Evidence-based guides in tracheostomy use in critical patients

Objetivos: Proporcionar guías de traqueostomía para el paciente crítico, basadas en la evidencia científica disponible, y facilitar la identificación de áreas en las cuales se requieren mayores estudios. Métodos: Un grupo de trabajo formado con representantes de 10 países pertenecientes a la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva y a la Latin American Critical Care Trial Investigators Network(LACCTIN) desarrollaron estas recomendaciones basadas en el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). Resultados: El grupo identificó 23 preguntas relevantes entre las 87 preguntas planteadas inicialmente. En la búsqueda inicial de la literatura se identificaron 333 estudios, de los cuales se escogieron un total de 226. El equipo de trabajo generó un total de 19 recomendaciones: 10 positivas (1B = 3, 2C = 3, 2D = 4) y 9 negativas (1B = 8, 2C = 1). En 6 ocasiones no se pudieron establecer recomendaciones. Conclusión: La traqueostomía percutánea se asocia a menor riesgo de infecciones en comparación con la traqueostomía quirúrgica. La traqueostomía precoz solo parece reducir la duración de la ventilación mecánica pero no la incidencia de neumonía, la duración de la estancia hospitalaria o la mortalidad a largo plazo. La evidencia no apoya el uso de broncoscopia de forma rutinaria ni el uso de máscara laríngea durante el procedimiento. Finalmente, el entrenamiento adecuado previo es tanto o más importante que la técnica utilizada para disminuir las complicaciones.(AU)

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.(AU)

Evidence-based guides in tracheostomy use in critical patients. / Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico.

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

[Percutaneous tracheostomy through dilatation with the Ciaglia Blue Dolphin(®) method]. / Traqueotomía percutánea por dilatación con el método Ciaglia Blue Dolphin(®)

OBJECTIVE: To describe the perioperative and postoperative complications in critically ill patients requiring percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique. DESIGN: A prospective, observational, cohort study was carried out. SCOPE: Two medical-surgical Intensive Care Units. PATIENTS: Adult patients subjected to prolonged mechanical ventilation. INTERVENTION: Percutaneous tracheostomy using Ciaglia Blue Dolphin(®) with an endoscopic guide. VARIABLES: Demographic variables, intraoperative and postoperative complications, and Intensive Care Unit and ward mortality were recorded. RESULTS: Seventy patients were included. Age: 68.6 ± 12 years (68.6% males). APACHE II score: 23.5±8.7. Duration of mechanical ventilation prior to percutaneous tracheostomy: 14.3 ± 5.5 days. Perioperative complications were recorded in 25 patients. In 23 of them the complications were mild: difficulty inserting the tracheostomy cannula (n=10), mild bleeding (n=7), partial atelectasis (n=3), cuff leak (n=2), and technical inability to complete the procedure (switch to Ciaglia Blue Rhino(®)) (n=1). Severe complications were recorded in 2 patients: severe bleeding that forced completion of the procedure via surgical tracheostomy (n=1), and false passage with desaturation (n=1). None of the complications proved life-threatening. Eleven complications occurred in the learning curve. As postoperative complications, mild peri-cannula bleeding was seen in 2 patients. CONCLUSIONS: Percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique with an endoscopic guide is a safe procedure. As with other procedures, the learning curve contributes to increase the incidence of complications. Potential benefits versus other percutaneous tracheostomy techniques should be explored by randomized trials.

[Current status of fibreoptic bronchoscopy in intensive care medicine]. / Situación actual de la realización de fibrobroncoscopias en los servicios de medicina intensiva.

Flexible bronchoscopy (FB) has been of great help in the management of critically ill patients. Its safety and usefulness in the hands of experienced professionals, with the required measures of caution, has resulted in the increasingly widespread use of the technique even in unstable critical patients subjected to mechanical ventilation and with high oxygen demands. The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC), through its Acute Respiratory Failure (GT-IRA) and Infectious Diseases (GT-EI) Work Groups, aims to promote knowledge and standards of quality in the use of FB among all specialists in Intensive Care Medicine. Through an expert committee, the SEMICYUC has established the objective of accrediting such training, with the preparation of a curriculum and definition of those Units qualified for providing training in the different techniques and levels. The accreditation process seeks to stimulate good learning practice and quality in training. Both specialists in Intensive Care Medicine and other specialists, and the patients, will benefit from the commitment and control afforded by such accreditation, and from the learning and training which the mentioned process entails.