Timing Of Tracheostomy In Patients Research Articles

The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a chinese tertiary hospital

ObjectivesThe timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV.DesignRetrospective cohort study.Setting and participantsOne thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital.MethodsTracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student’s t-test, analysis of variance (ANOVA), Mann–Whitney U test, Kruskal–Wallis test, Chi-square test, and Fisher’s exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death.ResultsIn both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT.ConclusionsIn a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes.Trial registrationChiCTR2100043905. Registered 05 March 2021.http://www.chictr.org.cn/listbycreater.aspx

Early Versus Late Tracheostomy in Mechanically Ventilated COVID-19 Patients: A Comparative Study

The decision to perform tracheostomy during the COVID-19 pandemic has been based mainly on practical and empirical standards. Also, the amount of scientific evidence to determine the exact timing of tracheostomy in patients with severe COVID-19 on mechanical ventilation is not significant. We conducted a retrospective cohort study on mechanically ventilated COVID-19 patients from April 25, 2021 to January 25, 2022 in intensive care units of Imam Khomeini Hospital Complex, Tehran, Iran. The 30-day survival of patients was calculated and compared between patients under tracheostomy and those without tracheostomy. A number of 135 COVID-19 cases (75 patients in the intubated group and 60 patients in the tracheostomy group) were included in this study. The mean age of the population was 53.6±12.4. The overall mortality rate was 101 (74.8%). The 30-day mortality rate was significantly higher in the intubated group (90.6%) than in the tracheostomy group (55%) (P&lt; 0.001). The mortality rate was 60% in the early (≤ 7 days) tracheostomy group and 50% in the late (&gt;7 days) group. This difference was not statistically significant (P&gt; 0.05). Tracheostomy is a preferred method in airway management of severe COVID-19 patients under mechanical ventilation; however, early tracheostomy during the first week of intubation may not be superior to late tracheostomy in decreasing the mortality rate.

Tracheostomy as a component of intensive care for central nervous system diseases

Objective. To reveal the effective and safe timing of tracheostomy in patients with CNS diseases by comparative assessment of the duration of respiratory support and ICU, the frequency of development ventilator-associated pneumonia, the assessment of the level of consciousness according to the Glasgow Coma Scale (GCS), survival rate, as well as the incidence of complications rate.Materials and methods. A retrospective study was conducted among neurological and neurosurgical patients treated from 2010 to 2017 who underwent tracheostomy. Patients (n=131) were divided into 3 groups depending on the tracheostomy time.Results. The relation between early tracheostomy and the duration of respiratory support, the ICU bed-day, the probability of developing ventilator-associated pneumonia in patients with the central nervous system pathology was revealed; no relationship was found between the tracheostomy time and the neurological outcome and survival rate in this category patients.Conclusion. The use of early tracheostomy in intensive care of patients with the central nervous system pathology is effective, which is proved by a 2,2 times reduction of the duration of mechanical ventilation, by a 1.9 times reduction of the duration of the ICU day, by a 1.6 times lower risk of developing ventilator-associated pneumonia, without affecting outcomes and being safe due to the absence a lot of complications both during and after the surgical intervention.

Влияние трахеостомии на некоторые показатели газообмена у пациентов с COVID-19

The COVID-19 pandemic has become an integral part of medical life. At different levels of medical care, doctors of all specialties, to one degree or another, are faced with this disease. Distinctive feature of the infection is the need for respiratory support of varying severity. Objective: A retrospective analysis and comparison of pO2 and pCO2 values as well as the PaO2/FiO2 (P/F) ratio were carried out in 20 patients with a new coronavirus infection on mechanical ventilation before and after tracheostomy on the 3rd day from the moment of orotracheal intubation from July 2021 to January 2022 at the Vidnovskaya Regional Clinical Hospital, which was redesigned to provide medical care to patients with a new coronavirus infection. Results. The assessment was carried out before and after the imposition of a tracheostomy on the 3rd day from the moment of orotracheal intubation. It was found that tracheostomy performed on the 3rd day after intubation had a dynamically significant effect on the decrease in the partial pressure of carbon dioxide in patients with COVID-19 infection and also caused an increase in the P/F ratio. At the same time, there were no differences in the dynamics of pO2 of venous blood. Considering the data, a possible shift in the timing of tracheostomy in patients with coronavirus infection on mechanical ventilation for 1 day from orotracheal intubation becomes relevant. This hypothesis requires further research.

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

BackgroundExtracorporeal membrane oxygenation (ECMO) is an integral method of life support in critically ill patients with severe cardiopulmonary failure; however, such patients generally require prolonged mechanical ventilation and exhibit high mortality rates. Tracheostomy is commonly performed in patients on mechanical ventilation, and its early implementation has potential advantages for favorable patient outcomes. This study aimed to investigate the association between tracheostomy timing and patient outcomes, including mortality, in patients requiring ECMO.MethodsWe conducted a single-center retrospective observational study of consecutively admitted patients who were supported by ECMO and underwent tracheostomy during intensive care unit (ICU) admission at a tertiary care center from April 2014 until December 2021. The primary outcome was hospital mortality. Using the quartiles of tracheostomy timing, the patients were classified into four groups for comparison. The association between the quartiles of tracheostomy timing and mortality was explored using multivariable logistic regression models.ResultsOf the 293 patients treated with ECMO, 98 eligible patients were divided into quartiles 1 (≤ 15 days), quartile 2:16–19 days, quartile 3:20–26 days, and 4 (> 26 days). All patients underwent surgical tracheostomy and 35 patients underwent tracheostomy during ECMO. The complications of tracheostomy were comparable between the groups, whereas the duration of ECMO and ICU length of stay increased significantly as the quartiles of tracheostomy timing increased. Patients in quartile 1 had the lowest hospital mortality rate (19.2%), whereas those in quartile 4 had the highest mortality rate (50.0%). Multivariate logistic regression analysis showed a significant association between the increment of the quartiles of tracheostomy timing and hospital mortality (adjusted odds ratio for quartile increment:1.55, 95% confidence interval 1.03–2.35, p for trend = 0.037).ConclusionsThe timing of tracheostomy in patients requiring ECMO was significantly associated with patient outcomes in a time-dependent manner. Further investigation is warranted to determine the optimal timing of tracheostomy in terms of mortality.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study.

International multi-institute retrospective cohort study. Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. Not applicable. A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified. COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

Early Versus Late Tracheostomy in Stroke Patients: A Retrospective Analysis.

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. 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. 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]). 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 Patients with Intracerebral Haemorrhage: A Propensity-Matched Analysis.

Although early tracheostomy (ET) is recommended for patients with severe stroke, the optimal timing of tracheostomy for patients with intracerebral haemorrhage (ICH) remains controversial. This study aimed to explore the clinical characteristics, risk factors and timing of tracheostomy in patients after tracheal intubation using a propensity-matched analysis. We conducted a retrospective database search and assessed 267 consecutive patients who underwent endotracheal intubation (175 of whom underwent tracheostomy) and ICH between July 2017 and June 2021. A logistic regression model was applied to identify the critical factors influencing the decision for tracheostomy by comparing factors in a tracheostomy group and a nontracheostomy group. Patients were divided into an early (≤5 days) or a late (>5 days) group according to the median time of tracheostomy. Propensity score matching was performed to adjust for possible confounders and investigate differences in outcomes between ET and late tracheostomy (LT). Among the 267 enrolled patients with ICH and endotracheal intubation, 65.5% received tracheostomy during hospitalisation, and 52.6% received ET. The independent risk factors for tracheostomy included National Institute of Health Stroke Scale (NIHSS) (odds ratio [OR]: 1.179; 95% confidence interval [CI]: 1.028-1.351; P = 0.018), aspiration (OR: 2.171; 95% CI: 1.054-4.471; P = 0.035) and infiltrates (OR: 2.149; 95% CI: 1.088-4.242; P = 0.028). Using propensity matching, we found that ET was associated with fewer antibiotic-using days (15 vs. 18; P < 0.001) and sedativeusing days (6 vs. 8; P < 0.001), shorter intensive care unit (ICU) Length of Study (LOS) (9 vs. 12; P < 0.05) and reduced in-ICU costs (3.59 vs. 7.4; P < 0.001) and total hospital costs (8.26 vs. 11.28, respectively; P < 0.001). Muscle relaxants (31.8% vs. 60.6%) were used less frequently in patients with ET (P = 0.001). However, there were no differences between the ET and LT groups in terms of modified Rankin Scale (mRS) (4 vs. 4; P = 0.932), in-general-ward costs (4.74 vs. 4.37; P = 0.052), mechanical ventilation days (6 vs. 6; P = 0.961) and hospital LOS (23 vs. 23; P = 0.735) as well as the incidences of ventilator-associated pneumonia (28.8% vs. 37.9%; P = 0.268), tracheostomyrelated complications (16.7% vs. 19.7%; P = 0.652), respiratory failure (24.2% vs. 31.8%; P = 0.333), all-cause deaths (15.2% vs. 16.7%; P = 0.812) and pneumonia (77.3% vs. 87.9%; P = 0.108). We recommend ET for high-risk patients with ICH. Although ET cannot reduce inhospital mortality or improve patient prognosis, it may help reduce hospital costs and ICU LOS as well as the use of antibiotics, sedatives and muscle relaxants.

Impact of Tracheostomy Timing on Outcomes After Cardiovascular Surgery

This study aimed to investigate whether tracheostomy timing in patients undergoing cardiac surgery had an impact on outcomes. Retrospective, observational study. Single-center university hospital. Patients requiring tracheostomy among a total of 961 patients who underwent cardiovascular surgery via a median sternotomy from January 2014 to March 2021. Early versus late tracheostomy. During the study period, tracheostomy was performed in 28 patients (2.9%). According to tracheostomy timing, postoperative day seven was chosen as the cutoff to define early (≤seven days) and late (>seven days) tracheostomy. Patients in the early-tracheostomy group had a significantly shorter ventilation time after tracheostomy compared with the late-tracheostomy group (p=0.039), and early tracheostomy resulted in a reduction in total ventilation time (p=0.001). The incidence of pressure ulcers was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group. There was a higher tracheal tube removal rate in the early-tracheostomy group compared with the late-tracheostomy group (p=0.0007). The one-year survival rate in the early- and late-tracheostomy groups was 65% and 31%, respectively. The long-term mortality rate was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group (p=0.04). Early tracheostomy (<seven days) may provide better clinical outcomes, with lower mortality and morbidity rates, when patients are judged to require at least seven days of ventilation after cardiovascular surgery.

Optimal timing of tracheostomy in patients on veno-venous extracorporeal membrane oxygenation for coronavirus 2019: a case series.

AimAn early tracheostomy is often considered for patients with veno‐venous extracorporeal membrane oxygenation (VV‐ECMO). However, there is no consensus on the timing of a tracheostomy in patients on VV‐ECMO for coronavirus disease 2019 (COVID‐19). The present report described the optimal timing of tracheostomy for these patients.MethodThe present study was a single‐center case series. We retrospectively reviewed the medical records of nine consecutive patients who underwent tracheostomy either during or after VV‐ECMO treatment in our center between January 1, 2020 and December 31, 2020.ResultsAll the patients received a percutaneous dilatational tracheostomy, which was performed during VV‐ECMO in four patients. Three of these patients experienced hemorrhagic complications, and the remaining patient required a circuit change on the day after the operation. Heparin was discontinued 8 h preoperatively and resumed 1–14 h later. The platelet count was below normal in two patients, but no transfusion was performed. APTT was almost normal, and D‐dimer was elevated postoperatively. The remaining five patients received a tracheostomy after weaning off VV‐ECMO, and no complication was observed. Eight patients were deeply sedated during VV‐ECMO to prioritize lung rest and prevent infecting the healthcare workers.ConclusionIn the present study, patients who underwent a tracheostomy during VV‐ECMO tended to have more hemorrhagic complications. Because an early tracheostomy during ECMO has little benefit for patients with COVID‐19, it should be performed after weaning off VV‐ECMO to protect the safety of the healthcare workers concerned.

Early Outcomes From Early Tracheostomy for Patients With COVID-19

Decision-making in the timing of tracheostomy in patients with coronavirus disease 2019 (COVID-19) has centered on the intersection of long-standing debates on the benefits of early vs late tracheostomy, assumptions about timelines of infectivity of the novel coronavirus, and concern over risk to surgeons performing tracheostomy. Multiple consensus guidelines recommend avoiding or delaying tracheostomy, without evidence to indicate anticipated improvement in outcomes as a result. To assess outcomes from early tracheostomy in the airway management of patients with COVID-19 requiring mechanical ventilation. A retrospective medical record review was completed of 148 patients with reverse transcriptase-polymerase chain reaction-confirmed COVID-19 requiring mechanical ventilation at a single tertiary-care medical center in New York City from March 1 to May 7, 2020. Open or percutaneous tracheostomy. The primary outcomes were time from symptom onset to (1) endotracheal intubation, (2) tracheostomy; time from endotracheal intubation to tracheostomy; time from tracheostomy to (1) tracheostomy tube downsizing, (2) decannulation; total time on mechanical ventilation; and total length of stay. Participants included 148 patients, 120 men and 28 women, with an overall mean (SD) age of 58.1 (15.8) years. Mean (SD; median) time from symptom onset to intubation was 10.57 (6.58; 9) days; from symptom onset to tracheostomy, 22.76 (8.84; 21) days; and from endotracheal intubation to tracheostomy, 12.23 (6.82; 12) days. The mean (SD; median) time to discontinuation of mechanical ventilation was 33.49 (18.82; 27) days; from tracheostomy to first downsize, 23.02 (13.76; 19) days; and from tracheostomy to decannulation, 30.16 (16.00; 26) days. The mean (SD; median) length of stay for all patients was 51.29 (23.66; 45) days. Timing of tracheostomy was significantly associated with length of stay: median length of stay was 40 days in those who underwent early tracheostomy (within 10 days of endotracheal intubation) and 49 days in those who underwent late tracheostomy (median difference, -8; 95% CI, -15 to -1). In a competing risks model with death as the competing risk, the late tracheostomy group was 16% less likely to discontinue mechanical ventilation (hazard ratio, 0.84; 95% CI, 0.55 to 1.28). This cohort study from the first 2 months of the pandemic in New York City provides an opportunity to reconsider guidelines for tracheostomy for patients with COVID-19. Findings demonstrated noninferiority of early tracheostomy and challenges recommendations to categorically delay or avoid tracheostomy in this patient population. When aligned with emerging evidence about the timeline of infectivity of the novel coronavirus, this approach may optimize outcomes from tracheostomy while keeping clinicians safe.

Surgical strategy and optimal timing of tracheostomy in patients with COVID-19: Early experiences in Japan

ObjectiveTracheostomy is an important surgical procedure for coronavirus disease-2019 (COVID-19) patients who underwent prolonged tracheal intubation. Surgical indication of tracheostomy is greatly affected by the general condition of the patient, comorbidity, prognosis, hospital resources, and staff experience. Thus, the optimal timing of tracheostomy remains controversial. MethodsWe reviewed our early experience with COVID-19 patients who underwent tracheostomy at one tertiary hospital in Japan from February to September 2020 and analyzed the timing of tracheostomy, operative results, and occupational infection in healthcare workers (HCWs). ResultsOf 16 patients received tracheal intubation with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, five patients (31%) received surgical tracheostomy in our hospital. The average consultation time for surgical tracheostomy was 7.4 days (range, 6 - 9 days) from the COVID-19 team to the otolaryngologist. The duration from tracheal intubation to tracheostomy ranged from 14 to 27 days (average, 20 days). The average time of tracheostomy was 27 min (range, 17 - 39 min), and post-wound bleeding occurred in only one patient. No significant differences in hemoglobin (Hb) levels were found between the pre- and postoperative periods (mean: 10.2 vs. 10.2 g/dl, p = 0.93). Similarly, no difference was found in white blood cell (WBC) count (mean: 12,200 vs. 9,900 cells /µl, p = 0.25). After the tracheostomy, there was no occupational infection among the HCWs who assisted the tracheostomy patients during the perioperative period. ConclusionWe proposed a modified weaning protocol and surgical indications of tracheostomy for COVID-19 patients and recommend that an optimal timing for tracheostomy in COVID-19 patients of 2 - 3 weeks after tracheal intubation, from our early experiences in Japan. An experienced multi-disciplinary tracheostomy team is essential to perform a safe tracheostomy in patients with COVID-19 and to minimize the risk of occupational infection in HCWs.

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.

Effect of early tracheostomy in mechanically ventilated patients

ObjectiveTo investigate the effect of the timing of tracheostomy in patients who required prolonged mechanical ventilation using two methods: analysis of early versus late tracheostomy and landmark analysis.Study DesignRetrospective cohort study.MethodsPatients who were emergently intubated and admitted into the intensive care unit or high dependency unit between January 2011 and August 2016, with or without tracheostomy, were included. In the early and late tracheostomy analysis, all patients were divided into early (≤10 days, n = 88) and late (>10 days, n = 132) groups. In the landmark analysis, 198 patients requiring ventilation for more than 10 days were divided into early tracheostomy (≤10 days, n = 57) and nonearly tracheostomy (>10 days, n = 141) groups. We compared 60‐day ventilation withdrawal rate and 60‐day mortality.ResultsEarly tracheostomy was a significant factor for early ventilation withdrawal, as shown by log‐rank test results (early and late tracheostomy: P = .001, landmark: P = .021). Multivariable analysis showed that the early group was also associated with a higher chance of ventilation withdrawal in each analysis (early and late tracheostomy: adjusted hazard ratio [aHR] = 1.69, 95% confidence interval [CI] = 1.20–2.39, P = .003; landmark: aHR = 1.61, 95% CI = 1.06–2.38, P = .027). Early tracheostomy, however, was not associated with improved 60‐day mortality (early and late tracheostomy: aHR = 0.88, 95% CI = 0.46–1.69, P = .71; landmark: aHR = 1.46; 95% CI = 0.58–3.66; P = .42).ConclusionFor patients requiring ventilation, performing tracheostomy within 10 days of admission was independently associated with shortened duration of mechanical ventilation; 60‐day mortality was not associated with the timing of tracheostomy.Level of Evidence2b

Meta analysis of effect of tracheostomy timing on prognosis of patients with cervical spinal cord injury

Objective To evaluate the effects of early tracheostomy and late tracheostomy on the prognosis of patients with cervical spinal cord injury, so as to provide evidence based guidance for the timing of tracheostomy. Methods Relevant literatures studying the timing of tracheostomy in patients with cervical spinal cord injury were searched in PubMed, Embase, Medline, Cochrane Library, Chinese Biological Medical Literature database (CBM), China National Knowledge Infrastructure database (CNKI), and VIP journal database with time range from journal establishment to March 2018. The retrieved articles were screened according to the inclusion and exclusion criteria. The article quality was rigorously evaluated according to the Newcastle-Ottawa scale (NOS). Meta analysis was conducted using Review Manager 5.3 software to compare the mechanical ventilation time, ICU stay, incidence of pneumonia, incidence of complications, and mortality between early and late tracheostomy in patients with cervical spinal cord injury. Results A total of eight articles of cohort study including 466 patients were included , with 241 patients in the early tracheostomy group and 225 patients in the late tracheostomy group. The eight articles were all determined as high quality studies according NOS. The results of Meta analysis showed that there were significant differences between the two groups in terms of the total mechanical ventilation time (MD=-12.28, 95%CI -20.09--4.47, P 0.05) and the incidence of post tracheostomy pneumonia (RR=0.80, 95%CI 0.51-1.26, P>0.05). Conclusion Early tracheostomy can shorten the mechanical ventilation time, ICU stay, incidence of complications, and mortality, but it cannot reduce the incidence of pneumonia. Key words: Tracheotomy; Spinal cord injuries; Prognosis; Meta analysis

Timing exploration of tracheostomy in patients with severe cerebrovascular disorders

Objective To explore the appropriate timing of tracheostomy in patients with severe cerebrovascular disorders requiring mechanical ventilation. Methods A retrospective analysis was conducted regarding patients with severe cerebrovascular disorders undergoing tracheostomy at the Neurosurgical Care Units (NICU) of General Hospital, Tianjin Institute of Neurology, Tianjin Medical University and Tianjin Haihe Hospital from January 2009 to December 2014. Early tracheostomy (ET) was defined as that performed on days 1-4 and late tracheostomy (LT) on days 7-14 post admission to NICU. ET was performed in 80 patients and LT in 73 patients. The primary outcome was length of stay at the NICU and secondary outcomes were diverse aspects of the NICU course. Results The ICU length of stay, total length of hospital stay, duration of sedation, days of mechanical ventilation and duration of antibiotic use for patients undergoing ET were significantly shorter in comparison with those in the LT group (all P<0.01). Patients receiving ET had a significantly lower incidence of pneumonia in comparison with those in the LT group (P<0.01). Between the ET and LT groups, no significant difference was observed with regard to ICU mortality, hospital mortality or average score at discharge according to the modified Rankin scale(all P<0.05). The follow-up time is 6 months. Decannulation occurred earlier (58.2±27.2 vs. 69.0±26.8 d, P=0.03) in the ET group. Conclusions Compared with LT, ET could be advantageous in patients with severe cerebrovascular disorders and relatively long period of mechanic ventilation in terms of shorter length of ICU stay, length of hospital stay, duration of sedation, days of mechanical ventilation and duration of antibiotic use. ET may reduce the incidence of pneumonia but does not seem to be associated with the improvement in mortality or neurologic outcome. Key words: Cerebrovascular disorders; Intensive care units; Tracheotomy; Prognosis

The Need for Early Tracheostomy in Patients with Traumatic Cervical Cord Injury.

BackgroundIn patients who need sustained endotracheal intubation and mechanical ventilation due to respiratory failure after traumatic cervical spinal cord injury, tracheostomy can be performed to reduce the duration of mechanical ventilation and respiratory complications. The purpose of this study was to determine criteria and timing of tracheostomy in patients with severe traumatic cervical spinal cord injury accompanied by motor weakness.MethodsWe reviewed 22 patients who underwent tracheostomy (study group) and 27 patients who did not (control group) from January 2005 to March 2016. We assessed the American Spinal Injury Association (ASIA) impairment scale score and investigated accompanying thoracic injury, paradoxical respiration, postoperative endotracheal intubation and other clinical parameters. The study group was also subdivided into the early tracheostomy group and late tracheostomy group depending on whether the tracheostomy was performed within or later than 7 days after surgery.ResultsTwenty-two patients in the study group had a mean ASIA impairment scale score of 14.1 points, which was lower than the control group's 23.4 points. Paradoxical respiration was observed in 77% of the patients in the study group compared to 18% in the control group. Postoperative intubation was maintained in 68% in the study group; 32% underwent endotracheal intubation due to respiratory failure within 4 days after surgery and had a tracheostomy. In the control group, postoperative intubation was maintained in 22%, and all of them were weaned off intubation within 4 days after surgery. The duration of intensive care unit hospitalization was 11.4 days for the early tracheostomy group, which was shorter than the late tracheostomy group's 19.7 days.ConclusionsIn patients with severe traumatic cervical spinal cord injury, tracheostomy may be needed when the motor grade of the ASIA scale is low, above the C4 segment is injured, or paradoxical respiration occurs after injuries. In addition, if endotracheal extubation is not feasible within 4 days after surgery, an early tracheostomy should be considered.

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 30years (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 21days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7days 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 7days of intubation had better results than those defining early tracheostomy as that done within 14 or 21days of intubation. In conclusion, early tracheostomy within 7days of intubation should be done for both adults and pediatric patients with prolonged intubation.

The effect of tracheostomy performed within 72 h after traumatic brain injury

The optimal timing of tracheostomy in patients with traumatic brain injury (TBI) remains unclear. The purpose of this study was to examine the effects of tracheostomy performed within 72 h after admission. In this retrospective cohort study, the authors reviewed the data for a series of 120 consecutive patients who underwent tracheostomy after suffering TBI with an Abbreviated Injury Scale (AIS) score of ≥4. The exclusion criteria were as follows: age <18 years, severe chest injury with an AIS score of ≥4, and a requirement for intubation because of upper airway obstruction. Patients who underwent tracheostomy ≤72 h and >72 h after admission were classified into early group and control groups, respectively. The duration of mechanical ventilation, length of stay (LOS) in intensive care unit (ICU), incidence of pneumonia, adverse event rate, unnecessary tracheostomy and outcomes were compared between the two groups. Of the 120 patients, 29 were excluded from the study, 40 were classified into the early group, and 51 were classified into the control group. The duration of mechanical ventilation and LOS in ICU were significantly less in the early group than in the control group. The 30-day mortality rates were 3% and 8% for the early and control groups, respectively. There was no significant difference in the adverse event rate, incidence of pneumonia, unnecessary tracheostomy rate and the rate of favorable outcome between groups. The results of this study suggest that the performance of tracheostomy within 72 h of admission may decrease the duration of mechanical ventilation and LOS in ICU, with acceptable mortality and morbidity rates.

Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury.

SummaryBackgroundData regarding the impact and timing of tracheostomy in patients with isolated traumatic brain injury (TBI) are ambiguous. Our goal was to evaluate the impact of tracheostomy on hospital mortality in patients with moderate or severe isolated TBI.Materials and MethodsWe performed a retrospective cohort analysis of data prospectively collected at 87 Austrian intensive care units (ICUs). All patients continuously admitted between 1998 and 2010 were evaluated for the study. In total, 4,735 patients were admitted to ICUs with isolated TBI. Of these patients, 2,156 had a moderate or severe TBI (1,603 patients were endotracheally intubated only, 553 patients underwent tracheostomy). Epidemiological data (trauma severity, treatment, and outcome) of the two groups were compared.ResultsPatients with moderate or severe isolated TBI undergoing tracheostomy had a similar Glasgow Coma Scale score, median (interquartile range): 6 (3–8) vs 6 (3–8); p = 0.90, and Simplified Acute Physiology Score II, 45 (37–54) vs 45 (35–56); p = 0.86, compared with intubated patients not undergoing tracheostomy. Furthermore, patients undergoing tracheostomy exhibited higher Abbreviated Injury Scale Head scores and had a longer ICU stay for survivors, 30 (22–42) vs 9 (3–17) days; p < 0.0001). In contrast, risk-adjusted mortality was lower in patients undergoing tracheostomy compared with patients who remained intubated, observed-to-expected mortality ratio (95 % confidence interval): 0.62 (0.53–0.72) vs 1.00 (0.95–1.05) respectively.ConclusionsDespite the greater severity of head injury, patients with isolated TBI who underwent tracheostomy had a lower risk-adjusted mortality than patients who remained intubated. Reasons for this difference in outcome may be multifactorial and require further investigation.