Tracheostomy Group Research Articles

Respiratory illness and respiratory syncytial virus hospitalization in infants with a tracheostomy following prophylaxis with palivizumab

Data on respiratory-related illness and respiratory syncytial virus (RSV) infection in children with a tracheostomy are sparse. We determined respiratory illness hospitalization (RIH) and RSV-related hospitalization (RSVH) hazard ratios in children with a tracheostomy following prophylaxis compared with infants' prophylaxed for standard indications (prematurity ≤ 35weeks' gestational age, bronchopulmonary dysplasia, and significant congenital heart disease) and children with complex medical disorders. Children who received ≥ 1 injection of palivizumab were prospectively enrolled across 32 Canadian sites during the RSV season. Respiratory illness event data were collected monthly. Data were analyzed using t tests, chi-square tests, and Cox proportional hazards adjusted for confounders. A total of 23,597 infants were enrolled; 220 tracheostomy, 19,402 standard indications, 3975 complex medical disorders. Of the 220 tracheostomy infants, 30 had bronchopulmonary dysplasia, 18 were premature, 12 had congenital heart disease, and 160 had other medical complexities. RIH and RSVH incidences (tracheostomy, standard indications, complex medical disorders) were 24.5%, 6.2%, and 9.8% and 2.0%, 1.5%, and 1.8% respectively. RIH hazard was significantly higher in tracheostomy infants compared with standard indications (HR = 1.8, 95% CI 1.1-3.0, p = 0.02) but was similar between the tracheostomy and complex medical disorders groups (HR = 1.3, 95% CI 0.7-2.2, p = 0.37). RSVH hazard was also similar in tracheostomy infants relative to standard indications and complex medical disorders (both p > 0.75). Children with tracheostomies who received palivizumab had an increased RIH hazard compared with the standard indications group. Similar RSVH hazard between tracheostomy, standard indications, and complex medical disorders groups suggests that children with tracheostomies may benefit from palivizumab by reducing RSVH during the RSV season.

Submental intubation versus tracheostomy in maxillofacial fractures.

To compare submental intubation with tracheostomy in patients with maxillofacial fractures who were operated under general anesthesia and nasotracheal intubation was contraindicated. This prospective comparative study was conducted on 32 patients undergoing maxillofacial operations. All patients had a panfacial trauma (including naso-ethmoid orbital fracture combined with mandibular fracture). Patients who had unstable cervical vertebra, laryngeal trauma, urgent tracheostomy, and patients with expected prolonged postoperative ventilation were excluded from the study. Patients were randomly assigned to elective tracheostomy and submental intubation groups. The patients were evaluated according to the time required to do elective tracheostomy or submental intubation, the operation comorbidity and complications, and the postoperative scar. The average time required to do submental intubation was 8.35min versus 30.75min required to do elective tracheostomy with significant difference (p < 0.0001). No complication was reported with submental intubation while in elective tracheostomy group, surgical emphysema was registered in two patients. The submental scar was acceptable in all patients while the tracheostomy scar needs scar revision in four cases (p = 0.0325). Submental endotracheal intubation appeared to be a simple, safe, and significantly faster reliable alternative to tracheostomy during surgical reconstruction of selected cases of maxillofacial fractures without indication for prolonged postoperative ventilation support with significantly lower morbidity.

Analysis of the risk factors for tracheostomy and decannulation after traumatic cervical spinal cord injury in an aging population.

Retrospective study. To investigate the risk factors associated with tracheostomy after traumatic cervical spinal cord injury (CSCI) and to identify factors associated with decannulation in an aging population. Advanced critical care and emergency center in Yokohama, Japan. Sixty-five patients over 60 years with traumatic CSCI treated between January 2010 and June 2017 were enrolled. The parameters analyzed were age, sex, American Spinal Injury Association impairment scale score (AIS) at admission and one year after injury, neurological level of injury (NLI), injury mechanism, Charlson's comorbidity index (CCI), smoking history, radiological findings, intubation at arrival, treatment choice, length of intensive care unit (ICU) stay, tracheostomy rate, improvement of AIS, decannulation rate, and mortality after one year. The study included 48 men (74%; mean age 72.8 ± 8.3 years). Twenty-two (34%), 10 (15%), 24 (37%), and 9 (14%) patients were classified as AIS A, B, C, and D, respectively. The tracheostomy group showed significantly more severe degree of paralysis, more patients with major fractures or dislocations, more operative treatment, longer ICU stay, poorer improvement in AIS score after one year and higher rate of intubation at arrival. AIS A at injury was the most significant risk factor for tracheostomy. The non-decannulation group had a significantly higher mortality. The risk factor for failure of decannulation was CCI. Risk factors for tracheostomy after traumatic CSCI were AIS A, operative treatment, major fracture/dislocation, and intubation at arrival. The only factor for failure of decannulation was CCI.

Compare the effect of noninvasive ventilation and tracheotomy in critically ill mechanically ventilated neurosurgical patients: a retrospective observe cohort study

ObjectivePatients with severe brain injury is usual at high risk of extubation failure, despite of those with no/minor primary respiratory problem, majority of them still needs long term respiratory support and has severe pulmonary complications. This retrospective study aimed to compare the effect of noninvasive ventilation (NIV) and tracheotomy on the prognosis in critically ill mechanically ventilated neurosurgical patients.MethodsThis is a single center, retrospective observe cohort study. Postoperative patients with brain injury consecutively admitted to ICU from November 1st, 2015 through February 28th, 2017, who had received invasive mechanical ventilation more than 48 h were screened, those who received NIV or tracheotomy procedure, meanwhile with Glasgow Coma Scale (GCS) score between 8 and 13 points before using NIV or undergoing tracheotomy, were retrospectively included in this study. The demographic data and clinical main outcomes such as ICU and hospital mortality, time of mechanical ventilation, length of ICU and hospital were collected. The primary outcome was the incidence of postoperative pulmonary infection between two groups.Results77 patients were included in this study. 33 patients received NIV, and 44 patients received tracheotomy through the ICU duration. The incidence of postoperative pulmonary infection in NIV group was significantly lower than that in tracheotomy group (54.5% VS 84.1%, P < 0.05), Application of NIV was associated with shorter duration of invasive mechanical ventilation ([median 123.0 h VS 195.0 h, P < 0.05). Moreover, GCS score at ICU discharge, as well as the difference of GCS score between at admission to ICU and ICU discharge were also better than the tracheotomy group (P < 0.001).ConclusionCompared with tracheotomy, use of NIV after extubation in critically ill mechanically ventilated neurosurgical patients may be associated with lower incidence of postoperative pulmonary infection, shorter duration of invasive mechanical ventilation and better improvement in brain function. Further studies need to verify the effect of NIV in this kind of patients.

Comparison of Percutaneous Dilatational Tracheostomy with Open Tracheostomy in Intensive Care Unit

Introduction: Tracheostomy is one of the frequent surgical procedure carried out in intensive care unit. Percutaneous tracheostomy is becoming increasingly popular compared to conventional open surgical tracheostomy in ICU.&#x0D; Methods: A prospective randomized trial with twenty patients in each group was conducted to compare the outcomes of percutaneous and surgical tracheostomy. Percutaneous tracheostomy was performed using Ciaglia Blue Rhino technique and surgical tracheostomy was performed using established technique. The outcomes were compared in relation to randomization to tracheostomy, completion of procedure, intra operative and post-operative complications, hospital length of stay and cost.&#x0D; Results: There were no major complications in either group. Most variables studied were not statistically significant. The two groups did not differ in terms of basic demographics or APACHE II score. The only variables to reach statistical significance were time duration from tracheostomy randomization to start of procedure and time taken for completion of procedure. It was mean 31.85±15.35 hours in Percutaneous Tracheostomy group and in Surgical Tracheostomy group it was mean 49.10±23.61 hours respectively (p&lt;0.009). Time taken to perform percutaneous tracheostomy was mean 15.50±3.22 minutes and for surgical tracheostomy it was mean 20.30±3.38 minutes. (p&lt;0.001).&#x0D; Conclusion: Percutaneous dilatational tracheostomy is simple, faster to perform and can be done at bedside to avoid considerable delay in the performance of open tracheostomy where there is high demand for elective and emergency procedures in operating room.

Comparison of Percutaneous Dilatational Tracheostomy with Open Tracheostomy in Intensive Care Unit

Introduction: Tracheostomy is one of the frequent surgical procedure carried out in intensive care unit. Percutaneous tracheostomy is becoming increasingly popular compared to conventional open surgical tracheostomy in ICU. Methods: A prospective randomized trial with twenty patients in each group was conducted to compare the outcomes of percutaneous and surgical tracheostomy. Percutaneous tracheostomy was performed using Ciaglia Blue Rhino technique and surgical tracheostomy was performed using established technique. The outcomes were compared in relation to randomization to tracheostomy, completion of procedure, intra operative and post-operative complications, hospital length of stay and cost. Results: There were no major complications in either group. Most variables studied were not statistically significant. The two groups did not differ in terms of basic demographics or APACHE II score. The only variables to reach statistical significance were time duration from tracheostomy randomization to start of procedure and time taken for completion of procedure. It was mean 31.85±15.35 hours in Percutaneous Tracheostomy group and in Surgical Tracheostomy group it was mean 49.10±23.61 hours respectively (p&lt;0.009). Time taken to perform percutaneous tracheostomy was mean 15.50±3.22 minutes and for surgical tracheostomy it was mean 20.30±3.38 minutes. (p&lt;0.001). Conclusion: Percutaneous dilatational tracheostomy is simple, faster to perform and can be done at bedside to avoid considerable delay in the performance of open tracheostomy where there is high demand for elective and emergency procedures in operating room.

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

Tracheostomy and Pediatric Heart Transplantation: The Loma Linda University Experience

Purpose Tracheostomy is often considered a contraindication to pediatric heart transplant (PHTX), however there is a paucity of information about clinical outcomes in this population. We sought to describe clinical outcomes for tracheostomy patients after PHTX at Loma Linda University (LLU). Methods Retrospective chart review of all PHTX recipients from 1985-2017 at LLU with a tracheostomy placed peri-PHTX. Cases were compared to propensity-matched controls (3:1). Baseline demographics, clinical co-variates, and post-PHTX outcomes [survival; freedom from infection, rejection, cardiac allograft vasculopathy (CAV), and malignancy] were assessed between the groups using the Kaplan-Meier method and were compared with the log-rank test (LRT) and Cox Proportional Hazards (CPH) model. Results Twenty (3.8%) PHTX tracheostomy patients and 504 PHTX patients without tracheostomies were identified, from which 60 matched pairs (3:1) were chosen. Seven (35%) had tracheostomy placement prior to PHTX, 8 (40%) were placed after PHTX prior to discharge, and 5 (25%) were placed after PHTX hospitalization discharge. Twelve (60%) were infants and 13 (65%) had congenital heart disease. After matching, there was lower freedom from infection (HR 2.10, 95% CI 1.12-3.95, CPH p=0.02, LRT p=0.0003, Figure 1a) in the tracheostomy group, however no difference in graft survival (CPH p=0.42, LRT p=0.07, Figure 1b) or death from infection (Chi-square p=0.18) was seen. No differences in freedom from rejection, CAV, nor malignancy (all p>0.05) were seen. Conclusion Tracheostomy in PHTX recipients is independently associated with increased risk of infection, though survival and freedom from other common co-morbidities is similar to matched peers.

Outcome of tracheostomy in critically ill patients receiving mechanical ventilation

Introduction: Acute respiratory failure requiring prolonged intubation is now the most common indication for tracheostomy. Aim: The aim of this study was to evaluate outcomes of tracheostomy, total days on ventilator and hospital stay, and ease of decannulation in intensive care unit (ICU) patients with regard to its timings (early versus late) and to compare the comorbidities and mortality in patients of both groups. Materials and Methods: The study was conducted on 45 critically ill patients who underwent endotracheal intubation followed by a tracheostomy. Results: In the early tracheostomy group ( 7 days). Early tracheostomy seems to have no benefit with respect to mean number of days on ventilator. Conclusion: Early tracheostomy has a significant positive impact on critically ill ICU patients.

Early Versus Late Tracheostomy After Decompressive Craniectomy.

ObjectiveThe goal of this study was to determine the efficacy of early tracheostomy (i.e., ≤ 10 days of intubation) compared with a late tracheostomy (> 10 days of intubation) with regards to timing, frequency of ventilator-associated pneumonia (VAP), mortality rate, and hospital stay in patients who received decompressive craniectomy.Study designWe conducted a retrospective study of data from 168 patients who underwent decompression in the department of critical care medicine at Shifa International Hospital, Islamabad, Pakistan, from January 2017 to December 2017.Materials and methodsThe study included men and women over the age of 18 years who had undergone tracheostomy following decompressive craniectomy in the intensive care unit as a result of stroke, traumatic brain injury, or acute severe injury. Data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Corp., Armonk, NY, US). We also applied the Chi-square test, and p ≤ 0.05 was considered significant.ResultsOf 168 patient records reviewed, tracheostomy was performed in 48 patients (21 men, 27 women). In the 48 tracheostomy patients, 15 (31%) were early tracheostomies and 33 (69%) were late tracheostomies. The mean age of patients was 44 ± 11 years. Twenty-eight patients (58.3%) were in the younger age group (age 18 to 45 years) and 20 patients (41.7%) were in the older age group (age > 45 years). Patients who received an early tracheostomy spent significantly less time on a ventilator (≤ 12 days) than those patients receiving a late tracheostomy (> 12 days, p = 0.004). The early tracheostomy group also had a lower incidence rate of VAP than patients with a late tracheostomy (𝑥2 = 7.855, p = 0.005). Patients who received an early tracheostomy had lower mortality rates than those who received late tracheostomies (𝑥2 = 6.158, p = 0.013). Finally, the length of hospital stay was ≤ 15 days for patients who received early tracheostomies; most patients who received a late tracheostomy had a hospital stay of > 15 days (𝑥2 =11.965, p = 0.001).ConclusionsPerforming a tracheostomy within 10 days of intubation following decompressive craniectomy significantly reduced ventilator time, mortality, the incidence of VAP, and length of hospital stay. Given the potential benefits of early tracheostomy in critical care patients following decompressive craniectomy, physicians should consider early tracheostomy in appropriate cases.

Percutaneous tracheostomy, making it easier

ObjectiveOpen and percutaneous tracheotomy (PT) lead to many perioperative complications. To minimize the complication and to save time and cost, certain assistive tools can be used like fiberoptic bronchoscope, ultrasound guidance and others.AimThe aim was to compare the three procedures, blind PT, fiberoptic bronchoscopy-guided PT and open tracheostomy, regarding ease of the technique, infection rate, bleeding, and complications of the procedure.DesignA retrospective comparative trial was conducted.SettingICU at Dar El Shefa Hospital and respiratory ICU, Ain Shams University Hospital, were the locations for study conduction. Patients and methods All patients required prolonged mechanical ventilation during period between August 2012 and August 2014.They were assigned into three groups: group I underwent open tracheostomy and included 16 patients, group II underwent blind PT and included 15 patients, and group III underwent fiberoptic-guided PT and included 12 patients.ResultsA total of 43 patients underwent tracheostomy during the study period. There was a statistically significant difference between the studied groups regarding neck circumference and intubation period before tracheostomy. Regarding hemodynamics, there is no statistically significant difference regarding mean heart rate, mean arterial pressure and FiO2, pH, PaO2, PCaO2, PaO2/FiO2 and oxygen saturation SPO2 before and after each procedure. Regarding complications after procedure, it shows that blind group had higher percentage of patients with no complications (86.7%) followed by fiberoptic group (75%) and open tracheostomy group (50%). It was noticed that the lowest mean of duration of the procedure was found in the blind group (15.7±5.3), followed by fiberoptic group (17.8±3.2) and lastly the open tracheostomy group (25.7±6.3).ConclusionThis study showed that PT had fewer complications than open tracheostomy, saved operating room resources as well as was more cost effective.

TRACHEOSTOMY AND ADMISSION DIAGNOSIS AS PREDICTORS FOR AN EXTENDED LENGTH OF STAY (ELOS)

SESSION TITLE: Practice Management and Administration SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Identifying factors which contribute to eLOS, defined as > 100 hospitalized days. METHODS: A retrospective chart review was conducted among all patients who had eLOS were hospitalized at a tertiary care center. Data on 133 patients was collected from January 2011 to August 2016. 75 (56%) were male and 58 (44%) were female. Mean LOS was 169 days (ranging from 100 to 611) and mean age was 55 years (18 to 90). Primary admission diagnosis, discharge location and survival data were collected. T-tests, regression analysis and p-values were calculated. eLOS for early tracheostomy (7 days or less) versus delayed tracheostomy (more than 7 days) were compared. RESULTS: 75 (56%) subjects had tracheostomies and 58 (44%) did not. Neurologic causes were the most common admitting diagnosis (36%), followed by pneumonia (31%), sepsis due to other causes (13%), non-neurologic trauma patients (12%) and all other reasons (8%). There was no clinically significant correlation of admitting diagnosis and eLOS when comparing all subjects collectively. Of the 133 patients, there were 17 (13%) deaths. 43 (32%) were discharged either home or to a long term facility, 58 (44%) to rehab or a SNF and 15 (11%) to hospice. In the tracheostomy group, 47 (63%) subjects presented with tracheostomies on admission, while 28 (37%) had new tracheostomies during admission. Early tracheostomy was associated with a decreased eLOS in patients who were admitted for pneumonia, (129 vs 175 days (p0.027), however this was not observed in patients with any other admitting diagnosis. Furthermore, no clinically significant differences were correlated with age (p0.18) or gender (p0.26). CONCLUSIONS: Our study showed that patients with early tracheostomies who were admitted for pneumonia had a significantly shorter eLOS, when compared to any other admitting diagnosis. This did not make a difference in eLOS in any other diagnosis. CLINICAL IMPLICATIONS: Investigating other preventable causes of prolonged hospitalization in patients may impact eLOS. DISCLOSURES: No relevant relationships by EMAN ALBADDAWI, source=Web Response No relevant relationships by Ali Ammar, source=Web Response No relevant relationships by Sunil Bali, source=Web Response No relevant relationships by Zahia Esber, source=Web Response no disclosure on file for Ahmed Khan; no disclosure on file for Wael Nasser

Safety of early tracheostomy in trauma patients after anterior cervical fusion.

Cervical spine injuries (CSIs) can have major effects on the respiratory system and carry a high incidence of pulmonary complications. Respiratory failure can be due to spinal cord injuries, concomitant facial fractures or chest injury, airway obstruction, or cognitive impairments. Early tracheostomy (ET) is often indicated in patients with CSI. However, in patients with anterior cervical fusion (ACF), concerns about cross-contamination often delay tracheostomy placement. This study aimed to demonstrate the safety of ET within 4 days of ACF. Retrospective chart review was performed for all trauma patients admitted to our institution between 2001 and 2015 with diagnosis of CSI who required both ACF and tracheostomy, with or without posterior cervical fusion, during the same hospitalization. Thirty-nine study patients with ET (within 4 days of ACF) were compared with 59 control patients with late tracheostomy (5-21 days after ACF). Univariate and logistic regression analyses were performed to compare risk of wound infection, length of intensive care unit and hospital stay, and mortality between both groups during initial hospitalization. There was no difference in age, sex, preexisting pulmonary or cardiac conditions, Glasgow Coma Scale score, Injury Severity Score, Chest Abbreviated Injury Scale score, American Spinal Injury Association score, cervical spinal cord injury levels, and tracheostomy technique between both groups. There was no statistically significant difference in surgical site infection between both groups. There were no cases of cervical fusion wound infection in the ET group (0%), but there were five cases (8.47%) in the late tracheostomy group (p = 0.15). Four involved the posterior cervical fusion wound, and one involved the ACF wound. There was no statistically significant difference in intensive care unit stay (p = 0.09), hospital stay (p = 0.09), or mortality (p = 0.06) between groups. Early tracheostomy within 4 days of ACF is safe without increased risk of infection compared with late tracheostomy. Evidence, level III.

Predictive Values of Magnetic Resonance Imaging Features for Tracheostomy in Traumatic Cervical Spinal Cord Injury.

ObjectiveTo evaluate the magnetic resonance (MR) imaging features that have a statistically significant association with the need for a tracheostomy in patients with cervical spinal cord injury (SCI) during the acute stage of injury. MethodsThis study retrospectively reviewed the clinical data of 130 patients with cervical SCI. We analyzed the factors believed to increase the risk of requiring a tracheostomy, including the severity of SCI, the level of injury as determined by radiological assessment, three quantitative MR imaging parameters, and eleven qualitative MR imaging parameters. ResultsSignificant differences between the non-tracheostomy and tracheostomy groups were determined by the following five factors on multivariate analysis : complete SCI (p=0.007), the radiological level of C5 and above (p=0.038), maximum canal compromise (MCC) (p=0.010), lesion length (p=0.022), and osteophyte formation (p=0.015). For the MCC, the cut-off value was 46%, and the risk of requiring a tracheostomy was three times higher at an interval between 50–60% and ten times higher between 60–70%. For lesion length, the cut-off value was 20 mm, and the risk of requiring a tracheostomy was two times higher at an interval between 20–30 mm and fourteen times higher between 40–50 mm. ConclusionThe American Spinal Injury Association grade A, a radiological injury level of C5 and above, an MCC ≥50%, a lesion length ≥20 mm, and osteophyte formation at the level of injury were considered to be predictive values for requiring tracheostomy intervention in patients with cervical SCI.

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 of Tracheostomy in Intensive Care Unit Patients.

Introduction The ideal timing of tracheostomy in intensive care units (ICUs) for critically ill patients undergoing prolonged mechanical ventilation (MV) is still a controversial issue. Objectives To determine the proper timing of tracheostomy and its impact on various clinical outcomes of adult patients in ICUs undergoing prolonged MV. Methods The present study consisted of a sample of 67 ICU adult patients who were submitted to open surgical tracheostomy and divided into two groups: 30 patients in the early tracheostomy (ET) group (within 1–10 days post intubation), and 37 patients in the late tracheostomy (LT) group (within 11–21 days post intubation). The correlation between the timing of tracheostomy of each group and various associated ICU clinical parameters were analyzed. Results The sample consisted of 61.19% male and 38.81% female patients, with a mean age of 47.263 ± 7.581 years. The mean MV duration in days was 7.91 ± 4.937 standard deviation (SD) in the ET group, and 15.32 ± 7.472 SD in the LT group ( p = 0.001), with a mean sedation time of 6.13 ± 4.647 SD in the ET group, and of 11.98 ± 6.596 SD in the LT group ( p = 0.001). The duration of the weaning process duration had a mean of 2.75 ± 2.586 SD days in the ET group, and of 5.39 ± 5.817 SD days in the LT group ( p = 0.025), with a weaning failure rate of 28.57% in the ET group and 71.42% in the LT group ( p = 0.01). The Mean ICU stay was 26.18 ± 4.732 SD in the ET group, and 11.98 ± 6.596 SD in the LT group ( p = 0.879), and the incidence of ventilator-associated pneumonia (VAP) of 23.33% in the ET group and of 27.02% in the LT group ( p = 0.15). Conclusion Early tracheostomy had a notable benefit in shortening the duration of the MV, lessening the sedation time and minimizing the risks of weaning failure, but it had no significant impact on both the overall duration of ICU stay and VAP incidence.

Tracheostomy and mortality in patients with severe burns: A nationwide observational study

BackgroundTracheostomy is often performed in patients with severe burns who are undergoing prolonged mechanical ventilation. However, the appropriate timing of tracheostomy and its effect on mortality remain unknown. The aim of this study was to determine whether tracheostomy can reduce mortality in patients with severe burns. MethodsUsing the Japanese Diagnosis Procedure Combination database from April 2010 to March 2014, we extracted data on adult patients with severe burns (burn index score of ≥15) who started mechanical ventilation within 3days of admission. We estimated the hazard ratio for 28-day in-hospital mortality associated with tracheotomy performed from day 5 to 28. We adjusted for baseline and time-dependent confounders using inverse probability of treatment weighting methods and fitted a marginal structural Cox proportional hazard model. ResultsWe identified 680 eligible patients (94 in the tracheostomy group, 2289 person-days; 586 in the non-tracheostomy group, 11,197 person-days). Patients who underwent a tracheostomy had worse prognostic factors for mortality. After adjustment for these factors, the hazard ratio for 28-day mortality associated with tracheostomy compared with non-tracheostomy was 0.73 (95% confidence interval, 0.39–1.34). ConclusionsThere was no significant association between 28-day in-hospital mortality and early tracheostomy in adult patients with severe burns.

Effect of early tracheostomy on clinical outcomes in critically ill lung transplant recipients.

The purpose of this study was to evaluate the effect of early tracheostomy in patients following lung transplantation and to determine its optimal timing and influence on clinical outcomes. We retrospectively reviewed records of 96 adult patients who underwent lung transplantation at our institution between August 2008 and January 2016. Time-to-tracheostomy was defined based on timing of the procedure: "early" if less than 3 days or "late" if 3 or more days after lung transplantation. Forty-nine patients (51%) underwent tracheostomy 3.2 ± 1.8days after lung transplantation. Among these patients, 21 patients (42.9%) underwent early tracheostomy and 28 patients (57.1%) underwent late tracheostomy. Multivariable logistic regression analysis indicated that preoperative performance status was a significant predictor for tracheostomy (p = 0.006, odds ratio 2.72). Patients in the early tracheostomy group began walking (p = 0.003) and oral feeding (p = 0.0006) earlier and had a shorter duration of mechanical ventilation (p = 0.04) and shorter length of intensive care unit (p = 0.01) and hospital stay (p = 0.04) than patients in the late tracheostomy group. No significant differences in postoperative walking (p = 0.06), oral feeding (p = 0.17), or length of hospital stay (p = 0.37) were observed between patients who underwent early tracheostomy and those who did not undergo tracheostomy. Early tracheostomy following lung transplantation decreased both intensive care and hospital stay, due to improved postoperative recovery, even in patients with poor preoperative conditions. Furthermore, length of hospital stay in patients with early tracheostomy was similar to that of patients without tracheostomy after lung transplantation.

30-Day Morbidity and Mortality Rates in Elderly Subjects Following Surgical Tracheostomy.

Tracheostomy is considered to be effective in the respiratory support of mechanically ventilated patients. We studied a single-center experience of surgical tracheostomy in mechanically ventilated patients to describe the demographics, risk factors, and outcomes of early (≤ 14 d after ventilation) versus late surgical tracheostomy (≥ 15 d after ventilation). In this retrospective study, we collected demographic data, medical history, timing of surgical tracheostomy in relation to ventilation day, blood test results, preoperative surgical assessment (subjective impression of neck length, difficulty in neck extension, presence of a goiter), intraoperative complications (bleeding > 100 mL, difficulties in cannula insertion), and postoperative morbidities (bleeding, wound infection, fever, inadvertent de-cannulation, and 30-d postoperative mortality rate) of subjects who underwent surgical tracheostomy in a secondary medical center during 2010-2015. Morbidity and mortality rates were compared between the early versus late surgical tracheostomy groups. Three hundred eleven subjects underwent surgical tracheostomy and met the eligibility criteria. Most of subjects were elderly, with a mean age of 82 y (range 62.5-88 y). There were 22 (7%) subjects in the early surgical tracheostomy group and 289 (93%) subjects in the late surgical tracheostomy group. Late surgical tracheostomy subjects were significantly older compared to early surgical tracheostomy subjects (median age 82 y vs 74 y, P = .001). With regard to intraoperative complications, no appreciable differences were observed between the groups. Timing of surgical tracheostomy was not associated with greater morbidity rates, nor was timing associated with higher postoperative complication rates. Those who survived 30 d were younger than those who died (median 81 vs 83 years, hazard ratio = 1.03). In elderly subjects, late surgical tracheostomy was not associated with increased 30-d morbidity or mortality rates. Comorbid conditions and subject age had a greater association with 30-d mortality rate than surgical tracheostomy timing.

Nasotracheal Intubation: The Preferred Airway in Oral Cavity Microvascular Reconstructive Surgery?

We aimed to describe the safety and effectiveness of nasotracheal intubation (NTI) in a cohort of patients undergoing reconstruction of oral cavity defects with free tissue transfer (FTT). We implemented a retrospective cohort study and enrolled a sample composed of consecutive patients undergoing FTT reconstruction of oral cavity, maxillary, or mandibular defects between 2013 and 2017. These patients were all subject to a newly developed enhanced recovery-after-surgery protocol. The primary outcome measurement was hospital length of stay (LOS). The secondary outcome variables were the duration of mechanical ventilation, intensive care unit (ICU) LOS, need for gastrostomy, and airway-related complications directly associated with either NTI or tracheostomy. Descriptive statistics and a multivariate logistic regression analysis were completed. The sample was composed of 141 patients who had undergone oral cavity FTT for both benign and malignant diseases (NTI, n=111; tracheostomy, n=30). Patients managed with NTI had a statistically significantly shorter hospital LOS (8days vs 15.5days, P<.0001) and ICU LOS (1day vs 2days, P=.0006), as well as a decreased requirement for gastrostomy (17.1% vs 76.7%, P<.0001). Airway-related complications were rare in both the tracheostomy (13.3%) and NTI (3.6%) groups. Multivariate analysis showed that patients undergoing tracheostomy were 3.14 (P=.004) times more likely to have a prolonged hospitalization and 10.4 (P<.0001) times more likely to require a gastrostomy. A sensitivity analysis of only patients with malignant diagnoses had similar statistically significant results. The delayed tracheostomy rate in the NTI group was 3.6%. To date, this is the largest study to evaluate the use of NTI in patients undergoing oral cavity reconstruction with FTT. Our results suggest that in the appropriate institutional setting, most patients can be safely managed with NTI. This approach results in a decreased hospital LOS and ICU LOS and an earlier resumption of oral intake with less need for gastrostomy.