02 Aug 10
Editorial by D Scales and N Ferguson
Endotracheal intubation is the most common procedure for airway control for patients requiring mechanical ventilation. Extubation is performed once patients have improved so that mechanical ventilation can be discontinued. For patients who require prolonged mechanical ventilation, replacement of the endotracheal tube with a tracheotomy is often considered. The most common reason for tracheotomy insertion in the intensive care unit (ICU) is to provide access for prolonged mechanical ventilation. From observational data, between 6% and 11% of mechanically ventilated patients receive a tracheotomy after a median of 9 to 12 days; however, there is significant variability around both patient selection and timing.
Tracheotomy practice is variable in large part because what constitutes prolonged mechanical ventilation (ie, the optimal timing for tracheotomy) is not known. Defining and predicting the need for prolonged ventilation has been a major methodological challenge. Research on tracheotomy timing involves evaluating a 2-part study……
By P Terragni, M Antonelli, R Fumagalli, C Faggiano, M Berardino, F Pallavicini, A Miletto et al
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.
Design, setting and patients
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).
Main outcome measures
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.
24 Mar 10
By Y Wu , Y Tsai , C Lan , C Huang , C Lee , K Kao and J Fu
Critical Care 2010, 14:R26
Mechanical ventilation of patients may be accomplished by either translaryngeal intubation or tracheostomy. While numerous ICU studies have compared various outcomes between the two techniques, there is no definitive consensus that tracheostomy is superior. Comparable studies have not been performed in a respiratory care center (RCC) setting.
This was a retrospective observational study of 985 tracheostomy and 227 translaryngeal intubated patients who received treatment in a 24-bed RCC between November 1999 and December 2005. Treatment and mortality outcomes were compared between tracheostomized and translaryngeal intubated patients, and the factors associated with positive outcomes in all patients were determined.
Duration of RCC (22 vs. 14 days) and total hospital stay (82 vs. 64 days) and total mechanical ventilation days (53 vs. 41 days) were significantly longer in tracheostomized patients (all P<0.05). The rate of in-hospital mortality was significantly higher in the translaryngeal group (45% vs. 31%, P<0.05). There were no significant differences in weaning success between the groups (both were over 55%), nor RCC mortality. Due to significant baseline between group heterogeneity, case match analysis was performed. This analysis confirmed the whole cohort findings, except for the fact that there was only a trend for in-hospital mortality to be higher in the translaryngeal group (P=0.08). Stepwise logistic regression revealed that patients with a lower median severity of disease (APACHE II score <18) who were properly nourished (albumin >2.5 g/dL) or had normal metabolism (BUN <40 mg/dL) were more likely to be successfully weaned and survive (all P<0.05). Patients who were tracheostomized were also significantly more likely to survive (P<0.05)
These findings suggest that the type of mechanical ventilation does not appear to be an important determinant of weaning success in an RCC setting. Focused care administered by experienced providers may be more important for facilitating weaning success than the ventilation method used. However, our findings do suggest that tracheostomy may increase the likelihood of patient survival.
13 Sep 08
By D Scales, D Thiruchelvam, A Kiss, D Redelmeier
Crit Care Med 2008; 36:2547-2557
Tracheostomy is common in intensive care unit patients, but the appropriate timing is controversial.
To determine whether earlier tracheostomy is associated with greater long-term survival.
Retrospective cohort analysis.
Acute care hospitals in Ontario, Canada (n = 114).
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).
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.
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).
This analysis provides guidance regarding timing but not patient selection for tracheostomy.
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