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Thursday, December 29, 2011

10-Year Outcomes Study on Trachs

This was a 10-year study done at a tertiary care teaching hospital in Tanzania and included 214 patients. Male to female ratio was 3:1, with a mean age of 38 years.  In their study, the most common indication for tracheostomy was upper airway obstruction secondary to trauma or neoplastic causes. Eighty-six percent of tracheostomies were temporary, and 14% were permanent tracheostomies.  Most (80%) of these tracheotomies were performed as an emergency and the complication rate was higher in that group, compared to the overall complication rate (74% vs. 21.5%).   Twenty-two percent of complications occurred in the first  postoperative week, and 65% occurred after the first postoperative week. Of the patients who had a tracheostomy placed for prolonged mechanical ventilation, the duration of intubation before tracheostomy ranged from 4-62 days, with a median of 26 days.  Duration of cannulation was 8 days to 46 months, with a median duration of 4 months.  Decannulation was successful in 72% of patients who survived.  Mortality rate was 13.6% and was due to the underlying illness, not the tracheostomy itself.

As the authors stated, and I would agree, that the majority of the complications can be prevented by meticulous attention to technique and postoperative care.

Source: Gilyoma, J.,Balumuka, D, Chalya, P. (2011). Ten-year experiences with tracheostomy at a university teaching hospital in northwestern Tanzania: A retrospective review of 214 cases. World J Emerg Surg, 6:38.

Saturday, December 17, 2011

Trach for Prolonged Mechanical Ventilation

A survey was done of intensive care units in Italy to learn about the clinical characteristics of patients with a tracheostomy, including types, complications, criteria for performing decannulation, and outcomes. They received responses from 22 intensive care units with 846 admissions of 719 patients. Reasons for admission included acute respiratory failure with underlying chronic co-morbidities (24.4%), exacerbation of COPD (34.4%), neuromuscular diseases (27.8%), surgical patients (10.7%), and obstructive sleep apnea (2.2%). They found a very low incidence of major complications (fistula or stenosis, 2%). Twenty-two percent of patients were decannulated prior to discharge; and 41% were discharged with home mechanical ventilation, while 26.5% maintained the tracheostomy despite being weaned from the ventilator, and 10% died or were lost (either transferred to other units or refused treatment). Those who maintained the trach without mechanical ventilation were either over age 70 or had co-morbidities, or both.
In this study, the criteria to indicate decannulation included: stable PaCO2, absence of swallowing problems, type and severity of disease, presence of effective cough, stability of respiratory parameters such as dyspnea, respiratory rate, SaO2, PaO2, PaCo2, pH, and successful capping.

Source: Marchese et al, (2010). Tracheostomy patients with long-term mechanical ventilation: A survey. Resp Med (104), 749-753.