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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 12-14

Outcome of tracheostomy in critically ill patients receiving mechanical ventilation


1 Consultant, Government District Hospital, Kanpur, India
2 Department of Otorhinolaryngology and Head Neck Surgery, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
3 Department of Respiratory Medicine, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

Date of Submission07-Jan-2020
Date of Acceptance13-Mar-2020
Date of Web Publication14-May-2020

Correspondence Address:
Dr. Rohit Sharma
Department of Otorhinolaryngology and Head Neck Surgery, SRMS Institute of Medical Sciences, Bareilly, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jlv.JLV_1_20

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   Abstract 


Introduction: Acute respiratory failure requiring prolonged intubation is now the most common indication for tracheostomy. Aim: The aim of this study was to evaluate outcomes of tracheostomy, total days on ventilator and hospital stay, and ease of decannulation in intensive care unit (ICU) patients with regard to its timings (early versus late) and to compare the comorbidities and mortality in patients of both groups. Materials and Methods: The study was conducted on 45 critically ill patients who underwent endotracheal intubation followed by a tracheostomy. Results: In the early tracheostomy group (<7 days), the mean number of days of hospital stay was less, and there was a lesser incidence of early postoperative complications and earlier decannulation compared to the late tracheostomy group (>7 days). Early tracheostomy seems to have no benefit with respect to mean number of days on ventilator. Conclusion: Early tracheostomy has a significant positive impact on critically ill ICU patients.

Keywords: Critically ill, mechanical ventilation, tracheostomy


How to cite this article:
Gupta A, Sharma R, Sharma VK, Rana AK, Singh L. Outcome of tracheostomy in critically ill patients receiving mechanical ventilation. J Laryngol Voice 2019;9:12-4

How to cite this URL:
Gupta A, Sharma R, Sharma VK, Rana AK, Singh L. Outcome of tracheostomy in critically ill patients receiving mechanical ventilation. J Laryngol Voice [serial online] 2019 [cited 2020 Sep 28];9:12-4. Available from: http://www.laryngologyandvoice.org/text.asp?2019/9/1/12/284234




   Introduction Top


Tracheostomy is the creation of a stoma on the skin surface which leads to the trachea.[1] General indications for the placement of tracheostomy include acute respiratory failure with the expected need for prolonged mechanical ventilation, failure to wean from mechanical ventilation, upper airway obstruction, difficult airway, and copious secretions. The most common indications for tracheostomy are (a) acute respiratory failure and need for prolonged mechanical ventilation (two-third of cases) and (b) traumatic or catastrophic neurologic insult requiring airway or mechanical ventilation or both. Upper airway obstruction is a less common indication for tracheostomy.[2]

Tracheostomy in the intensive care unit (ICU) is increasingly used as a means to up weaning from mechanical ventilation and to provide a safe airway. Tracheostomy allows earlier discharge of patients from the ICU, thus allowing better management of limited ICU resources, and may be associated with reduced mortality. Optimum timing for the placement of a tracheostomy remains a controversy. It has been suggested that early tracheostomy is associated with lower mortality in the ICU than late tracheostomy, which questions the practice of delaying tracheostomy beyond the 1st week.[3]

In patients receiving mechanical ventilation, tracheostomy has the following benefits versus translaryngeal intubation: nursing care becomes easier, improved comfort, more secure tube with increased patient mobility, allowance of speech, oral nutrition, and in some studies, early weaning from mechanical ventilation.

In contemporary practice, the importance of a clear airway following tracheostomy has been stressed and has been recognized that the tracheostomy is not the objective in treatment but only a means to the end of securing proper ventilation. During recent years, the complications and deaths due to tracheostomy are reduced to minimal because of the refinement of technique and better postoperative care. Complications related to tracheotomies include pneumothorax, bleeding, tube misplacement, posterior tracheal perforation, thyroid injury, subcutaneous emphysema, cardiopulmonary arrest, infection, pneumonia, tracheoesophageal fistula, and tracheal stenosis, delayed closure of tracheostomy wound, cosmetic deformities, tracheomalacia and tracheal granuloma, and voice changes.[4]


   Materials and Methods Top


The study was conducted in the department of otorhinolaryngology and head neck surgery and the department of intensive care in a tertiary care center of Bareilly, India, from October 2014 to May 2016. It was a prospective, nonrandomized study done in 45 patients. The study group consisted of those patients who underwent tracheostomy after endotracheal intubation in ICU of the institute. A preformed proforma which recorded patients age, sex and indication for tracheostomy was used for documentation. The study consisted of two subgroups: early tracheostomy (<7 days of endotracheal intubation) and late tracheostomy (>7 days of endotracheal intubation). We studied both the groups for total days on ventilator, comorbidities, length of ICU stay, total hospital stay, documentation, and mortality.


   Observation and Results Top


This study comprised 45 patients, of which 30 were male and 15 were female. The mean age of patients was 52.4 years. Majority of the patients who underwent tracheostomy in ICU were suffering from neurological disease (51%), followed by respiratory disease (20%) and road traffic accident (15.5%). In our study, early tracheostomy was defined as tracheostomy done before 7 days and late as after 7 days of intubation. The early tracheostomy group had 32 patients, whereas the late tracheostomy group had 13 patients. [Table 1] depicts the mean number of days on ventilator in the two groups, i.e., early and late. The difference in the mean number of days on ventilator in the two groups was not statistically significant.
Table 1: Timing of tracheostomy and mean days on ventilator

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The mean duration of hospital stay is shown in [Table 2]. The difference in the mean duration of hospital stay in the early and late groups was statistically significant, i.e., patients who underwent early tracheostomy had a lesser duration of hospital stay as compared to patients with late tracheostomy.
Table 2: Timing of tracheostomy and mean duration of hospital stay

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Comorbidities in the early and late tracheostomy groups were assessed as shown in [Table 3]. The incidence of surgical emphysema and granulation tissue around stoma was less in patients who underwent early tracheostomy, and the difference in the two groups was found to be statistically significant.
Table 3: Timing of tracheostomy and comorbidities

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On studying the difference in mortality, it was found that the early tracheostomy group had lesser mortality rates than the late tracheostomy group, which was not statistically significant. However, the small sample size prevented an appropriate comparison between the groups because of the influence of confounding factors.

The mean number of days for decannulation in the early and late tracheostomy groups is shown in [Table 4]. In our study, 11 patients underwent decannulation. Patients with early tracheostomy had an earlier decannulation as compared to late tracheostomy.
Table 4: Timing of tracheostomy and decannulation

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   Discussion Top


In critical care settings, tracheostomy is commonly performed when clinicians predict a patient who will need prolonged mechanical ventilation. In our study, we classified the patients as early and late tracheostomy groups. Various other authors have categorized patients into two groups, i.e., early and late, division line being 7 days of intubation.[5],[6]

According to our study in patients with early tracheostomy, the mean number of days on ventilator was 3 ± 2.31 days and the mean number of days on ventilator in the late tracheostomy group was 4.15 ± 4.94 days. Although the mean number of days on ventilator was more in the late group, it was statistically insignificant. This could be explained by the fact that following tracheostomy, there is a reduction of ventilator dead space, less airway resistance, and easier tracheobronchial toilet with a tracheostomy than with an endotracheal tube. In contrast, Huang et al.[7] concluded in their study that early tracheostomy as an intervention in critically ill adult patients did not reduce the duration of mechanical ventilation as compared to late tracheostomy.

The mean numbers of days of hospital stay were less in the early tracheostomy group as compared to the late group in our study. Similar results were obtained in a study done by Wells et al.,[8] where it was observed that early tracheostomy does appear to be highly significantly associated with decreased length of stay in the ICU and hospital. This can be explained by the less comorbidity in the early tracheostomy group. The incidence of surgical emphysema and granulation tissue around stoma was less in patients who underwent early tracheostomy, and the difference in the two groups was found to be statistically significant.

Shin et al.[9] concluded that early tracheostomy seems to have no benefit with respect to duration of ventilator support, severity of illness, nosocomial infections, and mortality. They suggested that the time of tracheostomy is better to be decided on clinical judgment in each case. The mortality in patients with early tracheostomy was less as compared to late tracheostomy. Our results are supported by several other authors.[10],[11] In contrast, Young et al.[12] in their study concluded that among mechanically ventilated critically ill patients in adult general critical care units in the United Kingdom, early tracheostomy (within the first 4 days) was not associated with an improvement in 30-day mortality or other important secondary outcomes.

We had certain limitations in our study. Our study had a small sample size. Selection bias may be present as the timing of tracheostomy was decided by ICU in charge and delayed till the consent for tracheostomy was given by patient or family. We did not assess secondary outcomes such as patient comfort which may be valuable indicator. It was not a blinded study.


   Conclusion Top


Early tracheostomy has a significant positive impact on critically ill patients hospitalized in ICU. These results support the tendency to balance the risk–benefit analysis in favor of early tracheostomy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gleeson M, Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS, et al., editors. Scott Brown's Otorhinolaryngology and Head and Neck Surgery. 7th ed. London: Butterworths Publication; 2008. p. 2292.  Back to cited text no. 1
    
2.
Cheung NH, Napolitano LM. Tracheostomy: Epidemiology, indications, timing, technique, and outcomes. Respir Care 2014;59:895-915.  Back to cited text no. 2
    
3.
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;57:251-4.  Back to cited text no. 3
    
4.
Cipriano A, Mao ML, Hon HH, Vazquez D, Stawicki SP, Sharpe RP, et al. An overview of complications associated with open and percutaneous tracheostomy procedures. Int J Crit Illn Inj Sci 2015;5:179-88.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Ziaeian B, Tahmasebi S, Niakan H, Fazelzadeh A. Short-term outcome of early tracheostomy in the trauma patients admitted to intensive care unit: A Comparative Study. Bull Emerg Trauma 2013;1:112-5.  Back to cited text no. 5
    
6.
Wang F, Wu Y, Bo L, Lou J, Zhu J, Chen F, et al. The timing of tracheotomy in critically ill patients undergoing mechanical ventilation: A systematic review and meta-analysis of randomized controlled trials. Chest 2011;140:1456-65.  Back to cited text no. 6
    
7.
Huang H, Li Y, Ariani F, Chen X, Lin J. Timing of tracheostomy in critically ill patients: A meta-analysis. PLoS One 2014;9:e92981.  Back to cited text no. 7
    
8.
Wells Z, Gauthier Z, Bascom M, Suh M, Meloro B, Lopez A, Joshi A. Timing of tracheostomy and its association with length and stay and mortality. Critical care medicine 2015;43:185-6.  Back to cited text no. 8
    
9.
Shin JE, Shin TR, Park Y, Nam JS, Cheon SH, Chang JH. Outcomes in relation to time of tracheostomy in patients with mechanical ventilation. Tuber Respir Dis 1999;3:365-73.  Back to cited text no. 9
    
10.
Silva PE, Cruz MC, Saback LM, Neves JL. Management of emergency situations in patients undergoing tracheostomy. Rev Bras Ter Intensiva 2009;21:169-72.  Back to cited text no. 10
    
11.
Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med 2007;35:802-7.  Back to cited text no. 11
    
12.
Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan Collaborators. Effect of early vs. late tracheostomy placement on survival in patients receiving mechanical ventilation: The TracMan randomized trial. JAMA 2013;309:2121-9.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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