Article

Tracheostomy practice in adults with acute respiratory failure

Department of Medicine (PEM), Section of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest School of Medicine, Winston Salem, NC.
Critical care medicine (Impact Factor: 6.15). 07/2012; 40(10):2890-6. DOI: 10.1097/CCM.0b013e31825bc948
Source: PubMed

ABSTRACT : Tracheostomy remains one of the most commonly performed surgical procedures in adults with acute respiratory failure and identifies a patient cohort which is among the most resource-intensive to provide care. The objective of this concise definitive review is the synthesis of current knowledge regarding tracheostomy practice in this context.
: Peer-reviewed, English language publications pertaining to tracheostomy indications, timing, technique, and management.
: Contemporary literature concerning tracheostomy use predominately focuses on two aspects: procedure timing and technical considerations. Three recent, large, randomized controlled trials failed to demonstrate an effect of "early" tracheostomy on mortality, infectious complications, intensive care unit, or hospital length of stay. Relative to continued translaryngeal intubation, tracheostomy was associated with less sedation use and earlier mobility. An accumulating body of literature suggests that, relative to conventional surgical methods, percutaneous dilational techniques are advantageous with respect to cost and complication profile. Literature addressing management following tracheostomy placement consists largely of single institution, nonrandomized reports, limiting the ability to formulate specific recommendations regarding this aspect of care.
: In patients who otherwise lack indication for surgical airway, clinicians should defer tracheostomy placement for at least 2 wks following the onset of acute respiratory failure to insure need for ongoing ventilatory support. Subpopulations of patients (e.g., those with acute neurological injury or stroke) may benefit from earlier tracheostomy. Percutaneous dilational tracheostomy should be considered the preferred technique for this intervention in the appropriately selected individual. Future investigations should include efforts to optimize post-tracheostomy management and to quantify tracheostomy effects on patient-centric outcomes.

0 Followers
 · 
161 Views
 · 
0 Downloads
  • Source
    • "Cette technique est en effet devenue majoritaire au niveau international [12] [13] [14], ce qui est retrouvé dans notre questionnaire, avec toutefois des variations de pratiques notables concernant le recours aux chirurgiens selon les centres. Cependant, faute de bé né fice clair et de recommandations fondé es sur des travaux de bon niveau [15], les pratiques de traché otomie sont trè s variables, avec dans notre e ´ tude d'importants e ´ carts-types de fré quence dé claré e de traché otomie quel que soit le type d'unité . Cet acte est volontiers ré alisé chez les patients Fig. 1. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Tracheostomy is a frequent procedure in ICU but patient follow-up and management after ICU has been poorly documented. We conducted a practice survey in French general ICUs and in neurointensive care units concerning tracheostomized ICU patients and their management after ICU. National observational descriptive transversal study as survey of opinion and practices. An email, with a link to an automated online questionnaire, was sent to two medical doctors of each French ICU. Demographic data and reported practices concerning indications, technique and post-ICU management were collected. We received 148 intensivists responses from different ICUs, of which 15% from neurointensivists. There was no difference between general intensivists and neurointensivists concerning the reported use of tracheostomy (10±13% vs 20±22%, P=0.05) and concerning the usual timing of the procedure (predominantly between the 10th and the 21th day) (P=0.62). Indications were weaning failure from the ventilator and neurological ventilatory dysfunction. Percutaneous tracheostomy was mainly performed irrespective of the type of unit. Only 48% of doctors declared usually be able to wean patient from the cannula before ICU discharge. Usual difficulties for post-ICU transfer due only to the presence of the cannula were found by 80% of respondants. Eighty-nine per cent of respondents felt that management of tracheostomized patients after the ICU could be improved. Tracheostomy is a frequent procedure, mostly percutaneous. Indications and timing for tracheostomy correspond to the recommendations. Reported difficulties in post-ICU management are important and present nationwide.
    Annales francaises d'anesthesie et de reanimation 03/2014; 33(4). DOI:10.1016/j.annfar.2014.01.020 · 0.84 Impact Factor
  • Source
    • "Cette technique est en effet devenue majoritaire au niveau international [12] [13] [14], ce qui est retrouvé dans notre questionnaire, avec toutefois des variations de pratiques notables concernant le recours aux chirurgiens selon les centres. Cependant, faute de bé né fice clair et de recommandations fondé es sur des travaux de bon niveau [15], les pratiques de traché otomie sont trè s variables, avec dans notre e ´ tude d'importants e ´ carts-types de fré quence dé claré e de traché otomie quel que soit le type d'unité . Cet acte est volontiers ré alisé chez les patients Fig. 1. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objectives Tracheostomy is a frequent procedure in ICU but patient follow-up and management after ICU has been poorly documented. We conducted a practice survey in French general ICUs and in neurointensive care units concerning tracheostomized ICU patients and their management after ICU. Study design National observational descriptive transversal study as survey of opinion and practices. Materials and methods An email, with a link to an automated online questionnaire, was sent to two medical doctors of each French ICU. Demographic data and reported practices concerning indications, technique and post-ICU management were collected. Results We received 148 intensivists responses from different ICUs, of which 15% from neurointensivists. There was no difference between general intensivists and neurointensivists concerning the reported use of tracheostomy (10 ± 13% vs 20 ± 22%, P = 0.05) and concerning the usual timing of the procedure (predominantly between the 10th and the 21th day) (P = 0.62). Indications were weaning failure from the ventilator and neurological ventilatory dysfunction. Percutaneous tracheostomy was mainly performed irrespective of the type of unit. Only 48% of doctors declared usually be able to wean patient from the cannula before ICU discharge. Usual difficulties for post-ICU transfer due only to the presence of the cannula were found by 80% of respondants. Eighty-nine per cent of respondents felt that management of tracheostomized patients after the ICU could be improved. Conclusion Tracheostomy is a frequent procedure, mostly percutaneous. Indications and timing for tracheostomy correspond to the recommendations. Reported difficulties in post-ICU management are important and present nationwide.
    Annales francaises d'anesthesie et de reanimation 01/2014; · 0.84 Impact Factor
  • Source
    • "Nevertheless, tracheostomy is being undertaken significantly earlier during ICU stay, as the intervention appears to be beneficial in terms of patient comfort, mobility, and reducing the requirement for sedation [1,6]. Percutaneous dilatational tracheostomy (PDT) has gained wide acceptance and has become the procedure of choice for tracheostomy in critically ill patients worldwide [7]. However this procedure, just like surgical tracheostomy, is associated with major complications, including death. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Since the introduction and widespread acceptance of percutaneous techniques in the intensive care unit (ICU) setting, the number of critically ill patients undergoing tracheostomy has steadily increased. However, this procedure can be associated with major complications, including death. The purpose of this study is to estimate the incidence and analyze the causes of lethal complications due to percutaneous dilatational tracheostomy (PDT). We analyzed cases of lethal outcome due to complications from PDT including cases published between 1985 and April 2013. A systematic literature search was performed and unpublished cases from our own departmental records were retrospectively analyzed. 71 cases of lethal outcome following PDT were identified including 68 published cases and 3 of our own patients. The incidence of lethal complications was calculated to be 0.17%. Of the fatal complications, 31.0% occurred during the procedure and 49.3% within seven days of the procedure. The main causes of death were: hemorrhage (38.0%), airway complications (29.6%), tracheal perforation (15.5%), and pneumothorax (5.6%). We found specific risk factors for complications in 73.2% of patients, 25.4% of patients had more than one risk factor. Bronchoscopic guidance was used in only 46.5% of cases. According to this analysis, PDT-related death occurs in 1 out of 600 patients receiving a PDT. Careful patient selection, bronchoscopic guidance, and securing the tracheal cannula with sutures are likely to reduce complication rates.
    Critical care (London, England) 10/2013; 17(5):R258. DOI:10.1186/cc13085
Show more