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ORIGINAL ARTICLE
Year : 2012  |  Volume : 6  |  Issue : 2  |  Page : 152-154

Early vs. late tracheostomy for the ICU patients: Experience in a referral hospital


1 Department of Otolaryngology, University of Jordan, and Jordan University Hospital, Jordan
2 Department of General Surgery, University of Jordan, and Jordan University Hospital, Jordan
3 Department of Anesthesia & Intensive Care, University of Jordan, and Jordan University Hospital, Jordan

Correspondence Address:
Tareq Mahafza
PO Box 13046, Jordan University Hospital, Amman
Jordan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.97029

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Date of Web Publication8-Jun-2012
 

  Abstract 

Objectives: The aim of this study is to present our experience with elective surgical tracheostomy for intensive care unit (ICU) patients who needed prolonged translaryngeal intubation in order to evaluate the proper timing and advantages of early vs. late tracheostomy and to stress upon the risks associated with delayed tracheostomy. Methods : Medical records of all patients, who underwent elective tracheostomy for prolonged intubation from September 2006 to August 2010 at Jordan University hospital, were reviewed. Results: A total of 106 patients (74 males) were included; their age ranged from 2 months to 90 yr with mean age of 46.5 yr. The mean time at which tracheostomy was done after initial tracheal intubation was 23 days (range 3-7 weeks). Trauma was the most frequent cause of ICU admission 38 (35.8%), followed by post-surgery causes 14 (13.2%). An early tracheostomy showed less complication vs late procedure. The length of stay in the ICU for patients who had an early tracheostomy was 26 days while this period for patients who had late tracheostomy was 47 days. Mortality rate among patients who had early tracheostomy was 17.1% while for late tracheostomy patients, it was 36.1%. Conclusion: Proper assessment and early tracheostomy is recommended for patients who require prolonged tracheal intubation in the ICU.

Keywords: Intensive care unit, prolonged tracheal intubation, tracheostomy


How to cite this article:
Mahafza T, Batarseh S, Bsoul N, Massad E, Qudaisat I, Al- Layla AE. Early vs. late tracheostomy for the ICU patients: Experience in a referral hospital. Saudi J Anaesth 2012;6:152-4

How to cite this URL:
Mahafza T, Batarseh S, Bsoul N, Massad E, Qudaisat I, Al- Layla AE. Early vs. late tracheostomy for the ICU patients: Experience in a referral hospital. Saudi J Anaesth [serial online] 2012 [cited 2019 Dec 11];6:152-4. Available from: http://www.saudija.org/text.asp?2012/6/2/152/97029


  Introduction Top


Tracheostomy is among the most frequently performed procedure in critically ill patients, being done in about 24% of patients in ICU [1] . The benefits of tracheostomy over prolonged intubation are: Reduced use of sedation, reduced trauma to the oropharynx and larynx, reduced work of breathing and improved clearance of pulmonary secretion, decreased periods of mechanical ventilation and consequently length of ICU and hospital stay. [2],[3],[4]

Patients, who had prolonged tracheal intubation and consequently had late tracheostomy, had more complications; airway injuries and ventilator-associated pneumonia than those who underwent early tracheostomy. [5],[6],[7],[8]

Consensus for timing of tracheostomy in critically ill patients has not yet been reached. [9] The 3-week time limit of tracheal intubation in critically ill patients was based on the belief that the risk ratio (laryngeal risk vs. surgical tracheostomy risk) was excessive if the endotracheal tube was left much longer than a month, and thus tracheostomy for the ICU patients is considered early if it is done within 3 weeks of tracheal intubation. [8],[9],[10],[11]

The purpose of our study is to assess the benefits of early vs. late tracheostomy, stress upon the risks associated with late tracheostomy and to compare our results with the international data.


  Methods Top


The medical records of all patients, who underwent tracheostomy because of prolonged tracheal intubation from September 2006 to August 2010 at Jordan university hospital, were reviewed. Over a period of 4 years (2006-2010), all patients admitted to the ICU, who had tracheal intubation at Jordan University hospital and failed extubation or/and weaning, were considered for inclusion in this study. Patients, who needed emergency tracheostomy, were excluded from this study. Tracheostomy was performed using standard surgical techniques in the main theater. The timing of tracheostomy depended on the attending physician's decision. Medical records were analyzed for age, sex, underlying diseases due to which patients were admitted to ICU, complications occurred with prolonged tracheal intubation, postoperative complications due to tracheostomy, mortality rate, and the length of stay in the ICU. A follow-up period ranged from 1 to 6 months.


  Results Top


A total of 106 patients, who underwent an elective surgical tracheostomy because of prolonged tracheal intubation and failed extubation or/and weaning, were included in this study. Out of these 106 cases, there were 74 (70%) males and 32 (30%) females, and their age ranged from 2 months to 90 yr with a mean age of 46.5 yr. The reasons for their tracheal intubation and consequently their admission to ICU are summarized in [Table 1]. Early tracheostomy (within 3 weeks of an ICU admission) was done in 70 (66%) patients while 26 (24.5%) patients had the tracheostomy done in the 4 th week, 6 (5.7%) done in the 5 th week, 3 (2.8%) cases done in the 6 th week, and 1 (.9%) case of tracheostomy was done in the 7 th week of tracheal intubation. The complications of tracheal intubation and their relation to the time at which tracheostomy was done are shown in [Table 2]. The length of stay in the ICU for these patients was 41 days, ranged from 3 to 28 weeks (26:47 days early to late tracheostomy ratio), and the overall mortality rate was 26 (24.5%), notably higher death rate 13 (36.1%) among late tracheostomy than early tracheostomy 13 (17.1%).
Table 1: Causes of intubation in the ICU at Jordan University Hospital (2006-2010)

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Table 2: Complications of tracheostomy in the ICU at Jordan University Hospital (2006-2010)

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  Discussion Top


We adopted a 3-week time limit to convert tracheal intubation into tracheostomy in critically ill patients based on the recommendations of American College of Chest Physicians. [12] Although percutaneous dilatational tracheostomy (PDT) has low complications rate, we used the standard open surgical tracheostomy and not PDT due to the fact that the later is associated with higher mortality rate. [13] Classically, tracheostomy is superior to prolonged tracheal intubation for the ICU patients due to reduction in dead space and airway resistance, early weaning from ventilator, decrease rate of airway infection, decrease in the ICU stay and consequently reduced overall cost. [14],[15],[16] In our study, we are still having a lot of delay in performing a tracheostomy for the ICU patients at Jordan University Hospital (34%) due to medical and non-medical reasons. In our series, trauma was the most frequent cause of ICU admission (35.8%), which is probably due to the fact that we have a high rate of road traffic and other accidents in Jordan. Pneumonia is the most commonly reported nosocomial infection among ICU patients, occurring predominantly in individuals requiring mechanical ventilation and the prevalence ranges from 10% to 65%, and the associated fatality rates are more than 20%. [17] The rate of ventilator-associated pneumonia among our patients was 33, more common with patients who had late tracheostomy (41.7%) than with early tracheostomy patients (28.6%). However, some evidence also exists, which suggest that an early tracheostomy does not improve patient outcome. [18],[19] Regarding airway injuries, we have found that 12 (33.3%) of our patients who had late tracheostomy did develop airway injuries while 16 (22.9%) of patients with early tracheostomy had airway injuries, and these figures are close to others studies. [14],[15] Among our patients, 3 (8.3%) developed acute respiratory distress syndrome with late tracheostomy and 3 (4.3%) developed this complication with early tracheostomy; same observation has been noticed by MÖller and coworkers. [14] ICU mortality rate among our patients was less in late tracheostomy patients, which is in consistence with Hsu and coworkers. [20] However, a meta-analysis did not demonstrate a decrease in mortality rates among patients who had an early tracheostomy. [21] In a retrospective analysis by Bickenbach et al, early tracheostomy was found to reduce the duration of artificial ventilation as well as ICU length of stay, which was observed among our patients as well. [22] The complications rate occurred due to the procedure itself among our ICU patients were close to the international data. [23],[24],[25]

In conclusion, our results show that an early tracheostomy helps to reduce the complications rate, shortens the ICU stay, lower the mortality in the ICU, and consequently will result in decreasing the cost in cases with prolonged tracheal intubation. Therefore, close assessment of ICU patients for proper timing of doing tracheostomy is essential.

 
  References Top

1.Esteban A, Anzueto A, Alia I, Gordo F, Apezteguía C, Pálizas F, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000;161:1450-8.  Back to cited text no. 1
    
2.Rodriguez JL, Steinberg SM, Luchett FA, Gibbons KJ, Taheri PA, Flint . Early tracheostomy for primary airway management in the surgical critical care setting. Surgery 1990;108:655-9.  Back to cited text no. 2
    
3.Bouderka MA, Fakhir B, Bouggad 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.Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective randomized study comparing early percutaneous dilatational tracheostomy to prolonged translaryngeal intubation (delayed tracheostomy) in critically ill medical patients. Crit Care Med 2004;32:1689-94.  Back to cited text no. 4
    
5.Kollef MH. The prevention of ventilator-associated pneumonia. N Engl J Med 1999;340:627-34.  Back to cited text no. 5
    
6.Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients, requiring tracheostomy in the intensive care unit. Crit Care Med 1999;27:1714-20.  Back to cited text no. 6
    
7.Kluger Y, Paul DB, Luke J, Cox P, Colella JJ, Townsend RN, et al. Early tracheostomy in trauma patients. Eur J Emerg Med 1996;3:95-101.  Back to cited text no. 7
    
8.Durbin CG. Indications for and timing of tracheostomy. Respir Care 2005;50:843-7.  Back to cited text no. 8
    
9.Payor JP, Rielly PM, Shapiro MB. Surgical airway management in the intensive care unit. Rrit Care Clin 2000;16:473-8.  Back to cited text no. 9
    
10.Elo' G, Penzes I. Role of percutaneous tracheostomy in intensive care: A review. Orv Hetil 2002;143:875-9.  Back to cited text no. 10
    
11.Plummer AL, Gracy DR. Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest 1989;96:178-80.  Back to cited text no. 11
    
12.American Thoracic Society. Hospital-acquired pneumonia in adults: Diagnosis, assessment of severity, initial antimicrobial therapy, and preventive stratigies. Am J Respir Crit Care Med 1996;153:1711-25.  Back to cited text no. 12
    
13.Bowen CP, Whitney LR, Truwit JD, Durbin CG, Moore MM. Comparison of safety and cost of percutaneous versus surgical tracheostomy. Am Surg 2001;67:54-60.  Back to cited text no. 13
    
14.Möller MG, Slikeu JD, Bonelli P, Davis AT, Hoogeboom JE, Bonnell BW. Early tracheostomy versus late tracheostomy in the surgical intensive care unit. Am J Surg 2005;189:293-6.  Back to cited text no. 14
    
15.Whited RE. A prospective study of translaryngeal sequelae in long term intubation. Laryngoscope 1984;94:67-77.  Back to cited text no. 15
    
16.Qureshi AL, Suarez JI, Parekh PD, Bhardwaj A. Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilator support. Crit Care Med 2000;28:1383-7.  Back to cited text no. 16
    
17.George DL. Epidemiology of nococomial pneumonia in ICU patients. Clin Chest Med 1995;16:29-44.  Back to cited text no. 17
    
18.Dunham C, LaMonica C. Prolonged tracheal intubation in the trauma patients. J Trauma 1984;24:120-4.  Back to cited text no. 18
    
19.Maziak D, Meade M, Todd T. The timing of tracheostomy: A systematic review. Chest 1998;114:605-9.  Back to cited text no. 19
    
20.Hsu CL, Chen KY, Chang CH, Jerng JS, Yu CJ, Yang PC. Timing of tracheostomy as a determinant of weaning in critically ill patient: A retrospective study. Crit Care 2005;9:46-52.  Back to cited text no. 20
    
21.Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adults patients undergoing artificial ventilation. BMJ 2005;330:1243-7.  Back to cited text no. 21
    
22.Bickenbach J, Fries M, Offermanns V, Von Stillfried R, Rossaint R, Marx G, et al. Impact of early vs late tracheostomy on weaning: A retrospective analysis. Minerva Anestesiol 2011;77:1176-83.  Back to cited text no. 22
    
23.Astrachan DI, Kirchner JC, Godwin WJ. Prolonged intubation vs. tracheostomy: Complications, practical and psychological considerations. Laryngoscope 1988;98:1165-9.  Back to cited text no. 23
    
24.Yarington CT, Frazer JP. Complications of tracheostomy. Arch Surg 1965;91:652-5.  Back to cited text no. 24
    
25.Dane TE, King EG. A prospective study of complications after tracheostomy for assisted ventilation. Chest 1975;67:398-404.  Back to cited text no. 25
    



 
 
    Tables

  [Table 1], [Table 2]


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