Evolution Over Time of Ventilatory Management and Outcome of Patients With Neurologic Disease.

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease.

Early versus late tracheotomy in ICU patients: A meta-analysis of randomized controlled trials.

BACKGROUND: This study aimed to quantitatively analyze the available randomized controlled trials (RCTs) and investigate whether early tracheotomy can improve clinical endpoints compared with late tracheotomy in critically ill patients undergoing mechanical ventilation. METHODS: The electronic databases of PubMed, Embase, and the Cochrane library were systematically searched in August 2019. The investigated outcomes were calculated using relative risks (RRs) and standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs) through the random-effects model for categories and continuous data, respectively. RESULTS: The electronic searches yielded 2289 records, including 15 RCTs comprising a total of 3003 patients and found to be relevant for the final quantitative analysis. The summary RRs that indicated early versus late tracheotomy were not associated with the risk of short-term mortality (RR: 0.87; 95% CI: 0.74-1.03; P = .114) and ventilator-associated pneumonia (RR: 0.90; 95% CI: 0.78-1.04; P = .156). Moreover, early tracheotomy was associated with shorter intensive care unit (ICU) stay (SMD: -1.81; 95% CI: -2.64 to -0.99; P < .001) and mechanical ventilation duration (SMD: -1.17; 95% CI: -2.10 to -0.24; P = .014). Finally, no significant difference was observed between early and late tracheotomy for hospital stay (SMD: -0.42; 95% CI: -1.36-0.52; P = .377). CONCLUSIONS: The present meta-analysis suggests that early tracheotomy can reduce the length of ICU stay and mechanical ventilation duration, but the timing of the tracheotomy was not associated with the short-term clinical endpoints in critically ill patients undergoing mechanical ventilation.

Decannulation of tracheotomized patients after long-term mechanical ventilation - results of a prospective multicentric study in German neurological early rehabilitation hospitals.

BACKGROUND: In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation. METHODS: From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge. RESULTS: Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated. CONCLUSIONS: This study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.

National changes in pediatric tracheotomy epidemiology during 36 years.

BACKGROUND: Information on the incidence, indications and morbidity of pediatric tracheotomy from a nationwide setting is sparse. METHODS: From the nationwide Danish National Patient Registry, we identified all cases: 0-15-year-old children registered with a first-time tracheotomy from 1979 to 2014. We extracted the date of surgery, admission, discharge, age, gender, hospital, department, hospitalization length, hospital contacts, and diagnosis-code related to the surgery. We estimated age-adjusted incidence rates (AAIR) and annual (APC) and average annual percentage change (AAPC) of tracheotomy incidence. RESULTS: A total of 510 children (328 boys, 63%) underwent tracheotomy. The median age at surgery was 8 years. The AAIR was 1.4/100,000 person-years (range 1.0-1.8) from 1980 to 2014. During 1979-2014, the AAPC decreased - 0.9% (95% confidential interval - 2.4; 0.8, p < 0.3). From 1979 to 2003 the APC decreased - 4.1% (95% CI - 5.4; - 2.8, p < 0.001) and from 2003 to 2014 the APC increased 6.6% (95% CI 2.0; 11.5, p < 0.001). Infants had the highest incidence (4.0/100,000 years) compared with the 12-15-year-olds (AAIR: 0.4/100,000 years). From 1979 to 2014 the most common indication for tracheotomy among children aged 0-2 years was congenital malformations (n = 48, 30%) and among children aged 3-11 and 12-15 years the most common indication was trauma (respectively n = 67, 36% and n = 85, 52%). During 2006-2014 the most common indications for all ages was neurological impairment (n = 25, 21%) and neoplasms (n = 20, 17%). CONCLUSIONS: Pediatric tracheotomy was a rare surgical procedure with decreasing incidence rates from 1980-89 to 1990-99 and increasing incidence rates from 2000-2009 to 2010-2014. Indications and postoperative morbidity have changed adjunct to the treatment of chronic disorders.

Is tracheotomy on the decline in otolaryngology? A single institutional analysis.

OBJECTIVE: A recent study reported decreasing trends in tracheotomy procedures by its otolaryngology service. We set out to determine whether the previously reported decrease in otolaryngology performed tracheotomies by one institution is a local or generalizable phenomenon. DESIGN: Retrospective cohort study from 2010 to 2015. SETTING: Tertiary care hospital and affiliated regional hospitals. SUBJECT AND METHODS: All patients who received tracheotomy during the period of analysis were included. Performing specialty, surgical technique, and procedure location were recorded. Procedures were stratified by year and specialty to generate incidence rate ratios for otolaryngologists and non-otolaryngologists. Incidence rate ratios were estimated with negative binomial regression across services. RESULTS: The otolaryngology service demonstrated a yearly decrease of 3.4% in the total number of tracheotomies (95% CI -7.9% to +1.4, P=0.17). While the thoracic service remained constant (+0.3%, 95% CI -2.6% to +3.3%, p=0.83), general surgery demonstrated the greatest increase in procedures (+4.4%, 95% CI -6.0% to +15.8%, P=0.42). Thoracic and general surgery both dramatically increased the number of percutaneous tracheotomies performed, with general surgery also performing a greater number of bedside procedures. CONCLUSIONS AND RELEVANCE: We observed a similar decline in the number of tracheotomies otolaryngology over six years. Our trend is likely due to changes in consultations patterns, increasing use of the percutaneous method, and an increase in adjunctive gastrostomy tube placements. Investigations on the impact of a greater number of non-otolaryngology performed tracheotomies on follow up care is warranted.

[Tracheotomy].

The number of tracheotomies in Denmark has roughly tripled over the past 15 years. During this period, percutaneous dilatational tracheotomy has become still more common because of its easier accessibility, and it accounted for 66% of all tracheotomies in 2015 vs. 9% in 2000. However, due to the risk of fatal complications the method is only applicable when anatomical and medical conditions are favourable. Surgical tracheotomy is a safer method in some patients, and it is preferred if the patient has had a tracheostomy previously or presents with a difficult anatomy, coagulopathy or previous neck irradiation.

Indications of pediatric tracheostomy over the last 30 years: Has anything changed?

IMPORTANCE: Recent reports have shown that the indications for pediatric tracheostomy have evolved over time. OBJECTIVE: To review the indications for pediatric tracheostomy over the last 30 years. DESIGN: Retrospective chart review. SETTING: Tertiary referral children's hospital. PARTICIPANTS: Patients who underwent tracheostomy. INTERVENTION: Surgical tracheostomy placement. MAIN OUTCOMES AND MEASURES: Medical records for patients who underwent surgical tracheostomy over the 30-year study period (1984-2014) were reviewed. Patient characteristics including age, gender, birth-weight, gestational age and death were collected and compared with the primary indication for tracheostomy using bivariable analysis. RESULTS: Five hundred and one patients met inclusion criteria. The most common primary indications for tracheostomy were cardiopulmonary disease (34%) and neurological impairment (32%), followed by airway obstruction (19%), craniofacial (11%), and traumatic injury (4%). Over the last five years (2010-14) cardiopulmonary disease became the most common indication for tracheostomy. CONCLUSIONS: and RELEVANCE: The indications for pediatric tracheostomy have evolved over the past 30 years. Infectious causes of airway obstruction and tracheostomy have almost disappeared. Tracheostomy is now most commonly performed in very premature patients with cardiopulmonary or neurological impairment who require prolonged ventilator support.

Tracheostomy and invasive mechanical ventilation in amyotrophic lateral sclerosis: decision-making factors and survival analysis.

BACKGROUND: Invasive and/or non-invasive mechanical ventilation are most important options of respiratory management in amyotrophic lateral sclerosis. METHODS: We evaluated the frequency, clinical characteristics, decision-making factors about ventilation and survival analysis of 190 people with amyotrophic lateral sclerosis patients from 1990 until 2013. RESULTS: Thirty-one percentage of patients underwent tracheostomy invasive ventilation with the rate increasing more than the past 20 years. The ratio of tracheostomy invasive ventilation in patients >65 years old was significantly increased after 2000 (25%) as compared to before (10%). After 2010, the standard use of non-invasive ventilation showed a tendency to reduce the frequency of tracheostomy invasive ventilation. Mechanical ventilation prolonged median survival (75 months in tracheostomy invasive ventilation, 43 months in non-invasive ventilation vs natural course, 32 months). The life-extending effects by tracheostomy invasive ventilation were longer in younger patients ≤65 years old at the time of ventilation support than in older patients. Presence of partners and care at home were associated with better survival. Following factors related to the decision to perform tracheostomy invasive ventilation: patients ≤65 years old: greater use of non-invasive ventilation: presence of a spouse: faster tracheostomy: higher progression rate; and preserved motor functions. No patients who underwent tracheostomy invasive ventilation died from a decision to withdraw mechanical ventilation. CONCLUSION: The present study provides factors related to decision-making process and survival after tracheostomy and help clinicians and family members to expand the knowledge about ventilation.

A randomized clinical trial for the timing of tracheotomy in critically ill patients: factors precluding inclusion in a single center study.

INTRODUCTION: We investigated the potential benefits of early tracheotomy performed before day eight of mechanical ventilation (MV) compared with late tracheotomy (from day 14 if it still indicated) in reducing mortality, days of MV, days of sedation and ICU length of stay (LOS). METHODS: Randomized controlled trial (RCT) including all-consecutive ICU admitted patients requiring seven or more days of MV. Between days five to seven of MV, before randomization, the attending physician (AP) was consulted about the expected duration of MV and acceptance of tracheotomy according to randomization. Only accepted patients received tracheotomy as result of randomization. An intention to treat analysis was performed including patients accepted for the AP and those rejected without exclusion criteria. RESULTS: A total of 489 patients were included in the RCT. Of 245 patients randomized to the early group, the procedure was performed for 167 patients (68.2%) whereas in the 244 patients randomized to the late group was performed for 135 patients (55.3%) (P <0.004). Mortality at day 90 was similar in both groups (25.7% versus 29.9%), but duration of sedation was shorter in the early tracheotomy group median 11 days (range 2 to 92) days compared to 14 days (range 0 to 79) in the late group (P <0.02). The AP accepted the protocol of randomization in 205 cases (42%), 101 were included in early group and 104 in the late group. In these subgroup of patients (per-protocol analysis) no differences existed in mortality at day 90 between the two groups, but the early group had more ventilator-free days, less duration of sedation and less LOS, than the late group. CONCLUSIONS: This study shows that early tracheotomy reduces the days of sedation in patients undergoing MV, but was underpowered to prove any other benefit. In those patients selected by their attending physicians as potential candidates for a tracheotomy, an early procedure can lessen the days of MV, the days of sedation and LOS. However, the imprecision of physicians to select patients who will require prolonged MV challenges the potential benefits of early tracheotomy. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN22208087 . Registered 27 March 2014.

Pediatric tracheotomy: are the indications changing?

OBJECTIVE: The most common indications for tracheotomy in pediatric patients include upper airway obstruction, prolonged ventilator dependence, and hypotonia secondary to neurologic impairment. In this study we review the indications for tracheotomy within our patient population over the last 11 years. METHODS: We conducted a retrospective chart review of consecutive patients undergoing tracheotomy at a tertiary care pediatric hospital from January 2000 to April 2011. We evaluated patient age, sex, pre-operative and post-operative diagnosis, and direct laryngoscopic and bronchoscopic findings. Patients were divided into six groups based on their indication for tracheotomy. In order to assess changing indications for tracheotomy over time, we compared an early (2000-2005) and a late (2006-2011) patient group. RESULTS: We had complete data available on 158/165 patients (95.8%) who underwent tracheotomy from 2000 to 2011. There was no significant difference in mean age between the early and late groups (4.73 ± 6.0 years vs. 3.6 ± 5.5 years, p=0.26). There was a change in the most common indication for tracheotomy between the early and late groups, with upper airway obstruction becoming more common in the late group and significantly fewer patients undergoing tracheotomy for prolonged ventilation in the late group (33/76 (43%) vs. 23/82 (28%), p=0.05). More patients underwent bronchoscopy at the time of tracheotomy in the late group (52/82 (63%) vs. 28/76 (37%), p=<0.01). CONCLUSION: A review of our pediatric tracheotomy experience demonstrated a change in the most common indication for tracheotomy between 2000 and 2011. In our patient population, there was a significant decline in the number of tracheotomies performed for prolonged intubation and an increasing number of patients who required tracheotomy for upper airway obstruction.

[Pediatric tracheotomy]. / Tracheotomie bei Kindern.

Tracheotomies are increasingly performed in the pediatric population in the context of long-term treatment. There are specific pediatric aspects that require attention: differences in the pediatric compared to adult anatomy, the necessity for later reconstruction and the negative impact on oral feeding and speech development. Caring for pediatric tracheostomy patients is more challenging compared to adult patients. This needs to be addressed by a dedicated team during both in- and outpatient treatment.

Changing patterns of tracheotomy use in anterior skull base surgery with free tissue reconstruction.

OBJECTIVE: To evaluate how changing patterns of tracheotomy use with free tissue reconstruction of the anterior skull base affect postoperative complications. DESIGN: Retrospective comparison of clinical cohort to historic control group. SETTING: Tertiary care medical center. PATIENTS: We reviewed 201 patients with a diagnosis of malignant or locally aggressive benign neoplasms of the nasal cavity and paranasal sinuses between January 1993 and December 2006. Of these, we studied 33 consecutive patients that underwent ablative anterior skull base surgery reconstructed with free tissue transfers. We divided the study group into two cohorts: Group 1, patients treated from 1993-2000, and Group 2, patients treated from 2000-2006. MAIN OUTCOME MEASURES: Tracheotomy use and postoperative complications. RESULTS: There were 16 patients in Group 1 and 17 patients in Group 2. There were 11 patients who received a tracheotomy in Group 1, and only 5 in Group 2 (P = .038). Five patients in either group experienced complications (P = 1.000). There was one case of meningitis in Group 1 and no cases in Group 2 (P = .485). There were two cases of pneumocephalus in Group 2 and none in Group 1 (P = .485) and no cases of tension pneumocephalus. Six patients in each group had recurrent disease (P = 1.000). There was no statistically significant difference in survival (P = .675). CONCLUSIONS: The decreased use of tracheotomy in patients undergoing free tissue transfer reconstruction of anterior skull base defects did not lead to an increase in complications. Routine use of tracheotomy in these patients is unnecessary and should be reserved for selected cases. Laryngoscope, 2009.

[The child with a tracheostomy, past and present: different indications, different children, different care]. / Het kind met een tracheostoma, vroeger en nu; andere indicaties, andere kinderen, andere zorg.

--Until a few decades ago, acute infectious airway obstruction was the primary indication for tracheotomy in children. Its incidence has decreased considerably due to vaccination programmes and antibiotic treatment. --Today, the primary reasons for performing tracheotomy in a child are chronic airway obstruction (laryngeal injury after intubation, craniofacial malformation, lymphangioma) and prolonged artificial ventilation. --Consequently, the percentage of children who may be decannulated after a short period has decreased. --Tracheotomised children now require longer and more intensive care than before. --Hospital discharge is possible if parents and care providers are provided thorough training and counselling; this process requires specific medical, nursing and psychosocial support. --The increasing proportion of tracheotomised children cared for at home necessitates greater involvement from family practitioners.

The shift in the indications for the tracheotomy between 1940 and 1955: an historical review.

In the period between 1940 and 1955 the indications for tracheotomy were extended. For centuries tracheotomies were performed to treat obstructive diseases of the upper airway (hypopharynx, larynx, trachea). With the end of the second World War tracheotomy was indicated more and more for the therapy of lower airway disturbances. Medical empiricism is thought to be responsible for the gradual shift in the indications during that period from upper to lower airway disturbances. Knowledge about the underlying principles of respiratory physiology was, however, already present at the end of the 19th century, but the shift in the indications did not occur until relatively recently. For many victims of World War II the discovery of the beneficial effect of a tracheotomy in a variety of traumatic disorders may have come too late.

Percutaneous or surgical tracheostomy: a meta-analysis.

OBJECTIVE: To compare percutaneous with surgical tracheostomy using a meta-analysis of studies published from 1960 to 1996. DATA SOURCES: Publications obtained through a MEDLINE database search with a Boolean combination (tracheostomy or tracheotomy) and complications, with constraints for human studies and English language. STUDY SELECTION: Publications addressing all peri- and postoperative complications. Studies limited to specific tracheostomy complications or containing insufficient details were excluded. Two authors independently selected the publications. DATA EXTRACTION: A list of relevant surgical variables and complications was compiled. Complications were divided into peri- and postoperative groups and further subclassified into severe, intermediate, and minor groups. Because most studies of percutaneous tracheostomy were published after 1985, surgical tracheostomy studies were divided into two periods: 1960 to 1984 and 1985 to 1996. The articles were analyzed independently by three investigators, and rare discrepancies were resolved through discussion and data reexamination. DATA SYNTHESIS: Earlier surgical tracheostomy studies (n = 17; patients, 4185) have the highest rates of both peri- (8.5%) and postoperative (33%) complications. Comparison of recent surgical (n = 21; patients, 3512) and percutaneous (n = 27; patients, 1817) tracheostomy trials shows that perioperative complications are more frequent with the percutaneous technique (10% vs. 3%), whereas postoperative complications occur more often with surgical tracheotomy (10% vs. 7%). The bulk of the differences is in minor complications, except perioperative death (0.44% vs. 0.03%) and serious cardiorespiratory events (0.33% vs. 0.06%), which were higher with the percutaneous technique. Heterogeneity analysis of complication rates shows higher heterogeneity in older and surgical trials. CONCLUSIONS: Percutaneous tracheostomy is associated with a higher prevalence of perioperative complications and, especially, perioperative deaths and cardiorespiratory arrests. Postoperative complication rates are higher with surgical tracheostomy.

Current trends in pediatric tracheotomy.

A retrospective analysis was performed on 103 pediatric patients, less than 5 years of age, undergoing tracheotomy at New York Hospital between 1980 and 1990. Charts were reviewed with respect to primary diagnosis, indication for tracheotomy, duration of the tracheotomy, complication rate and mortality rate. Approximately 62% of the tracheotomies were performed in patients less than 12 months of age, with the most common indication being an acquired or congenital airway abnormality. The number of patients receiving tracheotomies for neurological disorders, however, increased more than threefold over the course of this review. Approximately one-third of the patients experienced immediate, early or delayed complications. There was a significant correlation between the complication rate and weight at the time of the tracheotomy as well as the degree of prematurity of the child. Over one half of the infants under 2000 g suffered complications. A mortality rate of 2.9% was noted in our study with mucous plugging of the tracheotomy being the most common etiology of death.