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PubMed2000

A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients.

STUDY OBJECTIVES: Tracheostomy is one of the most commonly performed procedures in the patient receiving long-term mechanical ventilation. While percutaneous dilational tracheostomy (PDT) is becoming increasingly utilized as an alternative to conventional surgical tracheostomy, most literature evaluating these two techniques is neither prospective nor controlled. We performed a meta-analysis of available prospective controlled studies comparing PDT and surgical tracheostomy in critically ill patients to more fully understand the relative benefits and risks of these two procedures in this population. DESIGN: Meta-analysis using Mantel-Haenszel fixed effect model. INTERVENTIONS: We performed searches of MEDLINE, Current Contents, Best Evidence, Cochrane, and HealthSTAR databases from 1985 to present to identify prospective controlled studies comparing PDT and surgical tracheostomy in critically ill patients. After establishing clinical and statistical homogeneity (Q: statistic), studies were analyzed by a Mantel-Haenszel fixed effect model. For each clinical end point examined, PDT and surgical tracheostomy were compared by calculating either absolute differences or odds ratios (ORs) with 95% confidence intervals (CIs) for continuous or discrete variables, respectively. MEASUREMENTS AND RESULTS: We pooled data from five studies (236 patients) satisfying our search criteria to analyze eight clinical end points. Operative time was shorter for PDT than surgical tracheostomy: absolute difference with 95% CI, 9. 84 min (7.83 to 10.85 min). There was no difference comparing PDT and surgical tracheostomy with respect to overall operative complication rates: OR with 95% CI, 0.732 (0.05 to 9.37). However, relative to surgical tracheostomy, PDT was associated with less perioperative bleeding (OR with 95% CI, 0.14 [0.02 to 0.39]), a lower overall postoperative complication rate (OR with 95% CI, 0.14 [0.07 to 0.29]), as well as a lower postoperative incidence of bleeding (OR with 95% CI, 0.39 [0.17 to 0.88]), and stomal infection (OR with 95% CI, 0.02 [0.01 to 0.07]). No difference was identified in days intubated prior to tracheostomy (absolute difference with 95% CI, 0.16 days [- 0.9 to 1.22 days]), overall procedure-related complications (OR with 95% CI, 0.73 [0.06 to 9.37]), or death (OR with 95% CI, 0.63 [0.18 to 2.20]) comparing these two techniques. CONCLUSIONS: Despite its popularity, there are currently only a limited number of small studies prospectively evaluating PDT and surgical tracheostomy. Our meta-analysis of these studies suggests potential advantages of PDT relative to surgical tracheostomy, including ease of performance, and lower incidence of peristomal bleeding and postoperative infection. If confirmed by additional, adequately powered prospective trials, these findings support PDT as the procedure of choice for the establishment of elective tracheostomy in the appropriately selected critically ill patient.

Blood Loss, Surgical↗

PubMed2001

Open versus percutaneous dilatational tracheostomy: efficacy and cost analysis.

The economic advantages of percutaneous dilatational tracheostomies versus open tracheostomies in the operating room have been thoroughly evaluated. We are now reporting our comparison of the costs and charges of percutaneous dilatational tracheostomies with those of open bedside tracheostomies at our institution. The current literature comparing the two open techniques and the percutaneous method of placing tracheostomies was reviewed and the charges and costs for these procedures at our institution were compared. Patients were placed into one of three groups for analysis: open tracheostomies in the operating room (Group I), open tracheostomies in the intensive care unit (Group II), and percutaneous dilatational tracheostomies in the intensive care unit (Group III). Based on our own experience and a literature review it is evident that all three approaches to tracheostomies are safe. Economic analysis showed a savings of $180 in cost per procedure and a $658 savings in charges per procedure for the open method at the bedside when compared with the percutaneous method at the bedside. The professional fee for bronchoscopy was not included in this calculation; including this would lead to greater savings with the open method over the percutaneous method. Open tracheostomy in the operating room increased costs over the bedside procedure by $2194 and increased charges by $2871. For the 150 to 180 tracheostomies done each year at our institution utilization of the open technique at the bedside results in a cost savings of approximately $31,500 and a charge savings of $109,000 compared with the percutaneous dilatational tracheostomy. Both the open bedside and percutaneous dilatational methods are reasonable and safe options. However, the open bedside tracheostomy is a better utilization of resources and is more cost effective, and it is the procedure of choice at our institution.

Cost Savings↗

PubMed2005

Early tracheostomy in closed head injuries: experience at a tertiary center in a developing country--a prospective study.

BACKGROUND: An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving. Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury. METHODS: The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy. All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version. The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant. RESULTS: At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score. The average day of tracheostomy was 2.18 +/- 1.0038 days. The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group. Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury. CONCLUSION: It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.

Journal Article↗

PubMed1992

Tracheostomy in children with emphasis on home care.

Tracheostomy in children is not a benign procedure. Tracheostomy-related mortality rates among children have been previously reported to be as high as 10% to 27%. Children with tracheostomies are especially vulnerable after home discharge with mortality rates of 0.5 to 2 deaths per 100 months at home. In order to assess the impact of extensive parental education and home nursing care on tracheostomy-related mortality, we report our experience over 9 years with 44 children receiving tracheostomies. Each child was maintained at home with a tracheostomy for an average of 19 months for a total of 635 months of home tracheostomy care. Indications for tracheostomy were tracheomalacia (32%), obstructive airway lesions (23%), central nervous system lesions (16%), vocal cord paralysis (9%), Pierre Robin syndrome (9%), and a list of miscellaneous conditions (11%). Our tracheostomy care regimen begins with intensive parental training in tracheostomy management for a minimum of 10 days prior to discharge. Home nursing was arranged for 77% of these children for an average of 11 hours per day at the time of discharge. Eighty-three percent had home apnea monitors. Discharge of these children was delayed or transfer to a secondary hospital was made when parents failed to show adequate proficiency in tracheostomy management with existing home nursing. Eight percent were ventilator dependent at discharge. As of January 1, 1989, 34% of these children have been decannulated. There were six deaths, all due to underlying disease. There were no tracheostomy-related deaths in hospital or after discharge home.(ABSTRACT TRUNCATED AT 250 WORDS)

Child, Preschool↗

PubMed2005

Cricoid palpability as a selection criterion for bedside tracheostomy.

OBJECTIVE: To prospectively evaluate the significance of cricoid cartilage palpability as a selection criterion for bedside tracheostomy and to prospectively compare a cohort of patients undergoing bedside tracheostomy with another cohort receiving operating room tracheostomy. STUDY DESIGN/SETTING: Prospective trial comparing 2 cohorts of patients receiving tracheostomies at a tertiary care center (university hospital). In all, 220 consecutive intubated patients selected for elective tracheostomy were enrolled. Of them, 134 patients had palpable cricoid cartilage and underwent open surgical tracheostomy at the bedside. The remaining 68 patients received open surgical tracheostomies in the operating room. Demographic data, patient anatomic features, and perioperative complications were prospectively recorded. There were no statistically significant differences in age, gender, reason for admission, indication for tracheostomy, Acute Physiology and Chronic Health Evaluation II score, number of days intubated, or time required to perform the procedure for those patients whose tracheostomies were performed in the operating room versus the intensive care unit. RESULTS: Patients with a palpable cricoid cartilage had a significantly reduced perioperative complication rate compared with those without a palpable cricoid cartilage (2% vs 22%, P < 0.001). Comparison of cervical girth, mental-to-sternum distance, and thyroid-notch-to-sternum distance showed no significant difference between the 2 groups and did not further define selection criteria. CONCLUSION: This investigation prospectively confirms the safety of bedside tracheostomy placement in properly selected patients. Complication incidences are defined for open surgical tracheostomy at the bedside and in the operating room. Palpability of the cricoid cartilage has significant value as a selection criterion for bedside tracheostomy. SIGNIFICANCE: These findings will aid in the development of protocols and pathways for surgical airway management in critically ill patients to maximize cost-effective, high-quality care.

Adult↗

PubMed2001

[Percutaneous tracheostomy].

OBJECTIVES: The aim of this study was to evaluate the different techniques of percutaneous tracheostomies, their advantages, drawbacks, complications and to compare them to standard surgical tracheostomies. This study will consider only elective (non emergency) bedside procedures in intensive care units. DATA SOURCES: Extraction from Medline database of english and french articles on percutaneous tracheostomies and searching along with major review articles. STUDY SELECTION: The collected articles were selected according to their qualities regarding to their evidence level. In addition to several important or historic references, the literature of the five past years was studied. DATA EXTRACTION: The articles were reviewed according to their contribution for techniques, perioperative and postoperative complications, recent advances, advantages and drawbacks of all procedures. Publications addressing recent comparisons between surgical and percutaneous tracheostomies were specially studied. DATA SYNTHESIS: Four techniques of bedside percutaneous tracheostomies are available and marketed, in France: Ciaglia's dilation technique (with multiple or unique dilator), Griggs's technique (using a special designed forceps), and Fantoni's technique (Trans Laryngeal Tracheostomy). The most spred but also first described technique is the Ciaglia's (1985). The most recent articles comparing surgical and percutaneous tracheostomies techniques are not able to demonstrate a superiority of one of them in terms of feasibility or safety. In other words, there should be a slight advantage for the percutaneous tracheostomy regarding to the late post-operative complications, as there should be a slight advantage for the surgical techniques regarding to the perioperative complications. The literature analysis point out firstly the learning curve for percutaneous dilational tracheostomy, with a significant decrease of complication incidence with the operator's experience and secondly the continuous endoscopic guidance seems to increase the safety of the percutaneous procedure. CONCLUSION: Since there has been a great deal of percutaneous tracheostomy in the intensive care units, the incidence of tracheostomy have increased in those services. There is a trend to replace the surgical procedure by the percutaneous one. However, according to the potentially jeopardizing complications, percutaneous tracheostomy should be done by an experienced operator with the help of a continuous endoscopic guidance.

France↗

PubMed2006

Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up.

OBJECTIVE: To compare the safety, availability, and long-term sequelae of percutaneous vs. surgical tracheostomy. DESIGN: Prospective, randomized, controlled study. SETTING: Combined medical/surgical intensive care unit in a tertiary referral hospital. PATIENTS: Two hundred critically ill mechanically ventilated patients who required tracheostomy. INTERVENTIONS: Tracheostomy by either percutaneous tracheostomy or surgical tracheostomy performed in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the aggregate incidence of predefined moderate or severe complications. The secondary outcome measures were the incidence of each of the components of the primary outcome. Long-term follow-up included clinical assessment, flow volume loops, and bronchoscopy. Both groups were well matched for age, gender, admission Acute Physiology and Chronic Health Evaluation II score, period of endotracheal intubation, reason for intubation, and admission diagnosis. There was no statistical difference between groups for the primary outcome. Bleeding requiring surgical intervention occurred in three percutaneous tracheostomy patients and in no surgical tracheostomy patient (p = .2). Postoperative infection (p = .044) and cosmetic sequelae (p = .08) were more common in surgical tracheostomy patients. There was a shorter delay from randomization to percutaneous tracheostomy vs. surgical tracheostomy (p = .006). Long-term follow-up revealed no complications in either group. CONCLUSIONS: Both percutaneous tracheostomies and surgical tracheostomies can be safely performed at the bedside by experienced, skilled practitioners.

Aged↗

PubMed1990

Tracheostomy.

The records of all children who had a tracheostomy performed over a 10 year period from January 1979 were reviewed. Altogether 142 patients aged 1 day to 24.8 years received a tracheostomy, 70 in the first year of life. The conditions necessitating tracheostomy were trauma (n = 21), acquired subglottic stenosis (n = 21), subglottic haemangioma (n = 16), Guillain-Barré syndrome (n = 14), Pierre Robin syndrome (n = 9), craniofacial disorders (n = 9), micrognathia (n = 5), and others in 47. In patients successfully decannulated the median period of tracheostomy was 104 days (range 3 days to 9.0 years) and in 25 patients the tracheostomy is still in situ. Eighty four patients (60%) were discharged from hospital with their tracheostomy in situ and no patient was kept in hospital because of a tracheostomy beyond four weeks. There were two tracheostomy related deaths in hospital. Both patients had severe acquired subglottic stenosis secondary to ventilation for lung disease of prematurity. There were no tracheostomy related deaths at home; complications included tracheal granulomas and polyps (n = 19). After removal of the tracheostomy 13 children had a fistula requiring surgical closure and four required revision of the tracheostomy scar. Tracheostomy is well tolerated in small children, with few complications and can be managed safely in the home by the family.

Adolescent↗

PubMed2006

Repeat percutaneous tracheostomy in the neurocritically ill patient.

INTRODUCTION: Percutaneous tracheostomy is a widely used and accepted method for long-term mechanical ventilation and airway protection. Neurocritically ill patients sometimes require repeat tracheostomy, which is traditionally considered a relative contraindication for percutaneous procedure. The aim of this study was to determine the safety of repeat percutaneous tracheostomy in neurocritically ill patients with a history of previous tracheostomy. METHODS: In the 16-bed academic neurointensive care unit, we prospectively enrolled patients who needed new tracheostomy placement for airway protection or prolonged mechanical ventilation and had previously undergone percutaneous tracheostomy placement. We collected data on indications, procedure, periprocedural complications, and outcome of repeated tracheostomy. RESULTS: Between January 2001 and October 2005, we enrolled 12 consecutive patients (mean age 35.4 +/- 7.0 years) who underwent repeat percutaneous tracheostomy. Head injury was the most common underlying diagnosis (seven patients, 58%). Tracheostomy tube placement was easy and successful in all patients, and none of the patients needed conversion to surgical tracheostomy. In three patients, ultrasound-guided needle aspiration was used before the procedure to confirm the position of the trachea. No patients died or experienced serious complication related to the procedure. Two patients (17%) had a minor periprocedural bleeding, which was controlled with local compression. Long-term outcome was poor, with only two patients alive and off the ventilator at hospital discharge, both with serious disability. CONCLUSION: Repeat percutaneous tracheostomy can be performed safely in neurocritically ill patients who have undergone previous tracheostomy.

Adult↗

PubMed1996

Elective bedside tracheostomy in the intensive care unit.

BACKGROUND: Tracheostomy is a frequently performed procedure, and historically has had a high reported complication rate. This has led some authors to suggest that a tracheostomy should be done only in the operating room (OR). Concerns regarding the hazards of transporting critically ill patients to the OR may inhibit the use of tracheostomy. Bedside tracheostomy in the Intensive Care Unit (ICU) has been shown to be safe, but this concept has not been widely accepted. STUDY DESIGN: We retrospectively reviewed consecutive patients undergoing tracheostomy over a four-year period and compared the safety of elective beside tracheostomy with OR tracheostomy. RESULTS: We studied 536 patients who underwent tracheostomy during the four years, in 470 of whom the procedures were elective. Of these, 66 percent were done at the bedside without an anesthesiologist present. For the 311 patients who underwent bedside tracheostomy, the complication rate was 8.7 percent compared to 9.4 percent of 159 patients undergoing OR tracheostomy (p values were not significant). No deaths were directly associated with tracheostomy procedures, although the overall hospital mortality rate for these patients was 59 percent. CONCLUSIONS: A tracheostomy can safely be performed in an ICU without requiring transport of the patient to the operating suite, thereby eliminating the hazards of transport.

Adolescent↗

PubMed2001

Safety of pediatric bedside tracheostomy in the intensive care unit.

BACKGROUND: Elective bedside pediatric tracheostomies in the intensive care unit have not been widely reported. Unlike in the adult population, this is not yet considered a safe or routine procedure in the pediatric population. We performed a preliminary study suggesting that bedside pediatric tracheostomies can be done safely and at reduced cost. DESIGN: Retrospective medical chart review. SETTING: Tertiary care referral center at a single university hospital. PATIENTS: Fifty-seven patients, ranging in age from 15 days to 8 years. Thirty operating room tracheostomies and 27 bedside tracheostomies were performed during a 6-year period. The mean age of the patients was 20.5 months, with no significant age difference between the 2 groups. The top 3 diagnoses necessitating tracheostomy were laryngotracheal disorders (18 patients [32%]), bronchopulmonary dysplasia (9 [16%]), and neurologic disorders (6 [11%]). INTERVENTIONS: Tracheostomy. MAIN OUTCOME MEASURES: The initial 48-hour postoperative period was examined to compare complication rates between groups. RESULTS: Overall, the 2 groups had similar complication rates (chi(2) = 0.12; P =.73). The operating room group had 3 complications (10%) related to bleeding, infection, and pneumothorax. The bedside group had 2 complications (7%), both involving pneumothorax. Each operating room tracheostomy incurred charges totaling $1693 vs $235 for each bedside tracheostomy. CONCLUSIONS: Historically, pediatric tracheostomy has been viewed as a technically demanding procedure with a high complication rate, thus encouraging routine operating room use. We found that pediatric tracheostomy performed in the intensive care unit, with attention to prudent patient selection and adherence to consistent, sound techniques, was as safe as operating room tracheostomy.

Child↗

PubMed1998

The prognostic significance of tracheostomy in carcinoma of the larynx treated with radiotherapy and surgery for salvage.

PURPOSE: To determine retrospectively the prognostic significance of airway compromise necessitating tracheostomy in carcinoma of the larynx managed with radical radiotherapy and surgery for salvage (RRSS). METHODS AND MATERIALS: The charts of 270 patients managed with RRSS at the Toronto-Sunnybrook Regional Cancer Centre between June 1980 and December 1990 were reviewed. Airway compromise necessitating tracheostomy was documented in 26 patients prior to radiotherapy and 3 patients during radiotherapy. Of 29, 27 had T3T4 primaries. Patients have been followed for a median of 5 years. RESULTS: Patients managed without tracheostomy had a 2-year disease-free survival of 74% compared to 41% for those managed with tracheostomy. The adverse impact of airway compromise was more marked in patients with glottic primaries (78% vs. 32%, p = 0.0001) than those with supraglottic primaries (64% vs. 47%, p = 0.18). Tracheostomy was identified in univariate analysis, but not in multivariate analysis, as having a statistically significant impact on local control and local-regional control. Radiotherapy controlled disease above the clavicles in 185 of 267 (69%) evaluable patients. 83% of isolated local-regional failures underwent salvage surgery. Among those managed without tracheostomy, ultimate local-regional control (LRC) was achieved in 161 (94%) of 172 glottic primaries and 54 (81%) of 67 supraglottic primaries. Among those managed with tracheostomy, ultimate LRC was achieved in 9 (69%) of 13 glottic primaries and 12 (80%) of 15 supraglottic primaries. In a subset analysis of 76 patients with T3T4 primaries, there was no statistically significant difference in larynx preservation, disease-free survival, or cause-specific survival between those managed with and without tracheostomy. CONCLUSION: Airway compromise necessitating tracheostomy is an adverse prognostic factor in patients with carcinoma of the larynx. However, larynx preservation is possible in over 40% of those undergoing tracheostomy and radiotherapy with no compromise of cause-specific survival. The need for pretreatment tracheostomy should not rule out the possibility of RRSS.

Adult↗

PubMedDate not supplied

Rationale for 'early' percutaneous dilatational tracheostomy in patients with burn injuries.

Several investigators have cited the numerous complications that occur with conventional tracheostomies in patients with burn injuries. However, none of these studies included the technique of percutaneous dilatational tracheostomy, which has been shown to significantly decrease operative time, cost, perioperative, and long-term sequelae as compared to conventional tracheostomy. A retrospective analysis of 36 patients with burn injuries, from 1400 burn admissions, was conducted to compare conventional tracheostomy versus percutaneous dilatational tracheostomy. In this study, percutaneous dilatational tracheostomy resulted in significantly decreased operative times and cost compared to conventional tracheostomy. There were no major operative complications in either group, and alveolar-arterial oxygen gradients were improved in 71% of the patients with a tracheostomy. Percutaneous dilatational tracheostomy is an efficacious technique for airway management in patients with burn injuries. It can be safely performed at the bedside, at one fourth the cost of a conventional tracheostomy. Percutaneous dilatational tracheostomy may also benefit the patient with severe burns by decreasing alveolar-arterial oxygen gradients. Improved ventilatory mechanics might allow for a shorter duration of mechanical ventilation, thereby decreasing patient morbidity, hospital stay, and cost.

Adult↗

PubMed2003

Airway management after maxillectomy: routine tracheostomy is unnecessary.

OBJECTIVES/HYPOTHESIS: There is a paucity of data to guide the optimal management of the airway in patients after maxillectomy. The decision on whether a concomitant tracheostomy is needed is often dictated by the surgeon's training and experience. We reviewed our experience with maxillectomy to assess the need for tracheostomy in postoperative airway management. STUDY DESIGN: Retrospective analysis at a university hospital. METHODS: We identified 121 patients who underwent 130 maxillectomies between October 1990 and September 2001. Twenty-four of these were total (all six walls removed), 45 were subtotal (two or more walls removed), and 61 were limited (only one wall removed). Reconstruction ranged from none to microvascular free flap, with split-thickness skin graft being the most common reconstructive option. RESULTS: Only 10 tracheostomies (7.7%) were performed at the time of maxillectomy. These included four tracheostomies in patients who underwent bulky flap reconstruction, two tracheostomies in patients who underwent both flap reconstruction and mandibulectomy, one tracheostomy in a patient who underwent mandibulectomy, one tracheostomy in a patient with mucormycosis in anticipation of prolonged ventilatory support postoperatively, and two tracheostomies at the surgeons' discretion because of concern for upper airway edema. Among the 111 patients who underwent 120 maxillectomies without concomitant tracheostomy, 1 patient (0.9%), a 74 year-old man with oxygen-dependent chronic obstructive pulmonary disease, required repeat intubation on day 3 and again on day 10 after the surgery, because of respiratory failure; fiberoptic examination confirmed the absence of upper airway compromise. CONCLUSIONS: The routine performance of tracheostomy in patients undergoing maxillectomy is unnecessary. Selective use of tracheostomy may be indicated in situations in which mandibulectomy or bulky flap reconstruction is performed or a concern for postoperative oropharyngeal airway obstruction because of edema or packing exists.

Adult↗

PubMed2005

Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients.

OBJECTIVE: Tracheostomy practice in the setting of critical illness is controversial because evidence demonstrating unequivocal benefit is lacking. We undertook this study to determine the relationship between tracheostomy timing and duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay and to evaluate the relative influence of clinical and nonclinical factors on tracheostomy practice. DESIGN: Analysis of Project Impact, a multi-institutional critical care administrative database. SETTING: Medical school. PATIENTS: Data from 43,916 patients were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheostomy was performed in 2,473 (5.6%) of 43,916 patients analyzed. Tracheostomy patients had a higher survival rate than nontracheostomy patients (78.1 vs. 71.7%, p < .001) and underwent this procedure following a median (25th-75th percentile) of 9.0 (5.0-14.0) days of ventilatory support. Tracheostomy frequency and timing varied significantly comparing patient, intensive care unit, and hospital characteristics (p < .05 for all). Tracheostomy timing correlated significantly with duration of mechanical ventilation (r = .690), intensive care unit (r = .610), and hospital length of stay (r = .341, p < .001 for all). At most, 22% of patients were supported via tracheostomy at any given time. Although a minority, tracheostomy patients accounted for 26.2%, 21.0%, and 13.5% of all ventilator, intensive care unit, and hospital days, respectively. CONCLUSIONS: Although practice varies substantially, tracheostomy timing appears significantly associated with duration of mechanical ventilation, intensive care unit length of stay, and hospital length of stay. These findings emphasize the need for an adequately supported multiple-center trial to better define patient selection for tracheostomy and to test the hypothesis that timing of this procedure influences clinically important outcomes.

Critical Care↗

PubMed2004

Tracheostomy timing and the duration of weaning in patients with acute respiratory failure.

INTRODUCTION: The effect of various airway management strategies, such as the timing of tracheostomy, on liberation from mechanical ventilation (MV) is uncertain. We tested the hypothesis that tracheostomy, when performed prior to active weaning, does not influence the duration of weaning or of MV in comparison with a more selective use of tracheostomy. PATIENTS AND METHODS: In this observational prospective cohort study, surgical patients requiring >or= 72 hours of MV were followed prospectively. Patients undergoing tracheostomy prior to any active weaning attempts (early tracheostomy [ET]) were compared with patients in whom initial weaning attempts were made with the endotracheal tube in place (selective tracheostomy [ST]). RESULTS: We compared the duration of weaning, the total duration of MV and the frequency of fatigue and pneumonia. Seventy-four patients met inclusion criteria. Twenty-one patients in the ET group were compared with 53 patients in the ST group (47% of whom ultimately underwent tracheostomy). The median duration of weaning was shorter (3 days versus 6 days, P = 0.05) in patients in the ET group than in the ST group, but the duration of MV was not (median [interquartile range], 11 days [9-26 days] in the ET group versus 13 days [8-21 days] in the ST group). The frequencies of fatigue and pneumonia were lower in the ET group patients. DISCUSSION: Determining the ideal timing of tracheostomy in critically ill patients has been difficult and often subjective. To standardize this process, it is important to identify objective criteria to identify patients most likely to benefit from the procedure. Our data suggest that in surgical patients with resolving respiratory failure, a patient who meets typical criteria for a trial of spontaneous breathing but is not successfully extubated within 24 hours may benefit from a tracheostomy. Our data provide a framework for the conduct of a clinical trial in which tracheostomy timing can be assessed for its impact on the duration of weaning. CONCLUSION: Tracheostomy prior to active weaning may hasten liberation from ventilation and reduce complications. However, this does not reduce the overall duration of MV.

Acute Disease↗

PubMed2003

Audit on tracheostomies performed at the General Intensive Care Unit, Kuala Lumpur Hospital.

During a 6-month period from October 2000 to March 2001, we analysed the indications, methods, waiting period and complications following a tracheostomy at the General Intensive Care Unit (GIGU) of Hospital Kuala Lumpur. There were 49 tracheostomies performed during this period. Thirty of them were performed in the GICU using the percutaneous dilatational method while 19 were performed electively in the Operating Theatre (OT) by the ear, nose and throat (ENT) surgeons. The main indications for a tracheostomy were prolonged mechanical ventilation and airway protection for patients with a poor Glasgow Coma Scale. The average waiting time for a tracheostomy after a decision was made to perform one was 1.34 +/- 0.72 days for a percutaneous tracheostomy and 3.72 +/- 2.52 days for a surgical tracheostomy. This difference was statistically significant (p < 0.001). There was excessive bleeding in 3 patients in the percutaneous tracheostomy group and 1 patient in the surgical tracheostomy group. Percutaneous tracheostomy is now the main method of tracheostomy at the GICU in Hospital Kuala Lumpur. Haemorrhage is the most significant complication of this procedure. However the overall complication rate is comparable with that of a surgical tracheostomy.

Adult↗

PubMed2003

Tracheostomy in critically ill patients.

The authors made a retrospective analysis of results and complications of elective tracheostomies performed by percutaneous dilatational technique (PDT) as well as standard surgical procedure (ST) in critically ill patients in the ICU. The indication for tracheostomy was to facilitate long-term mechanical ventilation, to facilitate cleaning and management of the airway and to maintain upper airway patency. During a 5-year period there were 495 elective tracheostomies performed in the ICU setting, in 209 females and 286 males. From these, 408 were standard (82.4%) and 87 percutaneous dilatational tracheostomies (17.6%). Mean age of patients with tracheostomy was 63.3 years (range 17-93 years) and the mean duration of endotracheal intubation before tracheostomy was 7 days (range from 13 minutes to 21 days). During the monitored period 144 patients (29.0%) were decannulated, out of which 34 patients (23.6%) had PDT and 110 patients (76.4%) ST. A total of 265 patients (53.5%) with tracheostomy died and 86 patients (17.3%) had the tracheostomy cannule in place at the study conclusion. Perioperative complications totaled 14 (2.8%), the most serious being one cardiac arrest and death (0.4%) both in ST as well as in PDT groups. Early postoperative complications totaled 46 (9.2%). Late postoperative complications totaled 7 (1.4%). Percutaneous dilatational tracheostomy is an alternative method to standard surgical tracheostomy in critically ill patients in the ICUs. Standard surgical tracheostomy is an irreplaceable procedure in patients with complex anatomic condition or in high-risk patients. (Tab. 3, Ref. 11).

Adolescent↗