Tracheostomy Group Research Articles

Economic Advantages to a Distraction Decision Tree Model for Management of Neonatal Upper Airway Obstruction

Neonatal upper airway obstruction demands urgent attention. Tracheostomy can prove to be lifesaving but has morbidities. Recently, the authors found reduced morbidity/mortality when using a distraction decision tree model compared with conventional "case-by-case" management. In this current study, the authors assess the long-term costs of (1) a decision tree model versus conventional treatment and (2) tracheostomy versus distraction osteogenesis. An inpatient cost-matrix analysis study on neonates with upper airway obstruction and micrognathia was performed (n=149). In Part I, conventionally treated neonates managed on a case-by-case basis received home monitoring or a tracheostomy. Decision tree model-managed newborns had specialist consultations and diagnostic testing to determine whether home monitoring, tracheostomy, or distraction osteogenesis would be implemented. In Part II, tracheostomy treatment was compared directly to distraction osteogenesis. In Part I (conventional versus decision tree model), taking into account the costs of the distraction, tracheostomy, hospital stay, diagnostic studies, physician fees, and emergency department visits, the total per patient treatment cost was 1.5 greater in the conventional treatment group ($332,673) compared with the decision tree model ($225,998) (p<0.05). In Part II (tracheostomy versus distraction osteogenesis), the total per-patient treatment cost in the tracheostomy group was two times greater than in the distraction group ($382,246 versus $193,128) (p<0.05). In treating newborns with micrognathia and upper airway obstruction, a decision tree model with mandibular distraction decreases long-term health care costs compared with conventional treatment. Furthermore, when comparing distraction to tracheostomy, similar decreases in long-term health care costs occurred.

Early vs Late Tracheotomy for Prevention of Pneumonia in Mechanically Ventilated Adult ICU Patients

Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources. To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days. Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater. Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy). The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive. Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15). Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia. clinicaltrials.gov Identifier: NCT00262431.

Percutaneous versus Open Tracheostomy in the Pediatric Trauma Population

The purpose of this study was to determine the safety and efficacy of percutaneous versus open tracheostomy in the pediatric trauma population. A retrospective chart review was conducted of all tracheostomies performed on trauma patients younger than 18 years for an 8-year period. There was no difference in the incidence of brain, chest, or facial injury between the open and percutaneous tracheostomy groups. However, the open group had a significantly lower age (14.2 vs. 15.5 years; P < 0.01) and higher injury severity score (26 vs. 21; P = 0.015). Mean time from injury to tracheostomy was 9.1 days (range, 0 to 16 days) and was not different between the two methods. The majority of open tracheostomies were performed in the operating room and, of percutaneous tracheostomies, at the bedside. Concomitant feeding tube placement did not affect complication rates. There was not a significant difference between complication rates between the two methods of tracheostomy (percutaneous one of 29; open three of 20). Percutaneous tracheostomy can be safely performed in the injured older child.

Early Tracheostomy in Intensive Care Unit: A Retrospective Study of 506 Cases of Video-Guided Ciaglia Blue Rhino Tracheostomies

Percutaneous dilatational tracheostomy (PDT) is a common procedure in critically ill patients, but the correct timing is still controversial. This study was designed to establish whether an early timing in video-guided Ciaglia Blue Rhino PDT affects the duration of mechanical ventilation (MV) and the length of stay (LOS) in intensive care unit (ICU). Secondary clinical outcomes were the overall hospitalization duration and the mortality rate. A retrospective, single-center study of 2,210 patients admitted to the ICU of the Emergency Department of the Careggi Teaching Hospital (Florence, Italy) between 2002 and 2007. Among the 506 patients who underwent PDT, 256 and 250 patients were retrospectively assigned to the early tracheostomy (ET) or late tracheostomy (LT) group according to whether the procedure was performed before (ET) or after (LT) 3 days of MV (median time of procedure execution). The two groups of patients showed comparable demographic and clinical characteristics. The video-guided PDT procedures were performed without major complications in all cases. The average timing of tracheostomy in the ET group was 1.9 +/- 0.9 days, whereas in LT group resulted 6.8 +/- 3.8 days (mean +/- SD). Total hospital LOS and mortality rate were not different between the two groups. However, the duration of MV days and of ICU LOS group were significantly shorter in the ET group (13.3 +/- 9.6 and 16.9 +/- 13.0 days, respectively; p = 0.0001) than in the LT group (16.7 +/- 8.3 days and 20.8 +/- 9.2 days, respectively; p < 0.0001). Stratified analysis by the three major ICU admission diagnosis confirmed that both traumatized and nontraumatized (medical and postsurgical) ET patients had a shorter MV duration and ICU LOS as compared with LT patients. Video-guided Ciaglia Blue Rhino PDT is safe and easy to perform in ICU. No difference in overall hospital LOS, incidence of pneumonia, and mortality rate between the ET and LT groups was found. However, in both traumatized and nontraumatized patients, shortened duration of ICU LOS and MV in the ET group (<or=3 days) indicates this procedure as a useful approach for patients and healthcare system.

Assessment of Constipation in Children With Tracheostomy

To determine the prevalence of constipation among children with tracheostomy tubes compared with children without tracheostomy tubes. We theorize that patients with tracheostomy may be unable to achieve adequate subglottic pressure for the Valsalva maneuver, which may contribute to constipation. Prospective cohort study. Tertiary care children's hospital. Consecutive series of 36 children with tracheostomy and 72 general pediatric otolaryngology patients without tracheostomy. A pediatric constipation questionnaire (from previously published references) was given to parents of the study participants. Data were collected regarding patient medications, neurological status, and use of positive pressure airway assistance, speaking valves, and feeding tubes. Data were evaluated using chi(2) and t tests. Logistic regression analysis was used to search for independent variables impacting presence of constipation. The mean ages for the tracheostomy and control groups were 6.8 and 4.7 years, respectively (P = .07). A history of constipation was elicited in 60% of children with tracheostomy compared with only 16.7% of controls (P < .001). More patients with tracheostomy tubes (80.0%) than controls (20.8%) were taking medication to treat constipation (P < .001). Constipation was also significantly associated with older age (P = .02), use of medications with constipation as a known adverse effect (P = .02), and the presence of neurodevelopmental impairment (P < .001). Constipation was still independently associated with the presence of a tracheostomy tube when correcting for age and the use of constipation-causing medications. When controlling for neurodevelopmental impairment, the presence of a tracheostomy tube was not proven to be an independent predictor of constipation. Children with tracheostomy tubes are more likely to have a history of constipation, although a causal relationship between tracheostomy and constipation could not be determined due to the potentially confounding variable of neurodevelopmental delay.

急性喉頭蓋炎の臨床統計：気管切開に関連する因子

Acute epiglottitis causes sudden upper airway obstruction and may trigger death within hours. Intubation is difficult, often necessitating tracheostomy, due to epiglottal swelling. Although appropriate judgment is required for choosing tracheostomy or conservative management with steroids and antibiotics, no guideline yet exists for this disease. We retrospectively examined 113 subjects hospitalized with acute epiglottitis, dividing then into two groups—tracheostomy and nontracheostomy. Comparing them for age, gender, common symptoms, clinical aspects, past history, and hospitalization duration, we clarified factors that may determine which is better—tracheostomy or conservative treatment. Mean age of the subjects was 49 years (range, 11 to 88 years, mean: 49 years) and the male-to-female ratio was 2.2 to 1.0. The commonest symptoms were sore throat (97%), odynophagia (49%), and fever (44%). Tracheostomy was done 11 cases (10%), but most cases treated conservatively (90%). A 44-year-old man died of cardiopulumonary arrest, despite tracheostomy. All subjects recovered completely. Mean duration from symptom onset to the first medical examination was 0.6 days in the tracheostomy group and 1.9 days in the nontracheostomy group, statistically significant (p<0.01). Other independent factors were the chief complaint of respiratory distress and stridor, 71% and 16% in tracheostomy and 55% and 2% in nontracheostomy. A statistically significant difference was also seen in Katori's grading by endoscopic observation between groups (p<0.01). These four factors may thus be clinically useful in evaluating the necessity of airway intervention.

Análisis de la traqueotomía precoz y su impacto sobre la incidencia de neumonía, consumo de recursos y mortalidad en pacientes neurocríticos

We analyze the most suitable time to perform tracheostomy in neurocritically ill patients. We compare morbimortality and use of resources between those patients in which tracheostomy was done early (<or= 9 days) and those in which it was perform later (>9 days), in a selected group of patients. We made an observational prospective study involving a group of patients diagnosed as traumatic brain injury (TBI) or stroke, whose tracheostomy was performed during their stay at the Intensive Care Unit. We compared two groups: a) early tracheostomy (during first 9 days of ICU stay); b) late tracheostomy (made on 10th day or later). As variables, we studied: demographic data, severity of illness at admission, admittance department, diagnosis, length of intubation, length of mechanical ventilation (LMV), sedation and antibiotic treatment needs, ventilator-associated pneumonia (VAP) events, ICU length of stay and mortality. We calculated relative risk of suffering from pneumonia and made a multivariate logistic regression to establish which factors were associated with an increased risk of developing pneumonia. Statistical signification p <or= 0.05. We analyzed 118 patients, 60% with TBI. Mean length of intubation before tracheostomy was 12 days and mean LMV was 20 days. 94 VAP events were diagnosed in 81 patients (68.6%). Early tracheostomy group showed lower length of mechanical ventilation and ICU stay, lower length of sedation and antibiotic treatment, and less pneumonia events (p<0,001). The precocity of tracheostomy didn't have any influence either on hospital length of stay (p=0.844), ICU mortality (p=0.924) or in-hospital mortality (p=0.754). At the TBI group mean age was lower (p < 0.001), tracheostomy was made later (p=0.026), and patients needed a longer sedation (p=0.001) and a longer antibiotic treatment (p=0.002). Length of intubation (p=0.034, OR 1.177) and ICU length of stay (p=0.003, OR 1.100) were factors independently associated with development of pneumonia. Relative risk of suffering from pneumonia when tracheostomy was made after 9 days of ICU stay was 1.55 (IC 95%: 1.10-2.16). The number needed to treat (NNT) for early tracheostomy avoiding one pneumonia event was 3.13. VAP was not associated with a higher ICU (p=0.558) or in-hospital mortality (p=0.370). Early tracheostomy (<or= 9 days) provides significant advantages in neurocritically ill patients: it shortens length of mechanical ventilation and ICU stay and decreases antibiotic and sedatives requirements. Although later tracheostomy is not directly related with mortality, it increases considerably the risk of suffering from pneumonia, particularly in patients with TBI. These clinical circumstances should be evaluated individually in each patient, so the best time to perform tracheostomy in neurocritically ill patients could be established.

Does submental intubation technique show an edge over percutaneous tracheostomy? A prospective study in complex oromaxillofacial surgery

Background: Complex oromaxillofacial fractures pose unique challenge for securing the airway. Techniques other than conventional tracheostomy and orotracheal intubation need to be explored to overcome shortcomings associated with conventional methods. This study compares median approach of submental intubation with percutaneous tracheostomy with respect to procedure time, time for extubation/decannulation, length of stay in intensive care unit and complications encountered. Aims: To evaluate procedure time, time for extubation/decannulation, length of stay in intensive care unit and complications for two techniques of airway management in oromaxillofacial surgeries.Settings and Design: Institutional, prospective study.Materials and methods: This prospective study included 25 patients who sustained oromaxillofacial fracture operated under general anesthesia from August 2008 to December 2009. In 15 patients, submental intubation and in 10 patients percutaneous tracheostomy technique were adopted. Complex oromaxillofacial fractures included Lefort 1 and 2, nose, ethmoid and orbit, maxilla and mandible. Airway technique of submental intubation and percutaneous tracheostomy were attempted on the basis of interincisor gap. The procedure time for the two techniques, the time for extubation/decannulation and the length of stay in intensive care unit were evaluated statistically.Statistical analysis used: unpaired ‘t’ test. Results: Of the 25 patients, there were 12 males, 3 females and 8 males,2 females in the submental intubation and percutaneous tracheostomy group respectively. All patients belonged to ASA status 1 and 2. The first successful attempt achieved for submental intubation group and percutaneous tracheostomy group was 93% and 90% respectively. The mean time to perform the submental intubation procedure was 5.27 + 0.72(mean + standard deviation) minutes and 21.72 + 2.04 minutes for percutaneous tracheostomy group. The mean time for extubation was 4.73 + 8.18 days in submental intubation group and 23.3 + 5.25 days for decanulation in percutaneous tracheostomy group. The average length of stay in intensive care unit postoperatively were 6.73 + 8.18 days in submental intubation group and 25.8 + 6.81 days for percutaneous tracheostomy group. Theperformance time, the time for extubation/decannulation and the length of stay in intensive care unit were statistically highly significant for the two groups. Complications encountered in the two groups were recorded. Conclusions: Both, submental intubation and percutaneous tracheostomy can secure the airway in complex oromaxillofacial fracture reduction surgery. Both techniques allow uninterrupted surgical access to the operative field. Although submental intubation technique gives an imperceptible scar which has aesthetically greater acceptance compared to functionally challenging and unsightly tracheostoma which pose an enormous stress to the patient. The complications associated with tracheostomy are at times difficult to manage even in expert hands. Though submental intubation is easily performed, the selection of a particular technique should take into consideration factors other than preoperative airway assessment.

Use of nasotracheal intubation in patients receiving oral cavity free flap reconstruction

The aim of this study was to evaluate the effect airway management has on perioperative outcomes of patients undergoing oral cavity free flap reconstruction. A retrospective review was performed on patients receiving oral cavity free flap reconstruction between March 2006 and October 2007. Patient, tumor, and treatment variables were recorded. Patients were managed with nasotracheal intubation (NTI) or elective tracheotomy and different perioperative outcomes were measured. Thirty-seven patients received NTI and 21 received tracheotomy. No patients in the NTI group required conversion to tracheotomy or reintubation. The mean total hospital stay was prolonged in the tracheotomy group (12.4 days vs 8.4 days), as was their likelihood of requiring a feeding tube at discharge (76% vs 19%). In multivariate analyses, placement of a tracheotomy was independently correlated with longer hospital stay and feeding tube dependence at discharge. NTI is a safe alternative to tracheotomy for select patients receiving oral cavity free flap reconstruction and may reduce hospital stay and feeding tube dependence at discharge.

Tracheostomy in burns patients revisited

Objective The use of tracheostomy in burns patients has been controversial. A retrospective study was conducted to assess the use, complications and outcome of tracheostomy in ventilated adult burns patients. Methods Data was collected retrospectively regarding the extent of injury in each patient, the indication for tracheostomy, and outcome in terms of length of stay, days of mechanical ventilation, airway and pulmonary complications and survival. Patients were followed until discharge from the unit or death. Results Comparing patients who received tracheostomy to those who had translaryngeal intubation showed similar age distribution and no significant difference in the total burn surface area (TBSA). The use of tracheostomy was significantly higher in patients with TBSA >60%. Inhalation injury was significantly higher and mean probability of survival (ABSI), significantly lower in patients receiving tracheostomy. Duration of mechanical ventilation, length of stay in HDU/ITU and the incidence of pulmonary sepsis were significantly higher in tracheostomy group patients. However, there was no significant difference in mortality between the two groups. Conclusion Burn survivors with TBSA >60% are more likely to undergo repeated surgery and have burns to the head and neck region, therefore increasing the requirement for tracheostomy. Tracheostomy is a safe procedure with minimal perioperative complications. Late complications in this patient group may be related to duration of intubation and mechanical ventilation and the presence of an airway burn. Tracheostomy was associated with a higher prevalence of chest infection. We suspect that the cause of this is multifactorial, possibly due to a higher incidence of inhalation injury, greater burn size and prolonged mechanical ventilation in this group.

Development of a tracheostomy scoring system to guide airway management after major head and neck surgery

The use of elective tracheostomy in major head and neck surgery is well established, although practice varies between units. There is no published method that reliably predicts the need for tracheostomy. This paper describes the development of a surgical scoring system designed to achieve that aim. The system was devised using data obtained retrospectively from 148 consecutive major head and neck procedures. These procedures were grouped according to the airway management plan in place at the end of the procedure: elective extubation (group E, 52 procedures, 50 patients); elective overnight ventilation via an endotracheal tube (group ETT, 55 procedures, 52 patients); and elective overnight ventilation via a tracheostomy (group T, 41 procedures, 41 patients). 8 patients from group ETT required a late tracheostomy for either medical or surgical indications. Using statistical methods, a threshold score was defined above which the high risk of upper airway obstruction should prompt consideration of an elective tracheostomy.

Early tracheotomy in elderly patients results in less ventilator-associated pneumonia

To determine if the timing of tracheotomy in elderly patients results in less ventilator associated-pneumonia, mortality, and morbidity. Historical cohort study. This study included 158 ICU patients aged >65 who underwent tracheotomy from March 2003 to June 2007. Patient demographics, outcomes, and ventilation data were collected and analyzed. The early tracheotomy group (continuous intubation time <7 days) included 43 patients, and 115 patients were included in the late group. There were no statistically significant differences in the demographics of the two groups. A statistically significant difference in the rate of ventilator-associated pneumonia was noted in the early versus late tracheotomy group (-0.29% VAP, 95% CI: -0.46, -0.12). There were more intubations per patient noted in the early tracheotomy group versus the late tracheotomy group (0.70 intubations, 95% CI: 0.41, 0.99). The early tracheotomy group has a lower total ICU admission time (-9.5 days, 95% CI: -21.81, -2.25) and total hospital admission time (-10 days, 95% CI: -33.69, -2.249). There was no difference in mortality, although there was a trend of lower mortality in the early tracheotomy group (-11.3% mortality, 95% CI: -0.27, -0.05). Early tracheotomy in elderly patients is associated with less ventilator-associated pneumonia, more frequent intubations, less total admission time, and a trend toward lower mortality.

Tracheotomy versus prolonged intubation in medical intensive care unit patients

Introduction. The contribution of tracheotomy in comparison to intubation in patients on the resuscitation ward is debated. The main purpose of our study is to assess if tracheotomy compared to prolonged intubation, reduces the whole duration of ventilation, the frequency of nosocomial pneumopathy, the mean duration of hospitalisation in the resuscitation ward and mortality.Patients and method. It is a retrospective and comparative study between two groups of patients who presented neurologi-cal or respiratory pathology and required mechanical ventilation for more than three weeks. The study lasted 7 years and involved 60 patients divided into 2 groups : the Tracheotomy Group (TG, n=30), in which a tracheotomy was performed between the eighth day and the fifteenth day, after the first period of tracheal intubation; and the Intubation Group (IG, n=30), where the patients were intubated throughout the period of hospitalization until extubation or death. We monitored the whole duration of ventilation, the frequency of nosocomial pneumopathy, the incidence of each technique as well as the mean duration of hospitalization in the resuscitation ward and the mortality rate. The two groups were similar in age, sex and gravity score : SAPS II and APACHE II. Results. The results showed a significant statistical decrease of the whole duration of mechanical ventilation for the TG: 27.03 ± 3.31 days versus 31.63 ± 6.05 days for the IG (P = 0.001). However, there is no significant difference between the two groups, whereas the frequency of nosocomial pneumopathy is about 53.3% in the group with tracheotomy versus 70% for the intubated group (P = 0.18). This shows, on the other hand, the late prevalence of nosocomial pneumopathy in the tracheotomy group patients.We noticed one case of bleeding after tracheotomy. Sinusitis was also diagnosed but without a significant difference between the two groups, 6.7% (2 cases) in the TG and 10% (3 cases) for the IG (P = 0.31). The mean duration of hospitali-zation didn’t differ between the two groups; it was 30.96 ± 9.47 days for the TG versus 34.26 ± 9.74 days for the IG (P = 0.10). The study shows that there is no statistically significant difference in mortality between the two groups, 26.7% in the TG versus 46.7% for the IG (P = 0.10).Conclusion. It seems that tracheotomy, in medical ICU patients, leads to a shorter duration of ventilation, delayed nosoco-mial pneumopathy without the modification of its frequency and the mean duration of hospitalization or death.

Reconstruction of Extensive Head and Neck Defects with Multiple Simultaneous Free Flaps

Extensive head and neck defects may not be amenable to reconstruction with a single flap. The authors' evaluated the feasibility and functional outcomes of reconstructive surgery involving multiple simultaneous free flaps. Cases involving multiple simultaneous free flaps for head and neck reconstruction between 2001 and 2007 at the University of Texas M. D. Anderson Cancer Center were reviewed. Seventy-nine free flaps were performed in 39 patients. Thirty-four patients (87 percent) underwent mandibular reconstruction for 14 bone and full-thickness cheek defects (36 percent), nine bone and hemiglossectomy defects (23 percent), and 11 bone and near total or total glossectomy defects (28 percent). Five patients (13 percent) had extensive palatomaxillary defects. The mean operation time, including the time for extirpative surgery, was 13.8 hours. The mean intensive care unit stay was 4.3 days, and the mean hospital stay was 11.5 days. Two patients had laryngectomies and the remainder received tracheostomies. Of the tracheostomy group, 33 patients (89 percent) were decannulated. In this same group, 30 patients (81 percent) demonstrated speech with greater than 80 percent of words intelligible. Twenty-three of 29 patients (79 percent) who were feeding tube-independent preoperatively received all of their nutrition orally postoperatively. Patients who were partially or totally feeding tube-dependent postoperatively underwent either a hemiglossectomy or near total or total glossectomy, with mandibulectomy. Multiple simultaneous free flaps can be performed safely in patients, with acceptable recovery times and functional outcomes. In select cases, the authors advocate multiple free flap reconstruction to maximize quality of life even in patients with advanced cancers.

Course 449: Pediatrics: Natural History of Scoliosis in Spastic Tetriplegic Cerebral Palsy

Objective: To analyze development and progression of scoliosis in children with spastic tetriplegic cerebral palsy. Design: Retrospective review. Setting: Pediatric nursing home. Participants: 113 children, aged less than 18 years with scoliosis. Interventions: Not applicable. Main Outcome Measures: Cobb angle, weight, height, history of hip dislocation, tracheostomy, and osteoporosis. Results: The Cobb angle increased with age, weight, and height in a nonlinear fashion. A square root transformation of Cobb angle was chosen to model the nonlinear relationship between Cobb angle and predictors. Age, height, and weight were significant univariate predictors of the square root of Cobb's angle (slopes .367, .151, .039, respectively). After adjusting for age, we found that height and weight did not remain significant predictors. Age was to be a significant predictor of square root Cobb angle after adjusting, and the effect of age was stronger for those with tracheostomy (age slope=.722 vs .310) than those without. The relationship of age and Cobb angle does not differ significantly between hip dislocated and nondislocated groups, neither among normative bone density, osteopenia, and osteoporosis groups. Conclusions: Age was the most significant predictor of Cobb angle, and effect of age is greater in the tracheostomy group than in the nontracheostomy group. After adjustment of age, the weight and height were not significant predictors of Cobb angle.

Benefits of early tracheotomy: underpowered or overestimated?

To the editor: With interest we read the recent article from Blot et al. [1] in which they compared 28-day mortality of patients with early tracheotomy against those with prolonged intubation in a prospective randomized unblinded study. This trial is the first multi-centered randomized study on this topic and we would like to complement the investigators for their effort in achieving this trial. The study does not demonstrate any major benefit of early tracheotomy in a general population of intensive care unit-patients, but hints at putative comfort benefits. As the authors admit their study is severely underpowered. Indeed, the study was prematurely stopped because after about 2 years only 123 patients had been included. Of note, only 10–20% of the patients assessed for eligibility were actually included. One of the major reasons for noninclusion was the difficulty in anticipating mechanical ventilation lasting [7 days, one of the inclusion criteria of the study. We wonder how many patients in the prolonged intubation group finally reached 7 days of mechanical ventilation after randomization. If a substantial number of patients were extubated before that time the patients enrolled may not represent the population of interest (those at high risk of prolonged mechanical ventilation). Unfortunately, the authors did not use explicit criteria to predict prolonged mechanical ventilation (such as the presence of shock and multiorgan failure, oxygenation index, high APACHE II scores [2–4]). Another reason for non-inclusion was difficulties in organizing early tracheotomy. How long patients had to await a tracheotomy in the early tracheotomy group in this study? If this was ‘‘too’’ long the potential benefits may have been diluted? Two secondary endpoints were sedation requirements during the first 28 days and self-reported patient comfort. Sedation requirements were not different between the two study groups, which is in part in line with recent data from our group [5] but opposite to results from others [6]. Unfortunately, however, data on cumulative dose were not given. Although the number of sedation-free days was not different, the administered dose may have been different between the two groups. This could potentially explain the significant difference in self-reported comfort in favor of early tracheotomy.

Tracheostomy: How and When Should It Be Done in Cardiovascular Surgery ICU?

The aim of this study was to assess the effect of timing and techniques of tracheostomy on mortality and morbidity in cardiovascular surgery patients. Between January 2000 and October 2007, a total of 19,559 cardiac and vascular operations were performed in our hospital, and 205 of these patients (1.04%) who underwent a tracheostomy procedure were included in this retrospective study. Surgical tracheostomy (ST) was employed in 134 (65.4%) and percutaneous tracheostomy (PT) in 71 (34.6%) of the cases. There were 17 complications related to all tracheostomy procedures in 15 (7.3%) patients. Bleeding, requiring surgical intervention, occurred in five (3.7%) ST patients and in one (1.4%) PT patient. Cardiac arrest related to the procedure occurred in two (1.5%) ST patients. Pneumothorax occurred in three (2.2%) ST patients and in one (1.4%) PT patient, subcutaneous emphysema in three (2.2%) ST patients and in one (1.4%) PT patient, and tracheoesophageal fistula in one (0.7%) ST patient (p>0.05). The postoperative infection rate was significantly lower, and cooperation of the patients, postoperative patient mobilization, and oral feeding rates were higher in the early tracheostomy group. The multifactorial mortality rates of early (<seven days) and late tracheostomies were 71.4% and 88.1%, respectively (p=0.037). We believe that both techniques can be performed safely in the ICUs. Although the need of tracheostomy is one of the foremost causes of mortality and morbidity in cardiovascular surgery patients, an early application of the procedure may have favorable effects on the expected mortality and overall infection rates of the critically ill patients.

Early Tracheotomy in the Elderly Results in Less Pneumonia

Objective To determine if early tracheotomy in elderly patients (age &gt; 65) results in less ventilator associated pneumonia, mortality and morbidity. Methods This is a retrospective chart review of 158 ICU patients aged &gt;65 who underwent tracheotomy from March 2003 to June 2007. Patient demographic data, admission criteria, medical comorbidities, disposition, outcome, and ventilation data were collected and analyzed. Results 158 patients were included in the study. 43 patients were included in the early tracheotomy group (continuous intubation time &lt;7 days), and 115 patients were included in the late tracheotomy group. There were no statistically significant differences in the demographics of the 2 groups including age, gender, race, reason for intubation (respiratory failure, airway obstruction, etc), or medical comorbidities including COPD. A highly statistically significant difference in the rate of ventilator associated pneumonia was noted in the early vs. late tracheotomy group (23.3% vs 52.6%, p&lt;0.0009). There were more intubations per patient noted in the early tracheotomy group versus the late tracheotomy group (2.2 vs 1.5, p&lt;0.0001). The total admission time was also shorter in the early tracheotomy group (27.0 days vs 39.0 days, p&lt;.0171). There was no difference noted in mortality, although there was a general trend of lower mortality in the early tracheotomy group (20.1% vs 32.1%, p&lt;0.1683). Conclusions Early tracheotomy in elderly patients is associated with less ventilator associated pneumonia, more frequent intubations, less total admission time, and a trend towards lower mortality.

Submental Intubation Versus Tracheostomy in Maxillofacial Trauma Patients

To evaluate the indications and outcomes of airway management by submental intubation or tracheostomy in patients with maxillofacial trauma, and to describe the technique of submental intubation in detail and discuss its latest refinements. Of 356 patients admitted from January 2004 through September 2007 with maxillofacial trauma, 222 were operated on under general anesthesia. Eight patients underwent urgent or elective tracheostomy; 8 patients underwent submental intubation. Seven patients with submental intubation were extubated at the end of the procedure. One patient received elective tracheostomy 3 days later. We did not encounter any complications in the tracheostomy group, while 1 case of slight damage to the endotracheal tube occurred in the submental intubation group. Submental endotracheal intubation is a simple technique with very low morbidity and can replace tracheostomy in selected cases of maxillofacial trauma without indication for prolonged ventilation support.

Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children

Mechanically ventilated patients are at risk for aspiration of gastric contents. The aim of this observational study was to determine the prevalence of micro-aspiration in children with cuffed and uncuffed endotracheal (ET) tubes and with tracheostomies and to assess the effect of feeding status on aspiration. Micro-aspiration was determined by measuring gastric pepsin in tracheal aspirates. We studied 27 children on ventilators in paediatric intensive care unit (PICU) and 10 children undergoing elective surgeries for various indications. Tracheal aspirates were collected from children on ventilatory support in the intensive care unit during medically indicated suctioning and from the group of children undergoing elective surgery in the operation room. Pepsin was detected by enzymatic assay. Overall 70% of cases in PICU were positive for pepsin in at least one of the aspirates. Pepsin positivity was significantly lower in the cuffed group than in the uncuffed and tracheostomy groups. Tube feedings did not significantly influence the prevalence of pepsin positivity. Measurement of gastric pepsin in tracheobronchial fluid is a sensitive tool to detect aspirations in mechanically ventilated children and to assess the efficacy of preventive measures in PICU settings.