DOES EARLY TRACHEOSTOMY REALLY CHANGE OUTCOMES IN THE INTENSIVE CARE UNIT?

Authors: Siddiqui et al

 

Abstract:

Introduction: Studies done on small cohorts in the West have demonstrated that early tracheostomy (less than seven days), was associated with shorter length of sedation, shorter duration of Mechanical ventilation (MV) and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival. The main complications encountered are tracheal stenosis, bleeding, and the risk of infection.
Methodology: We carried out an audit in order to analyze the outcomes and results of patients undergoing early (< 7 days) versus late tracheostomies. We included all adults patients undergoing elective tracheostomy for ‘respiratory failure’. Our setting was an 11 bedded multidisciplinary adult Intensive Care Unit (ICU) of a University Hospital in Karachi, Pakistan.
Results: Twenty five patients underwent tracheostomy in one year out of a total of 350 patients. In our ICU the incidence of elective tracheostomy was therefore 7%. The most frequent reason for tracheostomy was ‘Failure to wean from ventilator’ (13.5%). Overall mortality in both groups was 39% with a slightly higher incidence in the Late tracheostomy group ( p value of 0.18 - not significant). ‘ICU length of stay’ and ‘Hospital duration’ was significantly different in the 2 groups (p values of 0.01 and 0.03).
Discussion: The benefits of early tracheostomy are improved care for patients in the critical care setting and hopefully reduced hospital and patient costs and it ‘really’ does improve ‘some’ outcomes while not affecting others significantly.
Key words: tracheostomy, early weaning, intensive care unit, prolonged ventilation.

Introduction:

Patients may require mechanical ventilation (MV) in the intensive care unit (ICU) for various reasons including low Glasgow coma scale (GCS), airway protection, lung injury or poor lung compliance(1). As Intensivists we often counsel patients’ families on the benefits of early tracheostomy claiming that it reduces duration of ventilation as it may decrease respiratory dead space, length of ventilator dependence and better patient tolerance(2, 3). Studies done on small cohorts in the West have demonstrated that early tracheostomy (</=7 days), was associated with shorter length of sedation, shorter duration of MV and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival(4). Often intensive care physicians feel that performing tracheostomy will facilitate weaning from MV and early oral nutrition, and would improve overall patient comfort. The main disadvantages encountered are tracheal complications, such as stenosis, bleeding, and the risk of infection. In literature, surgical techniques in the Operation theatre are largely preferred compared to percutaneous techniques(1, 5, 6). We have carried out a retrospective audit in order to analyze the clinical outcomes of patients undergoing early versus late tracheostomy.

 

Methods:

Our objectives were a) to determine the incidence of tracheostomies in our ICU, b) to assess the median timing of tracheostomies done, c) to establish the length of stay and outcome of patients undergoing early [< 7 days] versus late [> 7 days] tracheostomies, d) to assess success of weaning from ventilator after tracheostomy and e) to determine whether late trachestomy is independently predictive of higher mortality. Our setting was the 11 bedded multidisciplinary adult Intensive Care Unit of Aga Khan University Hospital, Karachi. Our study design is a retrospective, observational audit.
Study Population:
Inclusion criteria were all adults (≥16 years) undergoing elective tracheostomy for ‘respiratory failure’ and the exclusion criteria included all patients who were < 16 years, those patients undergoing tracheostomy in the Operation Room (OR) or those patients undergoing emergency tracheostomy.
Enrollment:
All patients admitted to the ICU from April 2006 – April 2007 and undergoing a tracheostomy were screened for enrollment by retrospective chart review. Cases for enrollment are adults (≥ 16 years), with a diagnosis of respiratory failure who are undergoing tracheostomy. A research officer used a case record form to record all data. Patient confidentiality was maintained at all times.

 

Results:


Variables were entered in SPSS version 13. Descriptive variables were compared for differences using the Student’s t test for continuous variables. Univariate & multivariate regression modeling to identify independent predictors of mortality were used and p values < 0.05 were considered significant.
Descriptive analysis:
Sample size was 25 patients in one year out of a total of 331 ICU admissions. In our ICU the average age of patients in years amongst this cohort was 50.68 +_ 14 years and 56% were female. The decision to perform a tracheostomy was made in 88% of cases by the Primary team and 12% by the ICU team.

Characteristics

n

%

Age, Years

50.68 ± 14

Gender

Male

11

44

Female

14

56

Reason for Tracheostomy

Low GCS

7

28

Restricted mouth opening

4

16

Unable to wean

13

52

Vocal cord palsy

1

4

Decision of Tracheostomy

Primary team

22

88

ICU team

3

12

Successful Weaning post tracheostomy

22

88

End Result

Expired

12

48

Alive

13

52

Table 1: Characteristics of patients undergoing tracheostomies in one year.

 

As shown in Table 1 the most frequent reason for tracheostomy was ‘failure to wean’ from the ventilator (13.52%) followed by ‘inability to protect airway due to poor neurological function’ defined as a GCS (Glasgow coma scale) of < 8 (7.28%); 16% were for ‘restricted mouth opening’ and 4% for ‘vocal cord palsy’., the characteristics of patients undergoing tracheostomies included the following. Survival rate amongst tracheostomized patients was 52%.

Characteristics

Median (IQR)

Day of tracheostomy

8

Hospital duration

30

ICU stay

20

Day of DNR decision

18

Duration of ventilation after tracheostomy

4

APACHE score

21

Predicted death rate

39

Table 2: Overall Median interquartile ranges (IQR) of tracheostomy patients.


Table 2 shows the Median interquartile ranges of patient characteristics. These show that day 8 was the median day of performing the tracheostomy; average hospital stay was 30 days and ICU stay was 16 days in these patients. DNR decision was taken in 25% of patients and on day 18 on average. Duration of ventilation following tracheostomy was a median of 4 days (+- 2 days). Median APACHE II score was 21.
Statistical Analysis:
A comparison of means was made using Students t- test between ‘early’ (<7 days) and ‘late’ (>7 days) as shown in Tables 3 and 4.

Characteristics

Early Tracheostomy

 (< 7 days)

Late Tracheostomy

(> 7 days)

p

Gender

Male

5(55.6)

6(37.5)

0.38

Female

4(44.4)

10(62.5)

Weaning

8(88.9)

14(87.5)

0.91

Reason of Tracheostomy

Low GCS

2(22.2)

5(31.3)

0.01

Restricted mouth opening

4(44.4)

0

Unable to wean

2(22.2)

11(68.8)

Vocal cord palsy

1(11.1)

0

Decision of tracheostomy

Primary team

9(100)

13(81.3)

0.16

ICU team

0

3(18.8)

End result

Expired

5(55.6)

7(43.8)

0.57

Alive

4(44.4)

9(56.3)

Table 3: Descriptive Comparison of early vs late tracheostomy patients.

Characteristics

Early Tracheostomy

 (< 7 days)

Late Tracheostomy

(> 7 days)

p

Age, Years

Mean ± SD

50.11 ± 14.0

51 ± 14.0

0.88

Median (Range)

55 (67-32)

53.5(79-26)

Hospital duration

Mean ± SD

22.78 ± 17.3

42 ± 24.1

0.03

Median (Range)

18 (64-2)

40(108-14)

ICU stay

Mean ± SD

13.89 ± 9.3

15(30-2)

0.01

Median (Range)

32.88 ± 21.5

29(92-10)

Day of DNR decision

Mean ± SD

19.25 ± 7.3

16.5(30-14)

0.29

Median (Range)

30.71 ± 18.2

31(60-10)

Duration of ventilation

Mean ± SD

8.67 ± 10.3

3(30.0)

0.42

Median (Range)

11.69 ± 12.9

5(38-1)

Predicted death rate

Mean ± SD

34.67 ± 18.6

46.88 ± 22.1

0.18

Median(Range)

29(64-11)

48(83-17)

APACHE score

Mean ± SD

19 ± 6.06

22.88 ± 6.8

0.17

Median(Range)

18(28-10)

23.50(35-13)

Table 4: Statistical Comparison of early vs late tracheostomy patients using Student’s t-test.

 

A p- value of < 0.05 was taken as significant. Low GCS (p value of 0.01) as a reason for early tracheostomy was strongly significant as was length of ICU stay (p=0.01) and length of hospital duration (p=0.03).

 

Discussion:


Sugarman(7) et al in 1997 showed in a randomized controlled trial on 157 patients with early tracheostomies that there were no significant differences in the primary end points of ICU length of stay and predicted mortality. However in more recent studies(8, 9) in select group of patients a shorter stay in the ICU for the early group than patients in the late group have been shown thereby reducing the total cost and complications such as nosocomial infections. Another meta analysis by Dunham(10) in 2006 on trauma patients was inconclusive. In our ICU we counsel families to consent for early tracheostomies in patients who are predicted to have prolonged ventilation due to pulmonary issues or neurologically poor predicted outcomes. We wished to see whether our predictions were actually true by doing this year long retrospective observational case controlled study.

Our median age in the 25 (n) patients who underwent ICU elective tracheostomies, was 50 years which was surprisingly a younger cohort. Perhaps this is explained by the fact that a large group (28%) belonged to patients with ‘low GCS’ scores, indicating neurologically impaired patients. However a larger group (52%) had respiratory failure leading to inability to wean as the main reason requiring early tracheostomy. There was no difference in the age, gender distribution or APACHE II scores between the two groups. The results interestingly showed that in the ‘Early’ group the decision to make the patient DNR (‘do not resuscitate’) was taken later than in the late group. This may indicate that the patients with early tracheostomies were deemed more salvageable by the ICU physicians. As shown in other studies time and again (11, 12) in our study ‘early tracheostomy’ did not significantly affect the predicted death rate or in hospital mortality. However, again like in other studies, there was a significant difference in ‘Hospital duration’ and ‘ICU length of stay’(13). This generally infers a smaller cost as compared to those who have late tracheostomies or none at all. Unlike other studies(14, 15), our post tracheostomy ventilation days were not significantly different. This may be as a result of a small sample size.

In conclusion, we can say that the next time we counsel families on the benefits of early tracheostomy for those patients in whom we predict a long period of ventilation or in order to shorten their ICU stay, we can be certain that early tracheostomy “really” does improve “some” outcomes, whilst not affecting others.

References:


1. Blot F, Melot C. Indications, timing, and techniques of tracheostomy in 152 French ICUs. Chest 2005;127(4):1347-52.
2. Aissaoui Y, Azendour H, Balkhi H, Haimeur C, Kamili Drissi N, Atmani M. [Timing of tracheostomy and outcome of patients requiring mechanical ventilation.]. Ann Fr Anesth Reanim 2007.
3. Barquist ES, Amortegui J, Hallal A, Giannotti G, Whinney R, Alzamel H, et al. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. J Trauma 2006;60(1):91-7.
4. Bouderka MA, Fakhir B, Bouaggad A, Hmamouchi B, Hamoudi D, Harti A. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma 2004;57(2):251-4.
5. Flaatten H, Gjerde S, Heimdal JH, Aardal S. The effect of tracheostomy on outcome in intensive care unit patients. Acta Anaesthesiol Scand 2006;50(1):92-8.
6. Gatti G, Cardu G, Bentini C, Pacilli P, Pugliese P. Weaning from ventilator after cardiac operation using the Ciaglia percutaneous tracheostomy. Eur J Cardiothorac Surg 2004;25(4):541-7.
7. Sugerman HJ, Wolfe L, Pasquale MD, Rogers FB, O'Malley KF, Knudson M, et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma 1997;43(5):741-7.
8. Ahmed N, Kuo YH. Early versus Late Tracheostomy in Patients with Severe Traumatic Head Injury. Surg Infect (Larchmt) 2007;8(3):343-8.
9. Aissaoui Y, Azendour H, Balkhi H, Haimeur C, Kamili Drissi N, Atmani M. [Timing of tracheostomy and outcome of patients requiring mechanical ventilation]. Ann Fr Anesth Reanim 2007;26(6):496-501.
10. Dunham CM, Ransom KJ. Assessment of early tracheostomy in trauma patients: a systematic review and meta-analysis. Am Surg 2006;72(3):276-81.
11. Kane TD, Rodriguez JL, Luchette FA. Early versus late tracheostomy in the trauma patient. Respir Care Clin N Am 1997;3(1):1-20.
12. Moller MG, Slaikeu JD, Bonelli P, Davis AT, Hoogeboom JE, Bonnell BW. Early tracheostomy versus late tracheostomy in the surgical intensive care unit. Am J Surg 2005;189(3):293-6.
13. Lukas J, Stritesky M. Tracheostomy in critically ill patients. Bratisl Lek Listy 2003;104(7-8):239-42.
14. Mittendorf EA, McHenry CR, Smith CM, Yowler CJ, Peerless JR. Early and late outcome of bedside percutaneous tracheostomy in the intensive care unit. Am Surg 2002;68(4):342-6; discussion 346-7.
15. Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007;23(1):35-53.

 

Authors

Dr. Shahla Siddiqui, MD, DABA.*
Assistant Professor,
Department of Anaesthesiology,
Aga Khan University,
Karachi, Pakistan,

Dr. Asghar Ali, MBBS.
Resident,
Department of Anaesthesiology,
Aga Khan University.

Dr. Nawal Salahuddin, MD, DABIM, FACCM.
Associate Professor,
Department of Pulmonary Medicine,
Aga Khan University.

Ms Roshan Manasia, RN.
Senior Registered Nurse,
Charge Nurse ICU,
Aga Khan University.


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