Early Tracheostomy Group Research Articles

Early versus standard tracheostomy in ventilated patients in neurosurgical intensive care unit: A randomized controlled trial

IntroductionTracheostomy is performed in patients with prolonged mechanical ventilation, who suffered catastrophic neurologic insult or upper airway obstruction. Thus far, there is no consensus on the optimal timing in performing a tracheostomy. This study aims to test whether early tracheostomy in mechanically ventilated patients in a neurosurgical setting would be associated with a shorter time of mechanical ventilation as compared to standard tracheostomy. MethodsThis single-center prospective randomized controlled trial was conducted at University Malaya Medical Centre from July 2019 to July 2021. The likelihood of prolonged ventilation was determined objectively using the TRACH score and the patient’s clinical presentation. The outcomes measured were days of mechanical ventilation post-tracheostomy, days of neuro-intensive care unit stay, and days of hospital stay. Tracheostomy-related complications were collected. The data collected were analyzed using Statistical Package for the Social Sciences version 25 for Windows (SPSS Inc., Chicago, IL, USA). ResultsIn all, 39 patients were randomly assigned. Of these, 20 were allocated to the early tracheostomy group (ET) and 19 were allocated to the standard tracheostomy group (ST). The demographic characteristics were similar between the groups. The primary outcome, mean (SD) days of mechanical ventilation post-tracheostomy, was statistically different in the 2 groups- early 11.9 (9.3) days, standard 18.9 (32.5) days; p = 0.014. There were comparable tracheostomy-related complications in both groups. ConclusionEarly tracheostomy is associated with a shorter duration of mechanical ventilation in a neurosurgical intensive care unit setting.

Cost-effectiveness and Clinical Outcomes of Early Tracheostomy in the Patients of Isolated Head Injury: A Retrospective Study

Introduction: Early tracheostomy (ET) proved to be effective in the intensive care unit (ICU) in patients who face difficulty in weaning off of mechanical ventilators easily. Tracheostomy is a common procedure applied in mechanically ventilated patients. It aims at reduction of complications and improvement of comfort of the patient. However, the benefits of the tracheostomy must be evaluated against the risks of the tracheostomy before its placement. Variables which are needed to be considered before performing a tracheostomy are the timing of the procedure, absence or presence of TBI, and severity of the injuries. Aim: To assess the cost-effectiveness and clinical outcomes of early tracheostomy in the patients of isolated head injury. Methodology: A total of 212 patients were included in the study. All the patients had isolated severe traumatic brain injury (TBI) and required mechanical ventilation. Tracheostomy was done within seven days of retaining TBI. Prolonged endotracheal intubation (EI) was defined as intubation more than seven days after TBI. A total of 103 (48.58%) patients underwent early tracheostomy (ET). A total of 109 (51.42%) patients underwent prolonged (EI). The patients were assessed according to the occurrence of ventilator associated pneumonia (VAP), Glasgow Outcome Score (GOS), and ICU stay. Results: The occurrence of VAP was 133 (62.74%) in the EI group which was higher compared to that of the ET group in which 79 (37.26%) had presented with VAP. The duration of need for a ventilator in the ET group was 10 days compared to 13 days of the prolonged EI group. Similarly, the need for ICU stay was 11 days in the ET group which was lesser than 13 days of the EI group. The complication rate in the ET group was 14% and in the EI group, it was 18%. The rate of mortality in the ET group was 7.77% and it was 16.51% in the EI group. The GCS of the ET group was better than the EI group. Moreover, the cost of the EI group was more than the ET group. Conclusion: ET reduces the total duration of ICU stay and ventilation in patients with severe TBI. The frequency of VAP is also lesser in the patients given ET. Hence, ET should be given in patients with severe head injuries that require prolonged support of mechanical ventilation

Early versus Late Tracheostomy in Patients with Acute Brain Injury: Importance of SET Score.

Introduction:Patients with acute brain injury presents are unique subset of neurocritical care patients with its long-term functional prognosis difficult to determine. They often have long intensive care unit (ICU) stay and presents as challenge to decide when to transfer out of ICU. This prospective study aims to assess the benefits of early tracheostomy in terms of ICU-length of stay (ICU-LOS), number of days on ventilator (ventilator days), incidence of ventilator-associated pneumonia (VAP), and mortality rates.Materials and Methods:After institutional ethical clearance, 80 patients were randomized into two groups: Group A, early tracheostomy group (tracheostomy within 3 days of intubation) and Group B, standard of care group (tracheostomy after 10 days of intubation: late tracheostomy). A cutoff of 10 in the SET score was used in predicting need of early tracheostomy; both groups were compared with respect to ICU-LOS, number of ventilator days (ventilation time), need of analgesia and sedation, incidence of VAP, and mortality data.Results:Both the groups were comparable in terms of demographic profile and various disease severity scores. ICU-LOS was 14.9 ± 3.6 days in Group A and 17.2 ± 4.6 in Group B. The number of days on ventilator and incidence of VAP was significantly lower in Group A as compared to Group B. There was significantly lower mortality in Group A subset of patients in ICU.Conclusion:SET score is a simple and reliable score with fair accuracy and high sensitivity and specificity in predicting need of tracheostomy in neurocritical patients. A cutoff of 10 in the score can be reliably used in predicting need of early tracheostomy as in few other studies. Early tracheostomy is clearly advantageous in neurocritical patients, but has no advantage in terms of long-term mortality rates.

Sedation and Analgesia in Patients Undergoing Tracheostomy in COVID-19, a Multi-Center Registry.

Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS. A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected. 128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012). This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.

Comparing the Outcomes of Early and Late Tracheostomy in Severe Traumatic Brain Injury Patient.

BackgroundPatients with severe traumatic brain injury (TBI) were expected to have poor Glasgow Coma Scale (GCS) recovery and prolonged intubation. Therefore, an early tracheostomy procedure was indicated for all severe TBI. In view of growing concern regarding the safety and outcome of early tracheostomy on these patients, it was deemed valid and needed to be addressed.MethodsThis study was conducted to compare the outcomes of early and late tracheostomies in severe TBI. Only severe TBI patients who were admitted to the Neurosurgery High Dependency Unit (NHDU), Hospital Sultanah Aminah (HSA), Johor Bahru, Johor, Malaysia and who had underwent a tracheostomy were recruited. Three main outcomes noted: duration on ventilation, length of NHDU stay and rate of ventilator associated pneumonia (VAP).ResultsOut of 155 patients, 72 (46.5%) were in early tracheostomy group (ETG) and 83 (53.5%) were in late tracheostomy group (LTG). The majority of the participants, 95 (61.3%) were ethnic Malays. The mean duration on ventilator use was 2.65 days (1.57) for ETG and 5.63 days (2.35) for LTG. While, mean NHDU stay was 4.75 days (1.98) for ETG and 9.77 days (2.70) for LTG. Upon independent t-test, early duration of tracheostomies had shown significant outcome in reducing length of NHDU stay, (P < 0.001) and had shortening participants’ time on mechanical ventilator (P < 0.001). Then, based on forward multiple logistic regression test, there were significant association between comorbid (P = 0.003) and tracheostomy (P = 0.020) towards presence of VAP when adjusted for other variables.ConclusionIn this study it was found that early tracheostomy was significant in shortening the duration on ventilator, reducing the length of NHDU stay and reducing the rate of VAP.

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.

Early or late tracheotomy in patients after multiple organ trauma.

The analysis of the study group of 124 patients revealed a statistically significant shortening of mechanical ventilation requirement period in patients in whom tracheotomy had been performed before hospitalization day 10 (G1). The average length of mechanical ventilation was shorter by 20.3 days in G1 as compared to G2. On average, the duration of ICU stay was shorter by 39.4 days in G1 as compared to G2. Total hospitalization time was also significantly shorter in this group of patients (G1). The overall length of hospital stay for patients in whom tracheotomy had been performed prior to hospitalization day 10 was on average 43.1 days shorter as compared to patients in whom the procedure had been performed at a later date. Tab. I. provides the comparison of the results obtained in both study groups. Statistically significant differences (p &lt; 0.05) were demonstrated between G1 and G2 regarding the length of the mechanical ventilation, the length of ICU stay, and length of hospitalization. null null No statistically significant differences were observed in mortality rates between the study groups (Fig. 1.) (P = 0.256). The mortality rate in early tracheotomy group (G1) was lower and amounted to 2%. In patients in whom tracheotomy was performed on day 10 or later (G2), the mortality rate was slightly higher and amounted to 9%. In some patients, initiation of treatment was required due to pneumonia developing as a complication in mechanically ventilated patients and referred to as ventilator-associated pneumonia. This complication developed in 6 patients in G1 and 26 patients in G2. The study assessed the relationship between the occurrence of this complication and the timing of tracheotomy. Pneumonia was significantly more frequent in patients in whom tracheotomy had been performed on hospitalization day 10 or later (P = 0.011). null null The comparison of results is presented in Tab. II.&lt;/br&gt; &lt;/br&gt;Another analyzed aspect of the study consisted in the results obtained by the patients in the baseline evaluation of the level of consciousness as assessed using the Glasgow Coma Scale (GCS). Data were checked for potential correlation between the GCS scores and the timing of the tracheotomy and the lengths of mechanical ventilation, ICU stay, and hospitalization. Correlation between GCS scores and the duration of stay within the ICU was demonstrated with a statistically significant correlation coefficient (Spearman's rank coefficient in the range of -0.4 to -0.2). &lt;/br&gt; &lt;/br&gt;ICU stay and total hospitalization lengths were shorter in patients with higher baseline GCS scores compared to patients with lower baseline GCS scores. The results are illustrated graphically (Fig. 2., 3.).

Early vs. late tracheostomy in ventilated COVID-19 patients – A retrospective study

BackgroundTracheostomy is one of the most common surgical procedures performed on ventilated COVID-19 patients, yet the appropriate timing for operating is controversial. ObjectivesAssessing the effect of early tracheostomy on mortality and decannulation; elucidating changes in ventilation parameters, vasopressors and sedatives dosages immediately following the procedure. MethodsA retrospective cohort of 38 ventilated COVID-19 patients, 19 of them (50%) underwent tracheostomy within 7 days of intubation (early tracheostomy group) and the rest underwent tracheostomy after 8 days or more (late tracheostomy group). ResultsDecannulation rates were significantly higher while mortality rates were non-significantly lower in the early tracheostomy group compared with the late tracheostomy group (58% vs 21% p < 0.05; 42% vs 74% p = 0.1, respectively). Tidal volume increased (446 ml vs 483 ml; p = 0.02) while PEEP (13 cmH20 vs 11.6 cmH2O, p = 0.04) decreased at the immediate time following the procedure. No staff member participating in the procedures was infected with SARS-CoV-2 virus. ConclusionEarly tracheostomy might offer improved outcomes with higher decannulation rates and lower mortality rates in ventilated COVID-19 patients, yet larger scale studies are needed. Most likely, early exposure to COVID-19 patients with appropriate personal protective equipment during open tracheostomy does not put the surgical team at risk.

Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation?

IntroductionWith the advancement of pediatric critical care services across India, many children require prolonged mechanical ventilation (MV), and tracheostomy is recommended to them. However, many pediatric intensivists have concerns regarding the safety, feasibility, and outcome of tracheostomy.We aimed to analyze clinical characteristics, indication, duration, and outcome of tracheostomized children with respect to timing of tracheostomy.Materials and methodsWe conducted a retrospective study from the hospital clinical database of consecutive patients below 12 years who had undergone tracheostomy after admission into the pediatric intensive care unit (PICU) for prolonged ventilation (≥96 hours) from January 2015 to December 2019. The study was approved by the Institutional Ethics Committee. Patients were divided into two groups: tracheostomies done within 14 days of MV (early tracheostomy) and patients with tracheostomies performed after 14 days (late tracheostomy). Patients’ age, sex, indications, complications, decannulation rate, length of MV, PICU, and hospital stay were analyzed.ResultsOf the 1,425 patients on invasive MV, 87 (6.1%) patients required tracheostomy after a mean 13.37 days of MV. The most common indication was encephalopathy 32 (36.7%) followed by acute respiratory distress syndrome 20 (22.9%). Factors like higher pediatric logistic organ dysfunction score, vasoactive inotrop score, incidence of pretracheostomy ventilator-associated pneumonia, and difficulty in obtaining parental consent were associated with late tracheostomy. The early tracheostomy group had a higher decannulation rate (odds ratio, 5.17; p, 0.01) and weaning rate (odds ratio, 5.94; p, 0.032). The late tracheostomy group needed a longer duration of MV, PICU, and hospital stay. Complications of tracheostomy were less in the early tracheostomy patients (odds ratio, 2.95; p, 0.03).ConclusionEarly tracheostomy was associated with lower complications, higher successful weaning rates, and less utilization of intensive care facilities in patients receiving prolonged MV.Clinical significanceIn the context of scarcity of data on the timing of tracheostomy in children with prolonged ventilation (≥96 hours) the study shows that early (<14 days) tracheostomy is associated with a better outcome.How to cite this articleSarkar M, Roychowdhoury S, Bhakta S, Raut S, Nandi M. Tracheostomy before 14 Days: Is It Associated with Better Outcomes in Pediatric Patients on Prolonged Mechanical Ventilation? Indian J Crit Care Med 2021;25(4):435–440.

Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—The Earlier, the Better

AbstractObjectives This study was aimed to assess the benefits of early tracheostomy (ET) compared with late tracheostomy (LT) on postoperative outcomes in pediatric cardiac surgical patients.Design Present one is a prospective, observational study.Setting The study was conducted at a cardiac surgical intensive care unit (ICU) of a tertiary care hospital.Participants All pediatric patients below 10 years of age, who underwent tracheostomy after cardiac surgery from January2019 to december2019, were subdivided into two groups according to the timing of tracheostomy: “early” if done before 7 days or “late” if done after 7 days postcardiac surgery.Interventions ET versus LT was measured in the study.Results Out of all 1,084 pediatric patients who underwent cardiac surgery over the study period, 41 (3.7%) received tracheostomy. Sixteen (39%) patients underwent ET and 25 (61%) underwent LT. ET had advantages by having reduced risk associations with the following variables: preoperative hospital stay (p = 0.0016), sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative sepsis (p = 0.001), C-reactive protein (p = 0.04), ventilator-associated pneumonia (VAP; p = 0.006), antibiotic escalation (p = 0.006), and antifungal therapy (p = 0.01) requirement. Furthermore, ET was associated with lesser duration of mechanical ventilation (p = 0.0027), length of ICU stay (LOICUS; p = 0.01), length of hospital stay (LOHS; p = 0.001), lesser days of feed interruption (p = 0.0017), and tracheostomy tube change (p = 0.02). ET group of children, who had higher total ventilation-free days (p = 0.02), were decannulated earlier (p = 0.03) and discharged earlier (p = 0.0089).Conclusion ET had significant benefits in reduction of postoperative morbidities with overall shorter mechanical ventilation, LOICUS, and LOHS, better nutrition supplementation, lesser infection, etc. These benefits may promote faster patient convalescence and rehabilitation with reduced hospital costs.

Timing, Complications, and Safety of Tracheotomy in Critically Ill Patients With COVID-19

The current coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented needs for invasive ventilation, with 10% to 15% of intubated patients subsequently requiring tracheotomy. To assess the complications, safety, and timing of tracheotomy performed for critically ill patients with COVID-19. This prospective cohort study assessed consecutive patients admitted to the intensive care unit (ICU) who had COVID-19 that required tracheotomy. Patients were recruited from March 16 to April 10, 2020, at a tertiary referral center. A surgical tracheotomy was performed for all patients following recommended criteria for use of personal protective equipment (PPE). The number of subthyroid operations, the tracheal entrance protocol, and use of PPE. Infections among the surgeons were monitored weekly by reverse-transcriptase polymerase chain reaction of nasopharyngeal swab samples. Short-term complications, weaning, and the association of timing of tracheotomy (early [≤10 days] vs late [>10 days]) with total required days of invasive ventilation were assessed. A total of 50 patients (mean [SD] age, 63.8 [9.2] years; 33 [66%] male) participated in the study. All tracheotomies were performed at the bedside. The median time from intubation to tracheotomy was 9 days (interquartile range, 2-24 days). A subthyroid approach was completed for 46 patients (92%), and the tracheal protocol was adequately achieved for 40 patients (80%). Adequate PPE was used, with no infection among surgeons identified 4 weeks after the last tracheotomy. Postoperative complications were rare, with minor bleeding (in 6 patients [12%]) being the most common complication. The successful weaning rate was higher in the early tracheotomy group than in the late tracheotomy group (adjusted hazard ratio, 2.55; 95% CI, 0.96-6.75), but the difference was not statistically significant. There was less time of invasive mechanical ventilatory support with early tracheotomy compared with late tracheotomy (mean [SD], 18 [5.4] vs 22.3 [5.7] days). The reduction of invasive ventilatory support was achieved at the expense of the pretracheotomy period. In this cohort study, with the use of a standardized protocol aimed at minimizing COVID-19 risks, bedside open tracheotomy was a safe procedure for patients and surgeons, with minimal complications. Timing of tracheotomy may be important in reducing time of invasive mechanical ventilation, with potential implications to intensive care unit availability during the COVID-19 pandemic.

Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis.

Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy. We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD). Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24-3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, -19.18 to -7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, -24.33 to -12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32-1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted. Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term outcomes of tracheostomy timing following acute SCI.

Efficacy and Safety of Early Tracheotomy in Acute Cervical Spinal Cord Injury.

To evaluate the clinical efficacy and safety of early tracheotomy versus delayed tracheotomy for patients with cervical spinal cord injury. A descriptive study. Department of Orthopedic Surgery, The 80th Army Hospital of PLA, Weifang, Shandong, China, from January 2012 to June 2019. Data of 45 patients with cervical spinal cord injury, who underwent tracheotomy and cervical spine internal fixation at the study place, were retrospectively analysed. Twenty-five patients underwent tracheotomy immediately after cervical spine internal fixation (early tracheotomy group) and 20 patients underwent tracheotomy 3-12 days after cervical spine internal fixation (delayed tracheotomy group). Clinical outcomes and tracheotomy complications were compared between the two groups. Compared with the delayed tracheotomy, the early tracheotomy significantly reduced the total duration of mechanical ventilation (p <0.01), duration of mechanical ventilation after tracheotomy (p <0.05), duration of indwelling tracheal tube (p <0.05), and hospital stay (p <0.01). There were no significant differences in pneumonia, mortality, and complications related to tracheotomy between the groups. No incision infection for tracheotomy and cervical spine internal fixation were found in all patients. Compared with delayed tracheotomy, early tracheotomy can significantly reduce the duration of mechanical ventilation, duration of indwelling tracheal tube, and hospital stay. Early tracheotomy did not increase the risk of infection of the cervical spine internal fixation. Therefore, early tracheotomy was beneficial and safe for patients. Key Words: Spinal cord injuries, Tracheotomy, Complications.

Time to tracheostomy impacts overall outcomes in patients with cervical spinal cord injury.

The morbidity associated with cervical spine injury increases in the setting of concomitant cervical spinal cord injury (CSCI). A significant proportion of these patients require placement of a tracheostomy. However, it remains unclear if timing to tracheostomy following traumatic CSCI can impact outcomes. The aim of our study was to characterize outcomes associated with tracheostomy timing following traumatic CSCI. We performed a 5-year (2010-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age, ≥18 years) trauma patients who had traumatic CSCI and received tracheostomy. Patients were subdivided into two groups: early tracheostomy (ET) (≤4 days from initial intubation) and late tracheostomy (LT) (>4 days). Outcome measures included respiratory complications, ventilator-free days, intensive care unit-free days and hospital length of stay, and mortality. Multivariate logistic regression analysis was performed. A total of 5,980 patients were included in the study, of which 1,010 (17%) patients received ET, while 4,970 (83%) patients received LT. Mean age was 46 years, and 73% were men. In terms of CSCI location, 48% of the patients had high CSCI (C1-C4), while 52% had low CSCI (C5-C7). Patients in the ET group had lower rates of respiratory complications (30% vs. 46%, p = 0.01), higher ventilator-free days (13 days vs. 9 days; p = 0.02), intensive care unit-free days (11 days vs. 8 days; p = 0.01), and a shorter hospital length of stay (22 days vs. 29 days; p = 0.01) compared with those in the LT group. On regression analysis, ET was associated with lower rates of respiratory complications in patients with high CSCI (odds ratio, 0.55 [0.41-0.81]) and low CSCI (odds ratio, 0.93 [0.72-0.95]). However, no association was found between time to tracheostomy and in-hospital mortality. Early tracheostomy regardless of CSCI level may lead to improved outcomes. Quality improvement efforts should focus on defining the optimal time to tracheostomy and considering ET as a component of SCI management bundle. Therapeutic, level IV.

Elective Tracheostomy in Critically Ill Children: A 10-Year Single-Center Experience From a Lower-Middle Income Country.

ObjectiveTracheostomy is a commonly performed procedure amongst critically ill patients, especially in cases of prolonged mechanical ventilation (PMV). This study aimed to describe the indications, clinical characteristics, and outcomes of elective pediatric tracheostomies in critically ill children at our center.MethodsA retrospective review of medical records of children who underwent elective tracheostomies in our pediatric intensive care unit (PICU) was conducted from January 2009 to June 2018. Data were extracted based on demographics, indications of tracheostomy, and patient outcomes. Results were reported as mean with standard deviation and as frequencies with percentage.ResultsOf the 3,200 patients admitted to the PICU during the study period, 1,130 were intubated. A total of 48 (4.2% of 1,130) children underwent an elective tracheostomy. 30/48 (62.5%) children had an early tracheostomy. 34/48 (71%) patients were males. Approximately 25% of our patients undergoing a tracheostomy had an underlying neurological condition as the primary diagnosis, followed by respiratory conditions (23%). The most common indications for elective tracheostomy were PMV (>7 days) (n=24, 50%) and extubation failure (n=9, 18.7%). Early tracheostomy (<14 days) had better patient outcomes in terms of ventilator-free days (8.57±4.64 in early tracheostomy vs. 6.38±6.17 days in late tracheostomy, P=0.04). The sedation-free days and ICU-free days were also significantly increased in the early tracheostomy group than in the late tracheostomy group. The successful weaning and ICU discharge rate were significantly higher in the early tracheostomy group than in the late tracheostomy group (78.1% vs. 59.7%, P<0.05; and 69.2% vs. 49.5%, P<0.05, respectively). Ventilator-associated pneumonia was more common in the late tracheostomy group (n= 14, 77%), compared to early tracheostomy group (n=12, 40%) (P=0.03). Two patients expired from tracheostomy-related complications.ConclusionPMV was the most common indication for an elective tracheostomy. Early tracheostomy is associated with improved patient outcomes; therefore, a standardized approach toward mechanically ventilated children is recommended.

Early Versus Late Tracheostomy in Outcome of Patients Admitted in Neurosurgical Intensive Care Unit

Background: Tracheostomy is a commonly performed procedure in neurosurgical Intensive Care Units (ICU) performed to secure airway, aid in pulmonary toileting, and minimize ventilator-associated pneumonia (VAP) in cases requiring prolonged mechanical ventilation. Although early tracheostomy has been advocated rampantly in recent days, its benefit over late tracheostomy and the timing itself has been very controversial. In this study, we tried to study the effect of timing of tracheostomy in the outcome of patients in our ICU.&#x0D; Materials and methods: This is a retrospective study carried out over a period of one and a half years in a tertiary care center in western Nepal. Early tracheostomy was defined as those done within 4 days of endotracheal intubation and late were those done thereafter. Outcomes were studied in terms of length of ICU stay, hospital stay, mechanical ventilation, duration of tracheostomy in situ, VAP and mortality and complication over 90 days. Statistical analysis was done using SPSS 20.0.&#x0D; Results: There were 67 cases included in the study, out of which 27(40.3%) underwent early and 40 (59.7%) underwent late tracheostomy. The Mean duration of ICU stay, tracheostomy in situ duration, mechanical ventilation duration, and VAP were the parameters showing a significant difference between the two groups. There were 13 (19.4%) cases having complications in our series of which 6 (9%) of cases were from the early tracheostomy group and 7 (10.4%) of the cases were from the late tracheostomy group (p=0.63).&#x0D; Conclusion: Early tracheostomy is beneficial in a neurosurgical patient in terms of a decrease in ICU stay, duration of mechanical ventilation, duration of tracheostomy in situ, and VAP.

Early tracheostomy in acute heart failure exacerbation

BackgroundThe optimal timing for tracheostomy among patients with acute heart failure (AHF) exacerbation has been controversial, despite multiple studies assessing the utility of early tracheostomy. Our objective was to assess the trend of utilization and outcomes of early tracheostomy among patients with AHF exacerbation in the United States. Methods and resultsA retrospective cohort study using the National Inpatient Sample from 2005 to 2014 was conducted. Among those who were admitted with AHF exacerbation (n = 1,390,356), 0.26% of patients underwent tracheostomy (n = 2,571), and among them, 19.4% received early tracheostomy (n = 496). There was no significant shift in the percentage of early tracheostomy from 2008 to 2014. We used propensity score matching to compare the clinical and economic outcomes between the early tracheostomy group and late tracheostomy group. In-hospital mortality did not show any difference between the two groups (13.97% in early group vs. 18.04% in late group; p =0.163). The median total hospital cost ($53,466), total hospital length of stay (19 days), and length of stay after intubation (16 days) in the early tracheostomy group were significantly lower than in the late tracheostomy group ($73,680; 26 days; 23 days, respectively). ConclusionEarly tracheostomy showed economic benefit with lower hospital costs and shorter length of stay, without a difference in in-hospital mortality compared to late tracheostomy.

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

To characterize the effects of tracheotomy timing at our institution on intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. Retrospective cohort study. 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. 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. 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. 4 Laryngoscope, 131:282-287, 2021.

Early Tracheostomy in Severe Traumatic Brain Injury Patients: A Meta-Analysis and Comparison With Late Tracheostomy.

To elucidate the impact of early tracheostomy on hospitalization outcomes in patients with traumatic brain injury. Lilacs, PubMed, and Cochrane databases were searched. The close-out date was August 8, 2018. Studies written in English, French, Spanish, or Portuguese with traumatic brain injury as the base trauma, clearly formulated question, patient's admission assessment, minimum follow-up during hospital stay, and minimum of two in-hospital outcomes were selected. Retrospective studies, prospective analyses, and case series were included. Studies without full reports or abstract, commentaries, editorials, and reviews were excluded. The study design, year, patient's demographics, mean time between admission and tracheostomy, neurologic assessment at admission, confirmed ventilator-assisted pneumonia, median ICU stay, median hospital stay, mortality rates, and ICU and hospital costs were extracted. A total of 4,219 studies were retrieved and screened. Eight studies were selected for the systematic review; of these, seven were eligible for the meta-analysis. Comparative analyses were performed between the early tracheostomy and late tracheostomy groups. Mean time for early tracheostomy and late tracheostomy procedures was 5.59 days (SD, 0.34 d) and 11.8 days (SD, 0.81 d), respectively. Meta-analysis revealed that early tracheostomy was associated with shorter mechanical ventilation duration (-4.15 [95% CI, -6.30 to -1.99]) as well as ICU (-5.87 d [95% CI, -8.74 to -3.00 d]) and hospital (-6.68 d [95% CI, -8.03 to -5.32 d]) stay durations when compared with late tracheostomy. Early tracheostomy presented less risk difference for ventilator-associated pneumonia (risk difference, 0.78; 95% CI, 0.70-0.88). No statistical difference in mortality was found between the groups. The findings from this meta-analysis suggest that early tracheostomy in severe traumatic brain injury patients contributes to a lower exposure to secondary insults and nosocomial adverse events, increasing the opportunity of patient's early rehabilitation and discharge.

Illustration of the current practice and outcome comparison of early versus late tracheostomy after pediatric ECMO.

Pediatric extracorporeal membrane oxygenation typically necessitates protracted ventilator support, yet not much is known about the use of tracheostomy in the pediatric subpopulation. The study was designed with an objective to quantify the prevalence of tracheostomy in children with respiratory/cardiac failure requiring extracorporeal membrane oxygenation and to compare outcomes for patients undergoing early, late, and no tracheostomy. Data of patients <18 years of age who underwent extracorporeal membrane oxygenation for respiratory/cardiac failure between 2009 and 2015 were obtained from the Virtual Pediatric Systems (VPS, LLC) Database. Patients who underwent post-operative cardiac ECMO were excluded. Early versus late tracheostomy was defined as ⩽21 or >21 days after intensive care unit admission. Data were analyzed for 2127 patients meeting inclusion and exclusion criteria. Five percent (107/2127) underwent a tracheostomy. Of these, 28% (30/107) underwent early and 72% (77/107) late tracheostomy. A higher mortality was found in the no tracheostomy group (41.3%) compared to early (13.3%) and late tracheostomy (14.3%) groups. Late tracheostomy was associated with 2.4 times the expected intensive care unit length of stay and 1.87 times the expected ventilator days as compared to patients with no tracheostomy. Early tracheostomy was associated with a shorter intensive care unit length of stay (p value < 0.001) and ventilator days (p value = 0.04) compared to late tracheostomy and no difference with the no tracheostomy group. Late tracheostomy (>21 days) is associated with worse outcomes in the cohort of children who underwent Pediatric extracorporeal membrane oxygenation compared to patients who did not undergo tracheostomy. Early tracheostomy is associated with shorter intensive care unit stay and ventilator duration when compared to late tracheostomy.