Opening the ventilator, or trachea, within the first seven days of the start of mechanical ventilation reduces the time patients spend on ventilators, shortening the time they are living in an ICU and reducing the risk of flu-related flu, according to a systematic study published Thursday (March) 11) JAMA Otolaryngology-Head & Neck Surgery.
We analyzed the existing medical literature to solve a question that is highly relevant to adult critical care. At what point should surgeons open the trachea in emergency care patients to get the most benefit for them? “
Alvaro Moreira, MD, MSc, Lead Author, University of Texas Health Science Center at San Antonio
The surgery, called a tracheotomy, is performed either in the operating room or at the bedside, depending on patient risk factors. The team analyzed 17 studies involving more than 3,000 patients. The systematic review compared early late tracheotomy, with “early” defined as performed seven days or less after initiation of ventilation and “late” defined as eight days or longer, a including patients who had never required a tracheotomy.
Results
Early tracheotomy was associated with improvement in three main clinical outcomes: shower-associated pneumonia (40% reduction in risk), days without ventilation (an additional 1.7 days off the cooler, on average) and ICU stay (6.3 shorter days per unit, on average). Performing the procedure early did not affect patient mortality, however.
Patients who receive mechanical ventilation are inhaled and breathe through a tube extending into their windpipe. After 48 hours of intubation, patients in emergency care units are at a higher risk of developing severe seizure-related seizures, Dr. Moreira said.
A tracheostomy is performed for patient comfort, to remove the patient from sedatives and to increase the speed at which the patient can get off the ventilator.
“One of the excuses for families is that their loved one is getting an intervention,” Dr. Moreira said. “But if the patient developed a flu pandemic, it would increase hospital stays and, in some patients, could be fatal.
“It is therefore a good balance that providers and families need to consider when assessing whether a patient is a good candidate for the intervention. “
Effects for pandemic
Although there were no patients in the COVID-positive study, the findings have the potential to translate into hospital emergency care during the pandemic.
In March 2020, a committee of the American Academy of Otolaryngology-Head & Neck Surgery advised health care workers “to avoid performing tracheotomy in COVID-19 positive or suspicious patients during periods of instability higher respiratory or air dependence. “The committee said tracheotomy may be considered” in patients with stable lung status but should not occur earlier than two or three weeks from the time of admission and, preferably, with the COVID-19 negative test. “
Since then, studies have shown that a tracheotomy can be performed safely in a negative pressure chamber, with proper personal protective equipment, patient sedation and frequent on-site suction.
“When inspectors followed the health care providers for a month, they found that the clinicians were not contracting COVID-19 when proper warning was taken,” said Dr. Moreira.
Various professional associations now say that COVID-19 patients should be considered like other patients. However, the timing for tracheostomy placement in this population remains to be debated.
Dr. Moreira is a professor at the Joe R. and Teresa Lozano School of Long Medicine at the University of Texas Health Science Center at San Antonio. Coauthors are from the University of Pennsylvania Perelman School of Medicine and Long School of Medicine.
Source:
University of Texas Health Science Center at San Antonio
Magazine Reference:
Chorath, K., et al. (2021) Association of Early vs. Late Tracheostomy Position with Pneumonia and Ventilator in patients with severe disease. A meta-analysis. JAMA Otolaryngology-Head & Neck Surgery. doi.org/10.1001/jamaoto.2021.0025.