Abstract
Tracheostomy is often indicated for patients requiring prolonged ventilation, as it can facilitate weaning from the ventilator, reduce work of breathing and allow cessation of sedation. Optimal timing and mode of tracheostomy is still under debate.
Objective
To evaluate the technique, timing, and clinical outcomes of tracheostomy in a large single-center cohort of medical intensive care unit (ICU) patients.
Methods
A retrospective cohort analysis was conducted on consecutive patients undergoing tracheostomy between 2006 and 2018 in a medical ICU. Patients received either a percutaneous dilatational tracheostomy or surgical tracheostomy. Data collected included patient demographics, APACHE-II scores, ICU mortality, duration of mechanical ventilation, length of ICU stays, tracheostomy technique, and timing of tracheostomy relative to intubation and initiation of mechanical ventilation.
Results
A total of 1570 tracheostomies were analyzed, comprising 1323 (84.2 %) dilatational tracheostomies and 247 (15.8 %) surgical tracheostomies. The type of tracheostomy did not significantly affect length of stays or length of mechanical ventilation. Subgroup analysis based on tracheostomy timing revealed that early tracheostomy (<7 days post-intubation) was associated with shorter length of mechanical ventilation (p < 0.001), reduced length of stays (p < 0.001), and lower mortality (p = 0.01). Multivariate regression analysis identified early tracheostomy as an independent predictor of reduced mortality, while tracheostomy type had no significant effect on mortality outcomes.
Conclusion
Early tracheostomy, within seven days of intubation, was associated with improved survival, shorter length of mechanical ventilation, and reduced ICU stays, independent of the tracheostomy technique in our retrospective cohort in medical ICU patients.
Highlights
- •
Retrospective analysis of 1570 tracheostomies on a medical ICU.
- •
Early tracheostomy did reduce overall mortality.
- •
Early tracheostomy did reduce length of stay and length of mechanical ventilation.
| APACHE II score | Acute Physiology and Chronic Health Evaluation II Score |
|---|---|
| ARDS | Acute respiratory distress syndrome |
| CI | Confidence interval |
| COPD | Chronic obstructive pulmonary disease |
| ENT | Ear, nose and Throat |
| ET | Early tracheostomy |
| ICU | Intensive Care Unit |
| IQR | Interquartile range |
| IRB | Institutional review board |
| LOMV | Length of mechanical ventilation |
| LOS | Length of stay |
| LT | Late tracheostomy |
| MV | Mechanical ventilation |
| OR | Odds ratio |
| PDT | Percutaneous dilatational tracheostomy |
| ST | Surgical tracheostomy |
| VAP | Ventilator-associated pneumonia |
1
Introduction
Tracheostomy is a commonly performed procedure in the intensive care unit (ICU) [ ]. Tracheostomy is often indicated for patients requiring prolonged ventilation, as it can facilitate weaning from the ventilator, reduce work of breathing and improve patient comfort which allows cessation of sedation [ ]. Despite its widespread use, standardized guidelines regarding its indications, technique, and optimal timing are rare and remain unclear [ ].
Indications for tracheostomy extend beyond prolonged ventilation and include airway obstruction, the need for airway protection due to impaired cough or swallowing reflexes, and enhanced secretion management [ ]. Additionally, tracheostomy has been shown to decrease the incidence of ventilator-associated pneumonia (VAP), shorten the duration of mechanical ventilation, and reduce ICU length of stay [ ]. Nonetheless, complications such as bleeding, wound infections, and tracheal stenosis, though rare (0.6–2.8 % prevalence), can occur [ ].
Multiple tracheostomy techniques, including percutaneous and surgical methods, are employed. The percutaneous dilatational tracheostomy (PDT), first described by Ciaglia et al., is now the preferred method in ICU settings due to its simplicity and bedside applicability using Seldinger techniques [ ]. A meta-analysis by Johnson-Obaseki et al. encompassing 22 studies with 1608 patients found no significant differences between PDT and surgical tracheostomy (ST) in terms of mortality or perioperative hemorrhage. However, PDT demonstrated lower infection rates and reduced operative time compared to ST [ ].
Optimal timing for tracheostomy remains subject of debate [ ]. A meta-analysis by Meng et al. including 2040 patients concluded that early tracheostomy (<10 days after intubation) might reduce the duration of sedation but had no significant effect on mortality, incidence of VAP, duration of mechanical ventilation, or length of ICU stay [ ]. Other recent meta-analyses have highlighted potential benefits of early tracheostomy, including reduced mortality, shorter ICU stays, and decreased ventilation duration [ ].
In this analysis, we present a large cohort of patients undergoing tracheostomy in a medical ICU, with a focus on evaluating the technique and timing of the procedure and their impact on clinical outcomes.
2
Methods
2.1
Type of study
We conducted a retrospective cohort study. A review of digital hospital records from 2006 to 2018 was done to identify patients admitted to the medical intensive care units within the Division of Nephrology and Intensive Care Medicine at a large tertiary care center in Berlin, Germany who received a tracheostomy procedure during the ICU stay. The institutional review board (IRB) granted a waiver of informed consent due to the retrospective nature of the study involving routine clinical data (IRB number EA4/176/18).
2.2
Inclusion and exclusion
All patients who underwent tracheostomy between 2006 and 2018 were included in the study (s. Fig. 1 ). Data collected included age, gender, diagnosis at ICU admission, ICU mortality, duration of mechanical ventilation (LOMV), ICU length of stay (LOS), type of tracheostomy (percutaneous dilatational or surgical), Acute Physiology and Chronic Health Evaluation (APACHE-II) scores at admission and discharge, and the timing of tracheostomy relative to initiation of mechanical ventilation. Patients with missing information on time window from intubation to tracheostomy were excluded from the final analysis.
2.3
Type of tracheostomy
Percutaneous dilatational tracheostomies were performed at the bedside using the single dilatator technique with bronchoscopic guidance. These procedures were conducted by senior intensivists (board-certified specialists in intensive care medicine) assisted by resident physicians and ICU nurses. Surgical tracheostomies were performed in the operating room by board-certified ear, nose, and throat (ENT) surgeons or maxillofacial surgeons, assisted by residents.
PDT was the standard approach unless contraindications necessitated surgical intervention. Indications for ST included a known difficult airway, anatomical abnormalities (e.g., inability to recline the neck, large thyroid gland), or severe acute respiratory distress syndrome (ARDS) to avoid PEEP loss, with ARDS diagnosed according to the Berlin definition [ ].
2.4
Statistical analysis and outcome measures
Statistical analyses were performed using SPSS and R software. Continuous variables were reported as medians with interquartile ranges (IQRs) or as absolute values with percentages. Group comparisons between PDT and ST, as well as between early tracheostomy (ET) and late tracheostomy (LT), were assessed using the Mann-Whitney U test for non-parametric data.
The level of significance was set at 5 % (two-tailed) without adjustment for multiple comparison. All p-values constitute exploratory analysis and do not allow for confirmatory generalization of results.
A multiple regression analysis was conducted to assess predictors of mortality, using gender, age, tracheostomy type, APACHE-II score at ICU admission, and tracheostomy timing (early vs. late) as independent variables.
2.5
Timing of tracheostomy
Early tracheostomy was defined as tracheostomy performed within seven days after initiation of mechanical ventilation, whereas late tracheostomy was defined as occurring after more than seven days. This classification was chosen in accordance with previous studies on tracheostomy timing to facilitate comparison [ , ].
3
Results
A total of 1570 tracheostomy procedures were included in the retrospective analysis. Patient characteristics are summarized in Table 1 .
| Variable | n = 1570 |
|---|---|
| Male sex, n (%) | 1025 (65.3) |
| Age, years | 65 (55–73) |
| APACHE-II score at ICU admission | 24 (17–31) |
| APACHE-II score at ICU discharge | 19 (14–28) |
| ICU stay, days | 41 (26–66) |
| LOMV, days | 28 (18–42) |
| Diagnosis, n (%) | |
| Sepsis | 229 (14.6) |
| Malignancies | 191 (12.2) |
| Myocardial infarction | 150 (9.6) |
| Pneumonia | 149 (9.5) |
| COPD | 110 (7.0) |
| Liver failure (acute or chronic) | 90 (5.7) |
| ARDS | 84 (5.4) |
| Heart failure | 72 (4.6) |
| Other cardiac disease | 57 (3.6) |
| Other pulmonary diseases | 57 (3.6) |
| Cardiac arrhythmia | 55 (3.5) |
| Acute kidney injury | 46 (2.9) |
| Neurological diseases | 44 (2.8) |
| Acute pulmonary embolism | 19 (1.2) |
| Other infections | 17 (1.1) |
| Chronic kidney disease | 17 (1.1) |
| Others | 183 (11.7) |
| Mortality, n (%) | 596 (37.9) |
3.1
Type of tracheostomy
The majority of procedures were percutaneous dilatational tracheostomies, performed at the bedside (n = 1323; 84.3 %), while surgical tracheostomies accounted for 247 cases (15.7 %). The duration of ICU stays and mechanical ventilation did not differ significantly between the PDT and ST groups ( Table 2 ). Patients undergoing ST were significantly younger (median age 63 vs. 66 years, p = 0.024). Mortality was lower in the ST group (29.6 %) compared to the PDT group (39.5 %, p = 0.002).
Related posts:
Recent advances in the development of invasive ventilator liberation
Video laryngoscopy for obstetric airway management: A narrativereview
Identifying and analyzing extremely productive authors in intensive care medicine: A scientometric analysis
Incision depth in surgical airway management using computed tomography of the neck to minimize complications
Challenges in laryngeal mask ventilation: Case of a vocal cord polyp
Anesthesia for Orthopedic Surgery
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
