Tracheostomy Timing in Unselected Critically Ill Patients with Prolonged Intubation: A Prospective Cohort Study

Background: Tracheostomy procedures are performed in the intensive care unit (ICU) for prolonged intubation, unsuccessful weaning and infection prevention through either percutaneous or surgical techniques. This study aimed to outline the impact of tracheostomy timing in the ICU on mortality, need for mechanical ventilation, and complications. Methods: Patients were included in the study on the day of tracheostomy. Demographic information, tracheostomy timing, technique, complications, sedation requirement and need for mechanical ventilation at discharge were recorded by an anesthesiologist, including the pre-tracheostomy period. Results: Tracheostomy was performed on 33 patients during the first 14 days of intubation and on 54 patients on the 15th day and beyond. There was no significant difference between the tracheostomy timing and mortality, sedation requirement, or weaning from the ventilator. We observed that patients who underwent tracheostomy with the surgical technique experienced more complications, but there was no significant difference. Tracheostomy performed after the 14th day was shown to be associated with prolonged hospital stay. Conclusions: Early tracheostomy does not have any influence on the need for mechanical ventilation, sedation and mortality. The optimal timing for tracheostomy is still controversial. We are of the opinion that randomized controlled trials involving patient groups with similar survival expectations are needed.

Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis

OBJECTIVES

To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models.

DESIGN

A retrospective observational study.

SETTING

Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients.

INTERVENTIONS

An ET versus late tracheostomy (LT).

MEASUREMENTS AND MAIN RESULTS

Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups.

CONCLUSIONS

The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.

Comparison of Outcomes Between Early and Late Tracheostomy

BACKGROUND

The timing of tracheostomy in ventilated patients remains controversial. This study aimed to compare the effect of early tracheostomy (≤7 d) with late tracheostomy (>7 d) on the prognosis of patients requiring prolonged mechanical ventilation.

METHODS

This was a retrospective observational cohort study. The data of 175 patients who received tracheostomy at the ICU between January 1, 2015-July 31, 2022, were collected. Patients were excluded from the study if medical records were incomplete or they underwent tracheostomy as part of a planned operation procedure. One-to-one propensity score matching was used to correct the baseline characteristics between the early and late tracheostomy groups. The treatment process and outcomes were compared between the two groups. The primary outcome was the incidence of ventilator-associated pneumonia (VAP) between groups.

RESULTS

After propensity score matching, 88 subjects were included in the analysis. Compared with the late tracheostomy group, the incidence of VAP, hospital length of stay, sedation-free days, ventilator-free days, and ICU-free days were longer in the early tracheostomy group. There were no significant differences in the 90-d mortality between the two groups. CONCLUSIONS;: Early tracheostomy can reduce the occurrence of complications for ICU patients.

Early Versus Late Tracheostomy in Stroke Patients: A Retrospective Analysis

OBJECTIVE

The timing of tracheostomy (TR) in severe stroke patients receiving mechanical ventilation has not been determined. In this study, we compared some prognostic indicators of early tracheostomy (ET) and late tracheostomy (LT). A meta-analysis was performed to obtain a higher level of evidence of the timing of TR in patients with severe stroke receiving mechanical ventilation.

METHODS

The study was a retrospective single-center study. We divided the severe stroke patients who received TR from June 2020 to June 2022 into the ET group and LT group. The demographic characteristics, clinical characteristics and prognostic indices were compared. For this meta-analysis, we systematically searched PubMed and other databases. The compared prognostic indicators included mechanical ventilation time, ICU length of stay (LOS), total LOS, ventilator-related pneumonia (VAP) incidence, and mortality.

RESULTS

A total of 61 patients were included in our study, including 32 patients in the ET group and 29 patients in the LT group. Univariate and multivariate analyses showed that the NIHSS score in the ET group was higher than that in the LT group (P < 0.05). In terms of outcome indicators, compared with the LT group, the median mechanical ventilation time in the ET group was shortened by 5.5 days (P = 0.034). The ICU LOS and total LOS in the ET group were significantly lower than those in the LT group (median 14.5 days vs 22 days, P = 0.004; 21 days vs 27 days, P = 0.019). The meta-analysis showed that ET could significantly shorten the ICU LOS (MD -3.89 [95% CI: -6.86, -0.92]) and the total LOS (MD -7.70 [95% CI: -8.57, -6.83]) and significantly reduce the occurrence of VAP (OR 0.75 [95% CI: 0.64, 0.87]).

CONCLUSION

The results of our retrospective study and meta-analysis support that ET can shorten the ICU LOS and total LOS and reduce the occurrence of VAP. Therefore, it has a positive effect on the prognosis of patients with severe stroke who need mechanical ventilation support.

Timing of tracheostomy in acute traumatic spinal cord injury: A systematic review and meta-analysis

BACKGROUND

Patients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes.

METHODS

Six databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale.

RESULTS

Seventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale.

CONCLUSION

Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes.

LEVEL OF EVIDENCE

Systematic Review, level III.

Patient selection and preoperative evaluation of percutaneous dilation tracheostomy in the intensive care unit

Percutaneous dilation tracheostomy (PDT) is increasingly performed at the bedside of critically ill patients in the intensive care unit (ICU). PDT is safe overall and has a number of benefits compared to surgical tracheostomy. A tracheostomy tube has numerous advantages compared to an endotracheal tube, including decreased work of breathing, ease of connecting to a mechanical ventilator, improved patient comfort and pulmonary hygiene. Common patient populations include those unable to wean from mechanical ventilation, those requiring enhanced pulmonary hygiene, and those with progressive neuromuscular weakness. Clinicians performing this procedure should be familiar with common indications for performing tracheostomy as well as absolute and relative contraindications. Special patient populations, including those with morbid obesity, aberrant anatomic and vascular anatomy, cervical spine injury, and high ventilatory requirements, should be approached with careful planning. Pre-procedure evaluation for coagulopathy, including basic laboratory analysis and medication review, should be undertaken. Pre-procedure ultrasound may be used to more accurately identify landmarks and vascular structures. The optimal timing for performing PDT is unknown and depends on the unique characteristics of each patient, perceived natural history of the disease process being addressed and open conversations with the patient or surrogate decision maker. In this review, we identify patient populations most likely to benefit from PDT and outline data behind optimal timing, pre-procedural laboratory evaluation and patient specific factors that may influence procedural success.

Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis

Introduction. Tracheostomy can help weaning in long-term ventilated patients, reducing the duration of mechanical ventilation and intensive care unit length of stay, and decreasing complications from prolonged tracheal intubation. In traumatic brain injury (TBI), ideal timing for tracheostomy is still debated. We performed a systematic review and meta-analysis to evaluate the effects of timing (early vs. late) of tracheostomy on mortality and incidence of VAP in traumatic brain-injured patients. Methods. This study was conducted in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a search in PubMed, using an association between heading terms: early, tracheostomy, TBI, prognosis, recovery, impact, mortality, morbidity, and brain trauma OR brain injury. Two reviewers independently assessed the methodological quality of eligible studies using the Newcastle–Ottawa Scale (NOS). Comparative analyses were made among Early Tracheostomy (ET) and late tracheostomy (LT) groups. Our primary outcome was the odds ratio of mortality and incidence of VAP between the ET and LT groups in acute brain injury patients. Secondary outcomes included the standardized mean difference (MD) of the duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS. Results. We included two randomized controlled trials, three observational trials, one cross-sectional study, and three retrospective cohort studies. The total number of participants in the ET group was 2509, while in the LT group it was 2597. Early tracheostomy reduced risk for incidence of pneumonia, ICU length of stay, hospital length of stay and duration of mechanical ventilation, but not mortality. Conclusions. In TBI patients, early tracheostomy compared with late tracheostomy might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, but increase the risk of mortality.

Optimal Timing of Tracheostomy in Injured Adolescents

OBJECTIVES

To evaluate the optimal timing of tracheostomy for injured adolescents.

DESIGN

Retrospective cohort study.

SETTING

Trauma facilities in the United States.

PATIENTS

Adolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

After stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point.

CONCLUSIONS

For injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.

The effect of tracheostomy delay time on outcome of patients with prolonged mechanical ventilation: A STROBE-compliant retrospective cohort study

The tracheostomy timing for patients with prolonged mechanical ventilation (PMV) was usually delayed in our country. Both physician decision time and tracheostomy delay time (time from physician's suggestion of tracheostomy to procedure day) affect tracheostomy timing. The effect of tracheostomy delay time on outcome has not yet been evaluated before.Patients older than 18 years who underwent tracheostomy for PMV were retrospectively collected. The outcomes between different timing of tracheostomy (early: ≤14 days; late: >14 days of intubation) were compared. We also analyzed the effect of physician decision time, tracheostomy delay time, and procedure type on clinical outcomes.A total of 134 patients were included. There were 57 subjects in the early tracheostomy group and 77 in the late group. The early group had significantly shorter mechanical ventilation duration, shorter intensive care unit stays, and shorter hospital stays than late group. There was no difference in weaning rate, ventilator-associated pneumonia, and in-hospital mortality. The physician decision time (8.1 ± 3.4 vs 18.2 ± 8.1 days, P < .001) and tracheostomy delay time (2.1 ± 1.9 vs 6.1 ± 6.8 days, P < .001) were shorter in the early group than in the late group. The tracheostomy delay time [odds ratio (OR) = 0.908, 95% confidence interval (CI) = 0.832-0.991, P = .031) and procedure type (percutaneous dilatation, OR = 2.489, 95% CI = 1.057-5.864, P = .037) affected successful weaning. Platelet count of >150 × 10/μL (OR = 0.217, 95% CI = 0.051-0.933, P = .043) and procedure type (percutaneous dilatation, OR = 0.252, 95% CI = 0.069-0.912, P = .036) were associated with in-hospital mortality.Shorter tracheostomy delay time is associated with higher weaning success. Percutaneous dilatation tracheostomy is associated with both higher weaning success and lower in-hospital mortality.

Tracheostomy timing affects stroke recovery

BACKGROUND

The timing of tracheostomy in stroke patients unable to protect their airway has become a topic of debate. Proponents for early tracheostomy (ET) cite benefits including less ventilation-associated pneumonia, less sedative drug use, shorter length of stay, and reduced mortality in comparison with late tracheostomy (LT).

METHODS

We examined the timing of tracheostomy on stroke patient outcomes across the United States using the Nationwide Inpatient Sample (2008-2010). Independent samples t tests and chi-squared tests were used to make comparisons between early (≤10 days) and late (11-25 days) tracheostomy. Multivariable models, adjusted for confounding factors, investigated outcome measures.

RESULTS

In total, 13,165 stroke cases were included in the study (5591 in the ET group and 7574 in the LT group). Patients receiving an ET had a significant reduction in the odds of ventilator-associated pneumonia in comparison with the LT group (OR: .688, P = .026). The length of stay for patients receiving an ET was significantly lower in comparison with the LT group (P < .001) and was associated with an 18% reduction in total hospital costs (P < .001).

CONCLUSIONS

Early tracheostomy for stroke patients may reduce the incidence of ventilator-associated pneumonia, thereby shortening the hospital stay and lowering total hospital costs. These relationships warrant further investigation in a large prospective multicenter trial.