Tracheostomy is common in intensive care unit patients, but the appropriate timing is controversial.
Objective
To determine whether earlier tracheostomy is associated with greater long-term survival.
Design
Retrospective cohort analysis.
Setting
Acute care hospitals in Ontario, Canada (n = 114).
Patients
All mechanically ventilated intensive care unit patients who received tracheostomy between April 1, 1992 and March 31, 2004, excluding extreme cases (<2 or >=28 days) and children (<18 yrs).
Measurements
For crude analyses, tracheostomy timing was classified as early (<=10 days) vs. late (>10 days) with mortality measured at multiple follow-up intervals. Proportional hazards analyses considered tracheostomy as a time-dependent variable to adjust for measurable confounders and possible survivor treatment bias. We used stratification, propensity score, and instrumental variable analyses to adjust for patient differences.
Results
A total of 10,927 patients received tracheostomy during the study, of which one-third (n = 3758) received early and two-thirds late (n = 7169). Patients receiving early tracheostomy had lower unadjusted 90-day (34.8% vs. 36.9%; p = 0.032), 1 yr (46.5% vs. 49.8%; p = 0.001), and study mortality (63.9% vs. 67.2%; p < 0.001) than patients receiving late tracheostomy. Multivariable analyses treating tracheostomy as a time-dependent variable showed that each additional delay of 1 day was associated with increased mortality (hazard ratio 1.008, 95% confidence interval 1.004-1.012), equivalent to an increase in 90-day mortality from 36.2% to 37.6% per week of delay (relative risk increase 3.9%; number needed to treat, 71 patients to save one life per week delay).
Limitations
This analysis provides guidance regarding timing but not patient selection for tracheostomy.
Conclusions
Physicians performing early tracheostomy should not anticipate a large potential survival benefit. Future research should concentrate on identifying which patients will receive the most benefit
By M Remacle, G Lawson, J Jamart, C Trussart, P Bulpa
Eur Arch Otorhinolaryngol. 2008 Apr 12
A prospective study was designed to compare two single-dilator percutaneous tracheotomy techniques, the Ciaglia BlueRhino and the Percutwist technique. One hundred and ninety adult patients were included, 166 with the BlueRhino, a conical shaped, flexible rubber dilator, and 24 with the Percutwist, a screw like dilating device. The procedure was performed under fiberscopy in the intensive care unit (ICU). Age, body mass index (BMI), indication for tracheotomy, surgical landmarks, duration of the procedure and surgical complications were recorded. Median age and indications were similar for the two groups. Dilation was successful in all patients. The mean time for surgery was shorter with the Ciaglia technique: 8 +/- 3 versus 12 +/- 5 min with the Percutwist technique (P = 0.004). There was no significant difference related to weight, BMI, duration of tracheotomy and complications between both groups. One posterior tracheal wall puncture was observed with the Ciaglia technique and four with the Percutwist technique. No serious complications were noted with either technique. The Percutwist technique represents an alternative to the more established Ciaglia BlueRhino technique. The Ciaglia technique is a safe and more rapid procedure for bedside tracheotomy.
PercuTwist is a new technique for percutaneous tracheostomy in that stoma dilation is achieved with a unique screwlike dilating device. We describe the technique itself and our first clinical experiences with PercuTwist.
This is the original movie made by Rusch. Approx. 14 minutes.
By C Clec’h, C Alberti, F Vincent, M Garrouste-Orgeas, A de Lassence, D Toledano et al on behalf of the OUTCOMEREA study group
Critical Care Medicine 2007;35:132-138
To examine the association between the performance of a tracheostomy and intensive care unit and postintensive care unit mortality, controlling for treatment selection bias and confounding variables.
Design
Prospective, observational, cohort study.
Setting
Twelve French medical or surgical intensive care units.
Patients
Unselected patients requiring mechanical ventilation for >=48 hrs enrolled between 1997 and 2004.
Measurements and Main Results
Two models of propensity scores for tracheostomy were built using multivariate logistic regression. After matching on these propensity scores, the association of tracheostomy with outcomes was assessed using multivariate conditional logistic regression. Results obtained with the two models were compared. Of the 2,186 patients included, 177 (8.1%) received a tracheostomy. Both models led to similar results. Tracheostomy did not improve intensive care unit survival (model 1: odds ratio, 0.94; 95% confidence interval, 0.63-1.39; p = .74; model 2: odds ratio, 1.12; 95% confidence interval, 0.75-1.67; p = .59). There was no difference whether tracheostomy was performed early (within 7 days of ventilation) or late (after 7 days of ventilation). In patients discharged free from mechanical ventilation, tracheostomy was associated with increased postintensive care unit mortality when the tracheostomy tube was left in place (model 1: odds ratio, 3.73; 95% confidence interval, 1.41-9.83; p = .008; model 2: odds ratio, 4.63; 95% confidence interval, 1.68-12.72, p = .003).
Conclusions
Tracheostomy does not seem to reduce intensive care unit mortality when performed in unselected patients but may represent a burden after intensive care unit discharge.