2000 OPEN FORUM Abstracts
Timing of Tracheostomy following Critical Illness or Injury
John H. Boynton Jr. R.R.T., Grant O'Keefe M.D., Kenneth Hawkins R.R.T. Parkland Health & Hospital Systems and The University of Texas Southwestern Medical Center. 5201 Harry Hines Blvd. Dallas, Texas 75235
Introduction: The optimal timing of tracheostomy in the management of patients with prolonged respiratory failure is controversial. Translaryngeal intubation is associated with a distinct set of complications, the frequency of which increase with the duration of intubation. In addition, it has been suggested that early tracheostomy can hasten liberation from mechanical ventilation following resolution of acute respiratory failure. Therefore, we undertook this study to determine whether tracheostomy performed prior to active weaning resulted in more rapid weaning and an overall shorter period of mechanical ventilation.
Methods: Surgical patients requiring >72 hours of MV were prospectively enrolled into a study examining the utility of weaning parameters. Clinical respiratory care, including the use of tracheostomy, was at the discretion of the attending physicians and respiratory therapists. Patients undergoing tracheostomy prior to any active weaning attempts (early tracheostomy: ET) were compared to patients in whom initial weaning attempts were made with the translaryngeal tube (selective tracheostomy: ST). Patients who underwent emergency tracheostomy for airway control and patients who were immediately extubated once readiness to wean criteria were met were not included. Differences between the groups were compared with the Mann-Whitney-U and chi-square tests. Cox regression was used to compare the timing of tracheostomy on the duration of weaning.
Results: A total of 74 patient (of the initial 95 requiring >72 hours of MV) met inclusion criteria. The 21 in the ET group were compared to 53 in the ST group and 25 (47%) of the ST group underwent tracheostomy. The ET group underwent tracheostomy after a median of 7 days of MV and the ST group after a median of 14 days of MV. ET actually delayed the onset of active weaning (3 vs. 1 day). The figure indicates the duration of weaning in ET vs. ST patients. Mean duration of weaning in the ET was 3 days compared to 7 days in the ST group (p = 0.06)
Conclusion: Tracheostomy prior to active weaning may decrease the time of active weaning. However, this does not reduce the overall duration of MV, and may delay the start of active weaning. (See Original for Figure)