Critical Care Bulletin - February 2022

 

Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis

 

by Yun Ji, Yumin Fang, Baoli Cheng, Libin Li and Xiangming Fang 

 

Critical Care volume 26, Article number: 40 (2022)

 

Background

The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients’ outcomes.

Methods

We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14 days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model.

Results

Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV (2098 patients; MD − 9.08 days, 95% CI − 10.91 to − 7.26 days, p < 0.01) and duration of ICU stay (1224 patients; MD − 9.41 days, 95% CI − 12.36 to − 6.46 days, p < 0.01). Mortality was reported for 2343 patients and was comparable between groups (OR 1.09, 95% CI 0.79–1.51, p = 0.59).

Conclusions

The results of this meta-analysis suggest that, compared with late tracheostomy, early tracheostomy in COVID-19 patients was associated with shorter duration of IMV and ICU stay without modifying the mortality rate. These findings may have important implications to improve ICU availability during the COVID-19 pandemic.

 

 

 

 

Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review

Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review

by Skoretz, Stacey A.; Riopelle, Stephanie J.; Wellman, Leslie; Dawson, Camilla 

Critical Care Medicine: February 2020 - Volume 48 - Issue 2 - p e141-e151

Objectives: Tracheostomy and dysphagia often coexist during critical illness; however, given the patient’s medical complexity, understanding the evidence to optimize swallowing assessment and intervention is challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting.

Data Sources: Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing.

Study Selection: Two blinded reviewers determined eligibility according to inclusion criteria: English-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded.

Data Extraction: We extracted data using a form designed a priori and conducted descriptive analyses.

Data Synthesis: We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categories: dysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies.

Conclusions: The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.

Timing of Tracheostomy in Pediatric Patients: A Systematic Review and Meta-Analysis*

Timing of Tracheostomy in Pediatric Patients: A Systematic Review and Meta-Analysis*

by Abdelaal Ahmed Mahmoud M. Alkhatip, Ahmed; Younis, Mohamed; Jamshidi, Negar; Hussein, Hazem A; Farag, Ehab; Hamza, Mohamed K.; Bahr, Mahmoud H.; Goda Ahmed, Ahmed; Sallam, Amr M.; Mohamed, Hassan; Elayashy, Mohamed; Hosny, Hisham; Yassin, Hany M.; Abdelhaq, Mohamed; Elramely, Mohamed A.; Reeves, David; Mills, Kerry E.; Kamal, Ahmed M.; Zakaria, Dina

Critical Care Medicine: February 2020 - Volume 48 - Issue 2 - p 233-240

Objectives: Tracheostomy is a very common clinical intervention in critically ill adult patients. The indications for tracheostomy procedures in pediatric patients with complex conditions have increased dramatically in recent years, but there are currently no guidelines on the optimal timing of tracheostomy in pediatric patients undergoing prolonged ventilation.

 Data Sources: We performed a systematic search of the existing literature in MEDLINE via PubMed and Embase databases and the Cochrane Library to identify clinical trials, observational studies, and cohort studies that compare early and late tracheostomy in children. The date of the last search was August 27, 2018. Included articles were subjected to manual searching.

Study Selection: Studies in mechanically ventilated children that compared early with late tracheostomy were included.

Data Extraction: Data were extracted into a spreadsheet and copied into Review Manager 5.3 (The Cochrane Collaboration, Copenhagen, Denmark).

Data Synthesis: Data were meta-analyzed using an inverse variance, random effects model. Continuous outcomes were calculated as mean differences with 95% CIs, and dichotomous outcomes were calculated as Mantel-Haenszel risk ratios with 95% CIs. We included eight studies (10 study arms). These studies were all retrospective cohort studies. Early tracheostomy was associated with significant reductions in mortality, days on mechanical ventilation, and length of intensive care and total hospital stay, although the lack of randomized, controlled trials limits the validity of these findings. Although variance was imputed for some studies, these conclusions did not change after removing these studies from the analysis.

Conclusions: In children on mechanical ventilation, early tracheostomy may improve important medical outcomes. However, our data demonstrate the urgent need for high-quality, randomized controlled trials in the pediatric population.

Physiological effects of high-flow oxygen in tracheostomized patients

Physiological effects of high-flow oxygen in tracheostomized patients

by Daniele Natalini, Domenico L. Grieco, Maria Teresa Santantonio, Lucrezia Mincione, Flavia Toni, Gian Marco Anzellotti, Davide Eleuteri, Pierluigi Di Giannatale, Massimo Antonelli and Salvatore Maurizio Maggiore

Annals of Intensive Care volume 9, Article number: 114 (2019)

Background

High-flow oxygen therapy via nasal cannula (HFOTNASAL) increases airway pressure, ameliorates oxygenation and reduces work of breathing. High-flow oxygen can be delivered through tracheostomy (HFOTTRACHEAL), but its physiological effects have not been systematically described. We conducted a cross-over study to elucidate the effects of increasing flow rates of HFOTTRACHEAL on gas exchange, respiratory rate and endotracheal pressure and to compare lower airway pressure produced by HFOTNASAL and HFOTTRACHEAL.

Methods

Twenty-six tracheostomized patients underwent standard oxygen therapy through a conventional heat and moisture exchanger, and then HFOTTRACHEAL through a heated humidifier, with gas flow set at 10, 30 and 50 L/min. Each step lasted 30 min; gas flow sequence during HFOTTRACHEAL was randomized. In five patients, measurements were repeated during HFOTTRACHEAL before tracheostomy decannulation and immediately after during HFOTNASAL. In each step, arterial blood gases, respiratory rate, and tracheal pressure were measured.

Results

During HFOTTRACHEAL, PaO2/FiO2 ratio and tracheal expiratory pressure slightly increased proportionally to gas flow. The mean [95% confidence interval] expiratory pressure raise induced by 10-L/min increase in flow was 0.2 [0.1–0.2] cmH2O (ρ = 0.77, p < 0.001). Compared to standard oxygen, HFOTTRACHEAL limited the negative inspiratory swing in tracheal pressure; at 50 L/min, but not with other settings, HFOTTRACHEAL increased mean tracheal expiratory pressure by (mean difference [95% CI]) 0.4 [0.3–0.6] cmH2O, peak tracheal expiratory pressure by 0.4 [0.2–0.6] cmH2O, improved PaO2/FiO2 ratio by 40 [8–71] mmHg, and reduced respiratory rate by 1.9 [0.3–3.6] breaths/min without PaCO2 changes. As compared to HFOTTRACHEAL, HFOTNASAL produced higher tracheal mean and peak expiratory pressure (at 50 L/min, mean difference [95% CI]: 3 [1–5] cmH2O and 4 [1–7] cmH2O, respectively).

Conclusions

As compared to standard oxygen, 50 L/min of HFOTTRACHEAL are needed to improve oxygenation, reduce respiratory rate and provide small degree of positive airway expiratory pressure, which, however, is significantly lower than the one produced by HFOTNASAL.

The communication experience of tracheostomy patients with nurses in the intensive care unit: A phenomenological study

The communication experience of tracheostomy patients with nurses in the intensive care unit: A phenomenological study

by Angela Tolotti, Annamaria Bagnasco, Gianluca Catania, Giuseppe Aleo, Nicola Pagnucci, Lucia Cadorin, Milko Zanini, Gennaro Rocco, Alessandro Stievano, Franco A. Carnevale, Loredana Sasso  

Intensive Critical Care Nursing – In press

Abstract

Objectives

To describe the experience and sources of comfort and discomfort in tracheostomy patients, when they communicate with nurses in the Intensive Care Unit.

Research methodology/design

Benner’s interpretive phenomenology. Data were collected through: a) semi-structured interviews conducted with the patients after leaving the intensive care unit; b) participant observation; c) situated interviews with intensive care nurses.

Setting

The intensive care unit of a hospital in Northern Italy.

Findings

Eight patients and seven nurses were included in this study. Two main themes were identified 1) feeling powerless and frustrated due to the impossibility to use voice to communicate; 2) facing continual misunderstanding, resignation, and anger during moments of difficulty and/or communication misunderstandings. The main communication discomfort factors were: struggling with not knowing what was happening, feeling like others had given up on me, living in isolation and feeling invisible. The main comfort factors were: being with family members, feeling reassured by having a call bell nearby and nurses' presence.

Conclusions

This study highlights the important role of communication in tracheostomy patients in intensive care and how closely it is linked to all the aspects of a person’s life, which cannot be underestimated as just not being able to use one’s voice.

Return of Voice for Ventilated Tracheostomy Patients in ICU: A Randomized Controlled Trial of Early-Targeted Intervention

Return of Voice for Ventilated Tracheostomy Patients in ICU: A Randomized Controlled Trial of Early-Targeted Intervention

Critical Care Medicine: June 2016 - Volume 44 - Issue 6 - p 1075–1081

Freeman-Sanderson, A L et al

Objectives: A cuffed tracheostomy tube facilitates prolonged mechanical ventilation and weaning but usually leads to prolonged voicelessness, which can be one of the most negative experiences of hospitalization. No randomized trials have examined the effects of targeted early communication intervention for the restoration of voice in ventilated tracheostomy patients in the ICU. Design: A prospective randomized clinical trial. Setting: The trial was conducted in the ICU of an urban tertiary level hospital. Patients: Thirty adult participants enrolled, with 15 randomly allocated to the intervention and control groups. Interventions: The early intervention group received early cuff deflation and insertion of an in-line speaking valve during mechanical ventilation. The control group received standard cuff deflation and a speaking valve during self-ventilation. A speech-language pathologist provided all treatments. Measurements and Main Results: The primary outcome measure was time from tracheostomy insertion to phonation. Early intervention significantly hastened return to phonation (median difference = 11 d; hazard ratio = 3.66; 95% CI, 1.54–8.68) with no significant effect on duration of tracheostomy cannulation (hazard ratio = 1.40; 95% CI, 0.65–3.03), duration of mechanical ventilation in days from tracheostomy insertion (hazard ratio = 1.19; 95% CI, 0.58–2.51), length of stay in ICU (hazard ratio = 1.16; 95% CI, 0.54–2.52), or time to return to oral intake (hazard ratio = 2.35; 95% CI, 0.79–6.98). Adverse events were low and equal in both groups. There was no significant change in measures of quality of life. Conclusions: Focused early intervention for communication during mechanical ventilation allows the restoration of phonation significantly sooner than standard treatment, with no increase in complications in a small patient cohort. Although these results are favorable, further research is needed to determine whether the effects on any of the secondary outcomes are statistically significant and clinically important.