Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study

Chia-Lin Hsu, Kuan-Yu Chen, Chia-Hsuin Chang, Jih-Shuin Jerng, Chong-Jen Yu, Pan-Chyr Yang, Chia-Lin Hsu, Kuan-Yu Chen, Chia-Hsuin Chang, Jih-Shuin Jerng, Chong-Jen Yu, Pan-Chyr Yang

Abstract

Introduction: Tracheostomy is frequently performed in critically ill patients for prolonged intubation. However, the optimal timing of tracheostomy, and its impact on weaning from mechanical ventilation and outcomes in critically ill patients who require mechanical ventilation remain controversial.

Methods: The medical records of patients who underwent tracheostomy in the medical intensive care unit (ICU) of a tertiary medical centre from July 1998 to June 2001 were reviewed. Clinical characteristics, length of stay in the ICU, rates of post-tracheostomy pneumonia, weaning from mechanical ventilation and mortality rates were analyzed.

Results: A total of 163 patients (93 men and 70 women) were included; their mean age was 70 years. Patients were classified into two groups: successful weaning (n = 78) and failure to wean (n = 85). Shorter intubation periods (P = 0.02), length of ICU stay (P = 0.001) and post-tracheostomy ICU stay (P = 0.005) were noted in patients in the successful weaning group. Patients who underwent tracheostomy more than 3 weeks after intubation had higher ICU mortality rates and rates of weaning failure. The length of intubation correlated with the length of ICU stay in the successful weaning group (r = 0.70; P < 0.001). Multivariate analysis revealed that tracheostomy after 3 weeks of intubation, poor oxygenation before tracheostomy (arterial oxygen tension/fractional inspired oxygen ratio <250) and occurrence of nosocomial pneumonia after tracheostomy were independent predictors of weaning failure.

Conclusion: The study suggests that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality.

Figures

Figure 1
Figure 1
The relationship of weaning rates, ICU mortality and durations of intubation. (a) Rate of successful weaning in patients who underwent tracheostomy after different durations of intubation. The rate of successful weaning declined when patients underwent tracheostomy after 21 days of intubation. (b) Intensive care unit (ICU) mortality rates in patients who underwent tracheostomy after different durations of intubation. The ICU mortality rates increased when the patients underwent tracheostomy after 21 days of intubation.
Figure 2
Figure 2
Correlation of intubation period and the length of intensive care unit (ICU) stay in patients who weaned successfully.
Figure 3
Figure 3
Survival curves of independent predictors of weaning failure. (a) Difference in rates of successful weaning between patients who underwent tracheostomy within 21 days (dotted line) and those who underwent tracheostomy later than 21 days (solid line; P < 0.001). (b) Difference in rates of successful weaning between patients with an arterial oxygen tension (PaO2)/fractional inspired oxygen (FiO2) ratio > 250 (dotted line) and those with a PaO2/FiO2 ratio < 250 (solid line; P < 0.001) before tracheostomy. (c) Difference in rates of successful weaning between the patients with post-tracheostomy pneumonia (solid line) and those without post-tracheostomy pneumonia (dotted line; P < 0.001)

References

    1. Esteban A, Anzueto A, Alia I, Gordo F, Apezteguia C, Palizas F, Cide D, Goldwaser R, Soto L, Bugedo G, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med. 2000;161:1450–1458.
    1. Heffner JE, Miller KS, Sahn SA. Tracheostomy in the intensive care unit. Part 1: Indications, technique, management. Chest. 1986;90:269–274.
    1. Heffner JE. Medical indications for tracheotomy. Chest. 1989;96:186–190.
    1. Astrachan DI, Kirchner JC, Goodwin WJ., Jr Prolonged intubation vs. tracheotomy: complications, practical and psychological considerations. Laryngoscope. 1988;98:1165–1169.
    1. Diehl JL, El Atrous S, Touchard D, Lemaire F, Brochard L. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med. 1999;159:383–388.
    1. Upadhyay A, Maurer J, Turner J, Tiszenkel H, Rosengart T. Elective bedside tracheostomy in the intensive care unit. J Am Coll Surg. 1996;183:51–55.
    1. Kahveci SF, Goren S, Kutlay O, Ozcan B, Korfali G. Bedside percutaneous tracheostomy experience with 72 critically ill patients. Eur J Anaesthesiol. 2000;17:688–691. doi: 10.1046/j.1365-2346.2000.00756.x.
    1. Zeitouni AG, Kost KM. Tracheostomy: a retrospective review of 281 cases. J Otolaryngol. 1994;23:61–66.
    1. Stock MC, Woodward CG, Shapiro BA, Cane RD, Lewis V, Pecaro B. Perioperative complications of elective tracheostomy in critically ill patients. Crit Care Med. 1986;14:861–863.
    1. Plummer AL, Gracey DR. Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest. 1989;96:178–180.
    1. MacIntyre NR, Cook DJ, Ely EW, Jr, Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ, American College of Chest Physicians; American Association for Respiratory Care; American College of Critical Care Medicine Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(Suppl):375S–395S. doi: 10.1378/chest.120.6_suppl.375S.
    1. Maziak DE, Meade MO, Todd TR. The timing of tracheostomy: a systematic review. Chest. 1998;114:605–609.
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–829.
    1. Torres A, Aznar R, Gatell JM, Jimenez P, Gonzalez J, Ferrer A, Celis R, Rodriguez-Roisin R. Incidence, risk, and prognostic factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis. 1990;142:523–528.
    1. Lesnik I, Rappaport W, Fulginiti J, Witzke D. The role of early tracheostomy in blunt, multiple organ trauma. Am Surg. 1992;58:346–349.
    1. Armstrong PA, McCarthy MC, Peoples JB. Reduced use of resources by early tracheostomy in ventilator-dependent patients with blunt trauma. Surgery. 1998;124:763–767. doi: 10.1067/msy.1998.91224.
    1. Sugerman HJ, Wolfe L, Pasquale MD, Rogers FB, O'Malley KF, Knudson M, DiNardo L, Gordon M, Schaffer S. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma. 1997;43:741–747.
    1. Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery. 1990;108:655–659.
    1. Koh WY, Lew TW, Chin NM, Wong MF. Trachostomy in a neuro-intensive care setting: Indications and timing. Anaesth Intensive Care. 1997;25:365–368.
    1. Ibrahim EH, Tracy L, Hill C, Fraser VJ, Kollef MH. The occurrence of ventilator-associated pneumonia in a community hospital. Chest. 2001;120:555–561. doi: 10.1378/chest.120.2.555.
    1. Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med. 1999;27:1714–1720. doi: 10.1097/00003246-199909000-00003.
    1. Brook AD, Sherman G, Malen J, Kollef MH. Early versus late tracheostomy in patients who require prolonged mechanical ventilation. Am J Crit Care. 2000;9:352–359.
    1. Ely EW, Baker AM, Evans GW, Haponik EF. The prognostic significance of passing a daily screen of weaning parameters. Intensive Care Med. 1999;25:581–587. doi: 10.1007/s001340050906.
    1. Yarington CT, Jr, Frazer JP. Complications of tracheostomy. Arch Surg. 1965;91:652–655.
    1. Dane TE, King EG. A prospective study of complications after tracheostomy for assisted ventilation. Chest. 1975;67:398–404.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe