the inflated endotracheal tube cuff in the distal trachea. This technique offers a significant mitigation for the risk of virus aerosolization during the procedure.

Results

From March 10 to April 15, 2020, 270 patients with COVID-19 required invasive mechanical ventilation at New York University Langone Health Manhattan’s campus; of those, 98 patients underwent percutaneous dilational tracheostomy. The mean time from intubation to the procedure was 10.6 ± 5 days. Currently, 32 patients (33%) do not require mechanical ventilatory support, 19 (19%) have their tracheostomy tube downsized, and 8 (8%) were decannulated. Forty patients (41%) remain on full ventilator support, and 19 (19%) are weaning from mechanical ventilation. Seven patients (7%) died as a result of respiratory and multiorgan failure. Tracheostomy-related bleeding was the most common complication (5 patients). None of health care providers has had symptoms or tested positive for COVID-19.

Conclusions

Our percutaneous tracheostomy technique appears to be safe and effective for COVID-19 patients and safe for health care workers.

Recomendaciones para realización de traqueostomías y atención de los pacientes traqueostomizados en Colombia durante la pandemia COVID-19

Establecer una serie de recomendaciones para la realización de las traqueostomías, que se centren en la seguridad de los pacientes y de los equipos de atención médica durante la pandemia de COVID-19, minimizando el riesgo, la exposición viral y agotamiento del equipo de protección personal (EPP). Este documento está destinado a proporcionar los antecedentes, consideraciones y recomendaciones basadas en la literatura e información de primera línea de esta etapa de la pandemia. Estas recomendaciones pueden requerir individualización en función de la región del país, la institución, la capacidad instalada, los recursos y los factores específicos del paciente. Se encuentran en constante actualización según la evolución de la enfermedad y aparición de nuevos datos.

Tracheotomy Timing and Outcomes in the Critically Ill: Complexity and Opportunities for Progress

OBJECTIVES/HYPOTHESIS

To characterize the effects of tracheotomy timing at our institution on intensive care unit (ICU) length of stay (LOS) and overall hospital LOS.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective study was performed at a tertiary care medical center for patients undergoing tracheotomy over 2.5 years from January 1, 2016 through June 30, 2018. Demographics, survival, duration of endotracheal intubation, timing of tracheotomy, and ICU and overall hospital LOS were assessed. Tracheotomy was considered early (ET) if it was performed by day 7 of mechanical ventilation and late (LT) thereafter. Readmission, mortality, and costs were also tabulated for each aggregate group. Nonparametric statistics were used to compare results.

RESULTS

Of the 536 patients included in the analysis, 160 received tracheotomy early and 376 late. Differences between age and sex were not statistically significant. Duration of total ICU stay was shortened by 65% (12.84 ± 17.69 days vs. 38.49 ± 26.61 days; P < .0001), and length of overall hospital course was reduced by 54% (22.71 ± 26.65 days vs. 50.37 ± 34.20 days; P < .0001) in the early tracheotomy group. Observed/expected (O/E) values standardized results to case mix index and revealed LOS of 1.5 for ET and 2.5 for LT, and mortality of 0.76 for ET and 1.25 for LT, and comparable readmissions of both groups.

CONCLUSIONS

Early tracheotomy in ICU patients is associated with earlier ICU discharge, decreased length of overall hospital stay, and lower mortality when controlling for case mix index. Opportunities exist to optimize patient outcomes and O/E performance.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:282-287, 2021.

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.

Our Experience with Percutaneous and Surgical Tracheotomy in Intubated Critically Ill Patients

Objective

Open surgical tracheotomy (OST) and percutaneous dilatational tracheotomy (PDT) are commonly used for securing airway in intubated critically ill patients. The purpose of this study was to compare the safety of OST and PDT, particularly in intubated critically ill patients.

Methods

The medical records of intubated critically ill patients who underwent tracheotomy between August 2006 and July 2017 were analyzed retrospectively. Minor and major complication rates were compared according to the tracheotomy technique. Preoperative intubation time, postoperative decannulation time, reason for hospitalization, and demographic data, including the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, were evaluated.

Results

A total of 332 cases were enrolled into the study. The minor and major complication rates for both techniques were 27.2%, 8.8%, 9.7% and 3.2%, respectively. Minor and major complication rates were higher in the OST group (p=0.01, p=0.03, respectively). The rate of every single complication was also compared on groups' basis. Accidental decannulation (p=0.02) and pneumothorax (p=0.05) were found to be significantly frequent in the OST group. There was no impact of the preoperative intubation time on the minor (p=0.20) and major complication (p=0.29) rates found. There was no statistically significant difference regarding the postoperative decannulation time (p=0.32). Also, there was no statistically significant difference between two groups in terms of the APACHE II (p=0.69) and SOFA (p=0.37) scores. However, a statistically significant difference between the groups in terms of overall survival was found, in favor of PDT (p<0.001).

Conclusion

This study revealed that PDT is safer than OST, particularly in intubated critically ill patients.

Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review

The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.

Open tracheostomy training: a nationwide survey among Otolaryngology-Head and Neck Surgery residents

The aim of this study was to examine the training methods and needs of Otolaryngology-Head and Neck Surgery (OTO-HNS) residents to independently perform open tracheostomy (OT). An anonymous 26-items questionnaire pertaining to OT teaching aspects was distributed to all 93 Israeli OTO-HNS residents during March-June 2016. Residents were categorized as 'juniors,' if they were in their post-graduate year (PGY)-1 and PGY-2; 'mid-residency' (PGY-3 and PGY-4); or 'seniors' (PGY-5 and PGY-6). Response rate was 74% (n = 69). There were 25 'juniors' (36%), 24 'mid-residency' (35%) and 20 'seniors' (29%). Overall, the responses of the 3 groups were similar. Forty-seven (68%) residents estimated that there are ≥ 50 tracheostomies/year in their hospital, which roughly corresponds to an exposure of ~ 8 tracheostomies/year/resident. There was an inconsistency between the number of teaching hours given and the number of hours requested for OT training (23% received ≥ 5 h, but 82% declared they needed ≥ 5 h). Eighty-two percentage reported that their main training was conducted during surgery with peer residents or senior physicians. Forty-five (65%) feel competent to perform OT, including juniors. Due to the need to perform OT in urgent scenarios, the competency of OTO-HNS resident is crucial. Training for OT in Israeli OTO-HNS residency programs is not well structured. Yet, residents reported they feel confident to perform OT, already in the beginning of their residency. Planned educational programs to improve OT training should be done in the beginning of the residency and may include designated 'hands-on' platforms; objective periodic surgical competence assessments; and specialist's feedback, using structured assessment forms.

Perspectives on neonatal and infant tracheostomy

Neonates and infants may need a tracheostomy for many different reasons, ranging from airway obstruction to a requirement for long term mechanical ventilator support. Here, we present the pathophysiology of the many congenital and acquired conditions that might be managed with a tracheostomy. Decisions about tracheostomy demand consideration of not only the benefits, but also the potential side-effects, which may differ in the short and long term and may be attributable to underlying conditions as well as the tracheostomy. Evaluation of potential advantages of tracheostomy will influence decisions about optimal timing. In many cases, an infant may 'graduate' from dependence on a tracheostomy and resume a natural airway, although some will require reconstructive airway surgery.

Comorbidities and factors associated with endoscopic surgical outcomes in adult laryngotracheal stenosis

This study which is a retrospective chart review aims to characterize the comorbidities associated with adult laryngotracheal stenosis and evaluate the relationship of these with stenosis grade, length, surgical interventions, and surgical intervals. Patients' demographics, medical and surgical comorbidities, grade of stenosis, quantity and degree of balloon dilations, dilation intervals, open airway procedures, and tracheotomy status were recorded from 2002 to 2012, at a tertiary voice and airway center. Surgical outcomes were evaluated in relation to patient comorbidities, stenosis quality, and surgical procedures. A total of 101 patients with laryngotracheal stenosis were examined with female patients comprising 71 % of the population. Seventeen patients (16.8 %) had idiopathic stenosis. Number of balloon dilations ranged from 0 to 24 (mean = 3.3). The average time between dilations was 38.4 weeks (range = 1.14-215.8 weeks). The patients with idiopathic stenosis were found to have a lower grade (p = 0.0066). Fifty-two patients (51.5 %) received a tracheotomy at one point during their management. The 14 patients (13.9 %) who remained tracheotomy dependent had a body mass index (BMI) of >30. No statistically significant correlation was found when the patients' age, BMI and comorbidites were compared with the grade of stenosis, number of balloon dilatations needed and other surgical interventions. On the other hand, interval in between surgeries was found to be longer in patients without an intubation history, and in idiopathic SGS (p = 0.004, p = 0.015, respectively). There was no significant relationship between surgical interval and gender, BMI, length of stenosis, grade (p = 0.059, p = 0.47, p = 0.97, p = 0.36, respectively). Airway stenosis in adults is complicated by the presence of multiple comorbidities. Better understanding of the etiology could aid in the prevention of the injury before it forms.

Late tracheotomy is associated with higher morbidity and mortality in mechanically ventilated patients

OBJECTIVES/HYPOTHESIS

To determine whether the timing of tracheotomy placement impacts ventilation weaning status and mortality.

STUDY DESIGN

Multi-institution retrospective cohort study.

METHODS

Demographic data, procedural details, and clinical outcomes were recorded for patients undergoing tracheotomy for prolonged mechanical ventilation across eight sites. The study group was divided into two groups: those undergoing tracheotomy within 14 days of initiation of mechanical ventilation and those undergoing tracheotomy at or after 14 days. Groups were compared for primary outcome measures of mortality and ability to wean from mechanical ventilation within the study period.

RESULTS

Of the 539 patients intubated for ventilator dependence with complete data available, 280 (51.9%) underwent tracheotomy within 14 days. Patients who underwent late tracheotomy were 1.72 times more likely to remain ventilator dependent during the follow-up period (95% confidence interval [CI]: 1.12-2.66), and had a 40% increased risk of death (odds ratio: 1.4, 95% CI: 0.96-1.99).

CONCLUSIONS

In this multicenter retrospective review of tracheotomy outcomes, late tracheotomy placement (>14 days) was associated with increased mortality and prolonged ventilator dependence. Standardized multidisciplinary management protocols for prolonged mechanical ventilation are recommended, and future work should confirm these results in a prospective manner.

LEVEL OF EVIDENCE

4.

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.

[Impact of early elective tracheotomy in critically ill patients]

INTRODUCTION

Tracheotomy is one of the most frequent surgical procedures performed in critically ill patients hospitalized at intensive care units. The ideal timing for a tracheotomy is still controversial, despite decades of experience.

OBJECTIVE

To determine the impact of performing early tracheotomies in critically ill patients on duration of mechanical ventilation, intensive care unit stay, overall hospital stay, morbidity, and mortality.

METHODS

Retrospective and observational study of cases subjected to elective tracheotomy at one of the intensive care units of this hospital during five consecutive years. The patients were stratified into two groups: early tracheotomy group (tracheotomy performed from day one up to and including day seven of mechanical ventilation) and late tracheotomy group (tracheotomy performed after day seven). The outcomes of the groups were compared.

RESULTS

In the early tracheotomy group, there was a statistically significant reduction in duration of mechanical ventilation (6 days vs. 19 days; p<0.001), duration of intensive care unit stay (10 days vs. 28 days; p=0.001), and incidence of ventilator-associated pneumonia (1 case vs. 44 cases; p=0.001).

CONCLUSION

Early tracheotomy has a significant positive impact on critically ill patients hospitalized at this intensive care unit. These results support the tendency to balance the risk-benefit analysis in favor of early tracheotomy.

Outcomes of early versus late tracheostomy: 2008-2010

OBJECTIVES/HYPOTHESIS

The ideal timing of tracheostomy varies. This study sought to determine demographic, management, and outcome differences in patients undergoing early tracheostomy (ET) versus late tracheostomy (LT) (<10 days vs. >10 days postintubation, respectively).

STUDY DESIGN

Retrospective review of the 2008 to 2010 Nationwide Inpatient Sample for patients with extreme severity of illness who underwent tracheostomy.

METHODS

Patients were subdivided based on the timing of tracheostomy placement (days 1-5, 6-10, 11-15, 16-20, 21-25). ET and LT were defined using a 10-day cutoff. Descriptive statistics were obtained for hospital and patient demographics. Multivariate models analyzed the effect of tracheostomy timing on primary outcomes of in-hospital morbidity/mortality, length of stay (LOS), and charges.

RESULTS

A total of 124,990 tracheostomy cases met inclusion criteria. Of the total cases, 53,749 underwent ET, and 71,244 underwent LT. Significant predictors (P < .01) of ET included patient age <65 years (odds ratio [OR]: 1.136), admission to a Midwest hospital (OR: 1.430), neurologic disorder (OR: 1.196), paralysis (OR: 1.264), and admission to a government, nonfederal hospital (OR: 1.434). Significant predictors of LT included admission to a small hospital (OR: 1.150), acute respiratory failure (OR: 1.601), and acute chronic respiratory failure (OR: 1.349). The economic outcomes of hospital costs and LOS increased linearly and significantly with time to tracheostomy, as did mortality (P < .001). ET was associated with a significantly increased rate of discharge to home (P < .001) and decreased rate of sepsis (P < .001) and ventilator-associated pneumonia (P < .001).

CONCLUSIONS

Efficient and effective healthcare delivery is paramount in today's economic climate. Identification of patients likely to need prolonged ventilator support and ET may prove to be a cost- and morbidity-saving measure and deserves further prospective examination.

Effect of timing of tracheotomy on clinical outcomes: an update meta-analysis including 11 trials

OBJECTIVE

To estimate the relative effect of early vs. late tracheotomy on clinical end-points in unselected intensive care unit (ICU) patients undergoing mechanical ventilation.

METHODS

We searched electronic databases (up to February 27, 2013) for both randomized control trials and observational studies satisfying the predefined inclusion criteria.

RESULTS

We retrieved 11 reports of studies including a total of 13 705 patients. Early tracheotomy was associated with significant reductions in mortality [33.3% vs. 36.3%; relative risk (RR); 0.92; 95% confidence interval (CI): 0.88, 0.97; I(2): 29%], length of ICU stay (mean difference: -6.55 days; 95% CI: -8.19, -4.90; I(2): 98%) and duration of mechanical ventilation (mean difference: -6.53 days; 95% CI: -11.43, -1.63; I(2): 100%). However, as compared with late tracheotomy, early tracheotomy did not reduce the incidence of hospital pneumonia (21.9% vs. 21.0%, RR: 0.85; 95% CI: 0.68, 1.06; I(2): 67%).

CONCLUSIONS

Early tracheotomy can reduce length of ICU stay, duration of mechanical ventilation and mortality but has no influence on hospital pneumonia when compared with late tracheotomy. Once the decision has been made about tracheotomy, clinical physicians should not hesitate to perform the procedure.

Effect of tracheostomy timing in premature infants

OBJECTIVE

To examine if timing of tracheostomy placement in premature infants affects the rates of decannulation and length of time required for mechanical ventilatory support.

MATERIALS AND METHODS

Consecutive case series with chart review of premature patients born at a gestational age of 36 weeks or less at a tertiary-care, academic children's hospital who underwent tracheostomy placement between July 1, 2007 and December 31, 2010 for failure to extubate and chronic lung disease of prematurity. Last follow-up data reviewed was January 1, 2013.

RESULTS

43 patients were identified. 32 patients (74.4%) were able to be weaned from mechanical ventilation by the end of follow-up period, and the average time that elapsed between tracheostomy placement and weaning from mechanical ventilator support was 17.9 months. 19 patients (44.2%) were able to be decannulated, and of those patients, the amount of time between tracheostomy placement and decannulation was 27.9 months. No statistical significance was found in the relationship between tracheostomy timing placement and ability to wean from mechanical ventilator support or decannulate. For those patients able to wean from mechanical ventilator support and get decannulated, no difference in the amount of time and tracheostomy timing was found. Earlier premature patients tended to undergo tracheostomy later in life.

CONCLUSIONS

Decisions regarding tracheostomy placement should be individualized. We were unable to detect a relationship between tracheostomy timing and the ability or duration for premature infants with chronic lung disease of prematurity to wean from mechanical ventilator support or successfully decannulate.

The otolaryngology hospitalist: a novel practice paradigm

OBJECTIVES/HYPOTHESIS

To define a new clinical hospitalist practice paradigm originating at the University of California, San Francisco.

DESIGN

Retrospective administrative database review at a tertiary referral hospital.

MATERIALS AND METHODS

A consortium model of an otolaryngologist hospitalist practice was developed. Billing records, including Current Procedural Terminology (CPT) and International Classification of Disease-9 (ICD-9) codes, were reviewed to evaluate the number and type of consultations and surgeries generated during a 2-year period.

RESULTS

A total of 375 new inpatient consultations generated 951 patient encounters. The most common diagnoses were respiratory failure (12%), sinusitis (10.6%), stridor (10.6%), and dysphonia (7.6%). Twenty-six percent of consultations involved a procedure or surgical intervention, the most common of which were endoscopic sinus surgery, laryngoscopy, and tracheotomy.

CONCLUSIONS

To our knowledge, ours is the first full-time otolaryngology hospitalist model in the United States. The hospitalist practice is a conceptually viable and clinically beneficial paradigm that should be considered at other similar institutions.

Tracheotomy tubes with suction above the cuff reduce the rate of ventilator-associated pneumonia in intensive care unit patients

OBJECTIVES

We evaluated the effect of tracheotomy tubes that enable suction immediately above the cuff on the development of ventilator-associated pneumonia (VAP).

METHODS

Patients without preexisting pneumonia who required tracheotomy were randomly assigned to receive a tracheotomy tube with or without above-the-cuff suction. The suction tube provided 10 mm Hg of continuous wall suction while the tracheotomy tube cuff was inflated. Data regarding the development of VAP, time on the ventilator, and length of stay in the intensive care unit (ICU) were recorded and compared between groups.

RESULTS

Eighteen patients were randomized and prospectively evaluated. Nine patients received standard tracheotomy tubes, and 9 received suction-above-the-cuff tracheotomy tubes. The prevalences of VAP were 56% in the control group and 11% in the suction tracheotomy group (p = 0.02). The mean times on the ventilator were 18 +/- 14 days in the control group and 11 +/- 11 days in the suction group (p = 0.12). The mean lengths of ICU stay were 26 +/- 15 days in the control group and 18 +/- 15 days in the suction group (p = 0.14).

CONCLUSIONS

Use of suction-above-the-cuff tracheotomy tubes significantly decreases the incidence of VAP in ICU patients. There were trends toward decreased time on the ventilator and decreased length of stay in the ICU.