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: 6.31). 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.

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    • "Recent studies have suggested that tracheotomy results in fewer oral-labial ulcerations, improves pulmonary toileting, and lowers incidence of pulmonary infections [4]. Furthermore , newer techniques such as percutaneous dilatation tracheotomy (PDT) have been shown to be cost-effective and safe, offering clinicians an effective alternative to surgical tracheostomy [5] [6]. "
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    ABSTRACT: Background. The optimal timing of tracheotomy and its impact on weaning from mechanical ventilation in critically ill morbidly obese patients remain controversial. Methods. We conducted a retrospective chart review of morbidly obese subjects (BMI ≥ 40 kg/m(2) or BMI ≥ 35 kg/m(2) and one or more comorbid conditions) who underwent a tracheotomy between July 2008 and June 2013 at a medical intensive care unit (ICU). Clinical characteristics, rates of nosocomial pneumonia (NP), weaning from mechanical ventilation (MV), and mortality rates were analyzed. Results. A total of 102 subjects (42 men and 60 women) were included; their mean age and BMI were 56.3 ± 15.1 years and 53.3 ± 13.6 kg/m(2), respectively. There was no difference in the rate of NP between groups stratified by successful weaning from MV (P = 0.43). Mortality was significantly higher in those who failed to wean (P = 0.02). A cutoff value of 9 days for the time to tracheotomy provided the best balanced sensitivity (72%) and specificity (59.8%) for predicting NP onset. Rates of NP and total duration of MV were significantly higher in those who had tracheostomy ≥ 9 days (P = 0.004 and P = 0.002, resp.). Conclusions. The study suggests that tracheotomy in morbidly obese subjects performed within the first 9 days may reduce MV and decrease NP but may not affect hospital mortality.
    Full-text · Article · Sep 2014 · Critical care research and practice
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    • "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. "
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    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.
    Full-text · Article · Mar 2014 · Annales francaises d'anesthesie et de reanimation
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    • "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. "
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    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.
    Full-text · Article · Jan 2014 · Annales francaises d'anesthesie et de reanimation
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