Predictores para la retirada de la cánula de traqueostomía / Predictors for the removal of the tracheostomy tube

Es imprescindible poder priorizar la decanulación de los pacientes traqueostomizados. El éxito en el procedimiento podría evitar estadías hospitalarias prolongadas y, por consiguiente, llegar a disminuir la mortalidad. La retirada de la cánula de traqueostomía es un tema muy controversial, dado que, para lograrla, existen diferentes tipos de abordajes y estrategias. Teniendo en cuenta que su uso prolongado debe ser evita do, ya que conlleva a diferentes complicaciones, como traqueomalacia, estenosis traqueal, fistula traqueo-esofágica, alteraciones funcionales en la deglución y la fonación, es de suma importancia poder conocer con exactitud cuáles son las variables que mensurar para que el paciente pueda ser decanulado. Diversos trabajos publicados difieren en cuáles son los mejores indicadores que deben ser observados para lograr el éxito. Por lo tanto, el objetivo de la presente revisión es analizar cuáles son las variables objetivables con mayor eficacia al momento de llevar a cabo la decanulación.

It is essential to prioritize the decannulation of tracheostomized patients. A successful procedure could avoid prolonged hospital stay. Accordingly, there could be a reduction in mortality. Removing the tracheotomy cannula is a very controversial issue, because there are different types of strategies and approaches to do so. The prolonged use of the cannula must be avoided, since it entails different complications such as tracheal malacia, tracheal stenosis, tracheoesophageal fistula, and functionally altered swal lowing and phonation; thus, it is very important to be able to know exactly which are the variables that need to be measured before a patient is decannulated. Several pub lished studies disagree on which are the best indicators that should be observed to be successful. So, the objective of this review was to analyze which are the most effective target variables when performing the decannulation.

[Predictors of weaning and mortality in prolonged mechanical ventilation ­ surviving survival]. / Predictores de desvinculación y mortalidad en ventilación mecánica prolongada-Sobrevivir al sobrevivir.

Objetive: to describe a sample of tracheostomized patients requiring prolonged mechanical ventilation who were admitted to a weaning center, to analyze their evolution and to determine the predictors of weaning failure from mechanical ventilation and of mortality. Design: Design: an observational and retrospective cohort study was carried out, in the period between January 2005 and December 2017. Setting: weaning and rehabilitation center. Patients: all tracheostomized patients requiring mechanical ventilation who were admitted during the study period were included. Of 1027 patients admitted to the respiratory care service, a consecutive sample of 677 patients was analyzed. Main variables of interest: the main variables were mortality and weaning failure from mechanical ventilation. Results: : age older than 70 years (OR 1,461 95% CI 1,016-2,099), a cardiovascular history (OR 1,533 95% CI 1,050-2,237), admission due to respiratory disease (OR 1,538 95% CI 1,001-2,364) and presenting more than 105 days of hospitalization (OR 0,408 95% CI 0,261-0,637) were found as predictors of weaning failure. The predictors of mortality were, age over 70 years (OR 2,116 95% CI 1,491-3,004), history of cerebrovascular accident (OR 1,991 95% CI 1,255-3,158), admission to intensive care due to cardiorespiratory arrest (OR 5,821 95% CI 2,193-15,445) and presenting more than 64 days of hospitalization (OR 1, 63 95% CI 1,116-2,292). Conclusions: The data found in this study manage to describe factors associated with weaning and mortality of patients in a weaning and rehabilitation center.

Objetivos: describir una muestra de pacientes traqueostomizados con requerimiento de ventilación mecánica prolongada que ingresaron a un centro de desvinculación, analizar su evolución y determinar los predictores de fracaso de desvinculación de la ventilación mecánica y de mortalidad. Diseño: se realizó un estudio de cohorte observacional y retrospectivo, en el período comprendido entre enero del 2005 y diciembre del 2017. Ámbito: centro de desvinculación de la ventilación mecánica y de rehabilitación. Pacientes: se incluyeron a todos los pacientes traqueostomizados con requerimiento de ventilación mecánica, que ingresaron durante el periodo de estudio. De 1027 pacientes ingresados al servicio de cuidados respiratorios, se analizó una muestra consecutiva de 677 pacientes. Variables de interés principales: las variables principales fueron mortalidad y falla en la desvinculación de la ventilación mecánica. Resultados: Se encontraron como predictores del fracaso de la desvinculación la edad mayor a 70 años (OR 1.461 IC95% 1.016-2.099), tener antecedentes cardiovasculares (OR 1.533 IC95% 1.050-2.237), motivo de ingreso por afección respiratoria (OR 1.538 IC95% 1.001-2.364) y presentar más de 105 días de internación (OR 0.408 IC95% 0.261-0.637). Los predictores de mortalidad fueron, la edad mayor a 70 años (OR 2.116 IC95% 1.491-3.004), tener como antecedente un accidente cerebro-vascular (OR 1.991 IC95% 1.255-3.158), motivo de ingreso a terapia intensiva por paro cardiorrespiratorio (OR 5.821 IC95% 2.193-15.445) y presentar más de 64 días de internación (OR1.63 IC95% 1.116-2.292). Conclusión: Los datos hallados en este estudio logran describir factores asociados a la desvinculación y mortalidad de los pacientes en un centro de desvinculación.

Prevalence of and Risk Factors for Mechanical Ventilation Reinstitution in Patients Weaned From Prolonged Mechanical Ventilation.

BACKGROUND: Prolonged mechanical ventilation is increasingly common in ICUs. Although a consensus conference defined weaning success in this patient population, few studies have used this definition. A clear definition of successful weaning is useful to assess clinical and epidemiological outcomes, facilitate clinical decision making, and set goals of care. The aims of our study were to describe the prevalence of reinstitution of mechanical ventilation within 28 d in patients successfully weaned according to our institution criterion (ie, weaning success as per consensus guidelines), to describe reasons to reestablish mechanical ventilation, and to identify associated factors. METHODS: An observational, analytical, cross-sectional study was conducted at a weaning and rehabilitation center. All patients liberated from mechanical ventilation (ie, no ventilatory support for 7 d) were included as subjects. Requirement of and reasons for reinstitution of mechanical ventilation within 28 d of weaning were recorded. RESULTS: A total of 639 tracheostomized subjects were analyzed. Of these, 219 (34%) were weaned, and 15 were eliminated due to lack of data. Of the remaining 204 subjects, 42 (21%) were reconnected to mechanical ventilation within 28 d. Sepsis accounted for 64% of reconnections. In the multivariate analysis, neurological comorbidity (adjusted odds ratio 5.1 [95% CI 2.3-11.1]) and delayed weaning (> 7 d after admission) (adjusted odds ratio 2.37 [95% CI 1.1-5.3]) were independently associated with reinstitution of mechanical ventilation within 28 d of weaning. The synergistic effect of both variables showed an adjusted odds ratio of 5.35 (95% CI 2.4-11.4). CONCLUSIONS: Reinstitution of mechanical ventilation within 28 d is a common event in patients considered to be weaned: 1 in 5 of such patients requires reconnection to mechanical ventilation, with sepsis being the most prevalent cause. Neurological comorbidity and delayed weaning are risk factors associated with reestablishment of mechanical ventilation. The presence of more than one risk factor increases the association with reinstitution of mechanical ventilation within 28 d of weaning.

Prevalence and Characteristics of Tracheal Lesions Observed in Tracheostomized Patients.

BACKGROUND: Our objective was to describe the prevalence and characteristics of tracheal lesions observed in flexile bronchoscopies of tracheostomized patients, and to determine those factors associated with severe injuries. METHODS: This is an analytical, observational, and transversal study. The flexible bronchoscopies of tracheostomized patients from our database were reviewed to assess their lesions. The tracheal lesions were classified according to their severity; lesions obstructing above 50% of the lumen were interpreted as severe and those obstructing <50% as mild. The lesions were also classified according to location as glottic, subglottic, at the level of the tracheal ostomy, tracheal, and bronchial. The types of lesions found were granuloma, stenosis, and excessive central airway collapse. Possible predictors of severe lesions were assessed. RESULTS: A total of 414 patients were included in the study, the mean age being 65 years (±16.2 y). Of all the bronchoscopies assessed, 202 (49%) showed mild lesions, and 91 (22%) were severe. We found granulomas in 230 patients (55%), and 32 (26%) were severe. Of the 27 patients with stenosis (7%), 17 (63%) were severe. Excessive central airway collapse was seen in 120 patients (31.8%), and 65 (54%) were severe. There were statistically significant differences related to age in the group that developed severe lesions (mean age, 73 y; Q1 to Q3, 58 to 81) compared with the group free of lesions (mean age, 69 y; Q1 to Q3, 55.7 to 75; P = 0.001) and also in the duration requiring an artificial airway (mean, 84.5 d; Q1 to Q3, 49 to 135.5) compared with the group free of lesions (mean of 59.5 d; Q1 to Q3, 42 to 98; P = 0.035). CONCLUSION: There was a high prevalence of tracheal lesions, mainly subglottic granulomas. Age and the duration for which the patient required an artificial airway were related to the presence of severe lesions.

Incidencia de infecciones respiratorias en pacientes traqueostomizados en un centro de desvinculación de la ventilación mecánica y rehabilitación / Incidence of respiratory tract infections in tracheostomized patients hospitalized in a weaning and rehabilitation center

Objetivos: Describir la incidencia de infecciones respiratorias (IR) en pacientes traqueostomizados (TQT) internados en un centro de desvinculación de la ventilación mecánica y rehabilitación (CDVMR). Identificar factores de riesgo (FR) para el desarrollo de IR. Materiales y métodos: Se realizó un estudio de casos y controles anidado en una cohorte. La variable utilizada para el apareamiento fue la edad. Se incluyeron a todos los pacientes TQT internados durante el período de marzo del 2013 a febrero del 2015. Se registró la incidencia de IR. Resultado: Se incluyeron 167 pacientes, registrándose 73 eventos de IR en 46 pacientes. La incidencia acumulada fue de 27,5% y la tasa de incidencia fue de 2,22 eventos/1000 días de estadía. De los 73 eventos registrados, se obtuvieron rescates bacteriológicos en 50 de ellos, siendo Pseudomonas aeruginosa (34,3%) el microorganismo más prevalente. Los valores más bajos de albúmina resultaron ser un FR para el desarrollo de IR (p 0.001, OR 5.82, IC 2.08-16.2). Los valores más altos de hemoglobina de ingreso se comportaron como factor protector (p 0.048, OR 0.74, IC 0.55-0.99). Se establecieron como FR para el evento IR: ingresar con diagnóstico de ACV (p 0.025, OR 3.45 1.16-10.2), Parkinson (p 0.011, OR 18.9, IC 1.93-185) o ELA (p 0.013, OR 6.34, IC 1.47-27.2). Conclusión: Se logró determinar por primera vez en nuestro medio la incidencia de IR en pacientes TQT y los patógenos más comunes, aunque esto necesita contraste con otros CDVMR. La asociación encontrada entre los valores de albúmina y el posterior desarrollo de IR podría estar relacionada más a un sesgo probabilístico que a una diferencia clínica significativa. Los pacientes con determinadas enfermedades neurológicas presentan mayor riesgo de IR.

Incidence of respiratory tract infections in tracheostomized patients hospitalized in a weaning and rehabilitation center

Objectives: To describe the incidence of respiratory tract infections (RTIs) in tracheostomized patients hospitalized in a weaning and rehabilitation center (WRC) and to identify risk factors (RFs) for the development of RTI. Materials and methods: A nested case-control study was conducted. Age was used as the matching variable. All tracheostomized patients who were hospitalized from March, 2013, to February, 2015, were included. The incidence of RTI was recorded. Results: A total of 167 patients were included, with 73 RTI episodes being recorded in 46 patients (27.5%). Cumulative incidence was 27.5%, and incidence rate was 2.22 episodes per 1,000 days of stay. Bacteria were recovered in 50 of the 73 episodes recorded, with Pseudomonas aeruginosa being the most prevalent organism (34.3%). The lowest albumin values proved to be a RF for the development of RTI (p 0.001, odds ratio [OR] 5.82, confidence interval [CI] 2.08-16.2). The highest hemoglobin values on admission acted as protective factors (p 0.048, OR 0.74, CI 0.55-0.99). Diagnoses of stroke (p 0.025, OR 3.45, CI 1.16-10.2), Parkinson (p 0.011, OR 18.9, CI 1.93-185) or amyotrophic lateral sclerosis (ALS) (p 0.013, OR 6.34, IC 1.47-27.2) on admission were established as risk factors for the development of RTI. Conclusion: For the first time in our setting, it was possible to determine the incidence of RTI in tracheostomized patients and the most common pathogens, although comparison with other WRCs is needed. The association found between albumin values and the subsequent development of RTI might be more related to an incidental finding than to a significant clinical difference. Patients with certain neurologic diseases are at increased risk for RTI.