REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
Official Publication of the Brazilian Society of Anesthesiologywww.sba.com.br
SCIENTIFIC
ARTICLE
Comparison
of
early
and
late
percutaneous
tracheotomies
in
adult
intensive
care
unit
Mehmet
Duran
a,
Ruslan
Abdullayev
a,∗,
Mevlüt
C
¸ömlekc
¸i
b,
Mustafa
Süren
c,
Mehmet
Bülbül
d,
Tayfun
Aldemir
eaAnesthesiologyDepartment,AdiyamanUniversityResearchHospital,Adiyaman,Turkey
bAnesthesiologyDepartment,BagcilarResearchHospital, ˙Istanbul,Turkey
cAnesthesiologyDepartment,GaziosmanPasaUniversity, ˙Istanbul,Turkey
dObstetricsandGynecologyDepartment,AdiyamanUniversityResearchHospital,Adiyaman,Turkey
eAnesthesiologyDepartment,KanuniSultanSuleymanResearchHospital, ˙Istanbul,Turkey
Received30June2013;accepted19August2013 Availableonline26October2013
KEYWORDS
Percutaneous tracheotomy; Earlytracheotomy; Latetracheotomy
Abstract
Backgroundandobjectives: Percutaneous tracheotomy has become a good alternative for patientsthoughttohaveprolongedintubationinintensivecareunits.Themostimportant bene-fitsoftracheotomyareearlydischargeofthepatientfromtheintensivecareunitandshortening ofthetimespentinthehospital.Prolongedendotrachealintubationhascomplicationssuchas laryngealdamage,vocalcordparalysis,glotticandsubglotticstenosis,infectionandtracheal damage.Theobjectiveofourstudywastoevaluatepotentialadvantagesofearlypercutaneous tracheotomyoverlatepercutaneoustracheotomyinintensivecareunit.
Methods:Percutaneoustracheotomiesappliedto158patientsinadultintensivecareunithave beenanalyzed retrospectively.Patientswere dividedinto twogroups asearlyandlate tra-cheotomyaccordingtotheirendotrachealintubationtimebeforepercutaneoustracheotomy. Tracheotomiesatthe0---7thdaysofendotrachealintubationweregroupedasearlyandafterthe 7thdayofendotrachealintubationaslatetracheotomies.Patientshavinginfectionatthesiteof tracheotomy,patientswithdifficultorpotentialdifficultintubation,thoseunder18yearsold, patientswithpositiveend-expiratorypressureabove10cmH2Oandthosewithbleeding
diathe-sisorplateletcountunder50,000dL−1werenotincludedinthestudy.Durationsofmechanical
ventilationandintensivecarestaywerenoted.
Results:There was no statistical difference among the demographic data of the patients. Mechanical ventilation time and time spent in intensive care unit inthe group with early tracheotomywasshorterandthedifferencewasstatisticallysignificant(p<0.05).
∗Correspondingauthor.
E-mail:[email protected](R.Abdullayev).
0104-0014/$–seefrontmatter©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.
Conclusion: Early tracheotomy shortens mechanicalventilation duration andintensive care unitstay.Forthatreasonwesuggestearlytracheotomyinpatientsthoughttohaveprolonged intubation.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
PALAVRAS-CHAVE
Traqueotomia percutânea; Traqueotomia precoce;
Traqueotomiatardia
Comparac¸ãodetraqueotomiapercutâneaprecoceetardiaemunidadedeterapia intensivaparaadultos
Resumo
Justificativaeobjetivos: A traqueotomiapercutânea tornou-seuma boaalternativa paraos pacientescomprevisãodeintubac¸ãoprolongadaemunidadesdeterapiaintensiva.Os bene-fíciosmaisimportantesdatraqueotomiasãoaltaprecoce daunidade deterapiaintensivae menostempodepermanêncianohospital.Ascomplicac¸õesdaintubac¸ãointratraqueal prolon-gadasão:lesãodalaringe,paralisiadaspregasvocais,estenoseglóticaesubglótica,infecc¸ão elesãotraqueal.Oobjetivodesteestudofoiavaliaraspotenciaisvantagensdatraqueotomia percutâneaprecoceversustraqueotomiapercutâneatardiaemunidadedeterapiaintensiva.
Métodos: Traqueotomiaspercutâneasforamrealizadasem158pacientesemunidadedeterapia intensivaparaadultoseanalisadasretrospectivamente.Ospacientesforamalocadosemdois gruposparatraqueotomiaprecoceetardia,deacordocomotempodeintubac¸ãointratraqueal antesdatraqueotomiapercutânea.Astraqueotomiasconsideradasprecocesforamrealizadas nosdias0-7deintubac¸ãointratraquealeastardiasrealizadasapósosétimodiadeintubac¸ão intratraqueal.Ospacientescominfecc¸ãonolocaldatraqueotomia,intubac¸ãodifícilou poten-cialmente difícil,idade inferiora 18 anos,pressão positivaao final daexpirac¸ão acimade 10cmH2Oeaquelescomdiátesehemorrágicaoucontagemdeplaquetasem50.000dL−1foram
excluídosdoestudo.Ostemposdeventilac¸ãomecânicaeinternac¸ãoemUTIforamregistrados.
Resultados: Nãohouvediferenc¸a estatística entreosdados demográficosdos pacientes. Os tempos deventilac¸ão mecânicae deinternac¸ão em unidade deterapia intensiva dogrupo traqueotomiaprecoceforammenoreseadiferenc¸afoiestatisticamentesignificativa(p<0,05).
Conclusão:Traqueotomiaprecocereduzotempodeventilac¸ãomecânicaedeinternac¸ãoem unidadedeterapiaintensiva.Portanto,sugerimosatraqueotomiaprecoceempacientescom suspeitadeintubac¸ãoprolongada.
©2013SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Tracheotomyisoneoftheproceduresfrequentlyappliedin intensivecareunits(ICUs).Themostimportantadvantages oftracheotomyareearlydischargefromICUandshortening ofthehospitalstayofthepatient.Tracheotomyisadvisable for thepatients whoareintubatedandpredictedtohave beenonmechanicalventilationforalongperiodoftime.1,2
Prolongedendotrachealintubationhascomplications includ-ing laryngeal damage, vocal cord paralysis, glottic and subglotticstenosis,infection,trachealdamage (tracheoma-lasia,trachealdilatationandtrachealstenosis),etc.3,4
While surgical tracheotomy was the single alternative until1969,percutaneoustracheotomy(PT)hasbeenanew alternativeafterthefirsthalfof80th.Tracheotomyhaving alotofadvantages is agoodalternative forendotracheal intubationinICUs.5
Themainconcerniswhenandtowhichpatientsapplythe tracheotomy.In1998areviewnotifiedweakproofaboutthe effectoftimingoftracheotomyonmechanicalventilation timeandpreventingtheairwaydamageincriticalpatients.6
Some studies show that early tracheotomy shortens
mechanicalventilationtime,ICUandhospitalstaytimesand resultsinlessdamagetotheairways.7,8
Oldreferencesproposetracheotomytopatientsthought tobeintubatedformorethan21days.Buttodayitis advis-abletoevaluatethepatientbetweenthesecondandtenth daysofintubationandconsidertracheotomyforthemwho will require intubation for more than 14 days. Early tra-cheotomyisbeneficialforsomespecialcircumstancessuch aspatientswithpolytrauma,headtraumaandlowGlaskow ComaScale (GCS). EarNoseThroat specialistsalsoadvise earlytracheotomyforpreventionoflaryngealdamage.9
Weaimedtoevaluatetheeffectofearlyapplicationof PTinourstudyandseetheadvantages,ifany,overlatePT regardingmechanicalventilatorandhospitallengthofstay ofthepatient.
Methods
Table1 Sex distributionof patients withearly andlate tracheotomy.
Groups Early tracheotomy
n(%)
Late tracheotomy
n(%)
p
Male 74(64.3) 27(62.8) 0.375
Female 41(35.7) 16(37.2)
Total 115(100) 43(100)
examinedretrospectively.Totalnumberofthepatientswas 158,withthe age rangeof 18---98 years.The First-degree relativeofeachpatientwasinformedabouttheprocedure andinformedconsenthadbeentakenfromthem.Patients weredividedintotwogroups.Thepatientsundergoneearly tracheotomy(tracheotomy betweenthe0and7thdaysof endotrachealintubation)namedasGroupIandthose under-gonelatetracheotomy(tracheotomy afterthe 7thday of endotrachealintubation)asGroupII.Patientswithinfection onthesite of tracheotomy,bleeding diathesisor platelet countlessthan50,000dL−1,thosewithknownorsuspected
difficultairway,patientsunder18yearsoldandthosewith PEEPmorethan10cmH2Owereexcludedfromthestudy.
Demographicdatasuchasage,sex,bodymassandheight werenoted,aswellasICUhospitalizationreason,theday oftracheotomy,averagemechanicalventilationtimeafter tracheotomyandtotalmechanicalventilationduration.
AllthepatientshadbeenroutinelymonitorizedwithECG, NIBPandpulseoxymetry.Allpatientshadreceivedpropofol 3mgkg−1,fentanyl 2gkg−1, midazolam 0.03mgkg−1 and
vecuronium0.1mgkg−1 ivfor sedation.The patientswere
pre-oxygenized for 15min and during the procedure with 100%oxygen.
Percutaneous tracheotomy kit (Portex®) tracheotomy
canullawithinternaldiameterof8mmhadbeenusedforthe patientsofbothgroups.Thesiteoftracheotomyhadbeen controlled for any haemorrhage, infection,decannulation duringthehospitalstay.
Statistical analysis was made via SPSS 15.0 program. Kolmogorov---Smirnovtest wasusedfor assessment of nor-maldistribution.Regardingthecomparisonofquantitative data betweenthe groups IndependentSamples t-test was used for evaluation of data with normal distribution and MannWhitneyUtestfordatawithoutnormaldistribution. PairedSamples t-test wasusedfor evaluationof thedata withnormaldistributionandWilcoxontestforthedata with-outnormaldistribution.2testwasusedforcomparisonof
qualitative data.Theresults inconfidenceintervalof 95% andwithp<0.05wereconsideredstatisticallysignificant.
Results
158 patients were included in the study. 101 of them weremales and57females. Malesand femaleratioswith
Table2 AgeandBMIdistributionoftracheotomies.
Groups Earlytracheotomy Latetracheotomy p
Mean SD Mean SD
Age(years) 59.591 18.987 62.628 19.428 0.375
BMI(kgm−2) 29.174 6.031 28.279 5.409 0.395
Table3 DistributionoftracheotomyaccordingtoICUacceptanceindication.
Earlytracheotomy Latetracheotomy p
n % n %
ICUacceptanceindication
Cerebrovascularyaccident 41 35.7 16 37.2 0.827
Cardiacpathology 21 18.3 8 18.6
Pulmonarypathology 28 24.3 9 20.9
Sepsis 15 13.0 4 9.3
Trauma 7 6.1 3 7.0
Other 3 2.6 3 7.0
Table4 MechanicalventilationtimeandICUstaydurationafterearlyandlatetracheotomy.
Groups Earlytracheotomy Latetracheotomy p
Mean SD Mean SD
Totalmechanicalventilationduration(days) 11.27 13.122 16.40 16.377 0.043a
ICUstayduration(days) 17.38 14.561 30.95 19.166 <0.001a
earlytracheotomywererespectively64.3%and35.7%,while withlatetracheotomywererespectively62.8%and37.2%. Therewasnostatisticallysignificantdifferencebetweentwo groupsaccordingtothesexesofthepatients(p>0.05).Early PTwasappliedto115patients,whilelatePTto43patients. There was no statistically significant difference between two groups according to the demographic data (p>0.05) (Tables1and2).
Therewasnostatisticallysignificantdifferencebetween twogroupsregardinghospitalizationindicationintotheICU (p>0.05)(Table3).
Mechanicalventilationtimeaftertracheotomywaslong inGroupIIcomparedwithGroupI.Thisdifferencewas sta-tisticallysignificant(p<0.05)(Table4).
ICU stay durationaftertracheotomywaslong inGroup II comparedwithGroupI.This differencewasstatistically significant(p<0.05)(Table4).
Discussion
While it was advisable to apply tracheotomy before 21st day ofendotracheal intubation inthe past,Durbin etal.9
have proposed to evaluate the patient for tracheotomy betweendays2---10ofmechanicalventilationandperform tracheotomyfor patients thoughttobeleftintubatedfor more than 14 days, especially for some selected patient groupssuchasmajorpolytrauma,lowGCSandheadtrauma. Zaglietal.10havecomparedeffectsofearlyandlate
tra-cheotomiesin506patients.Earlytracheotomywasdefined astracheotomyinthefirstthreedaysofendotracheal intu-bationinthisstudyandmechanicalventilationdurationand hospitallengthofstaywereshorterintheearlytracheotomy group.
However,therearesomestudiesthatshownodifference betweenearlyandlatetracheotomy.Sugermanetal.11have
shown nodifferencebetween early and latetracheotomy regarding ICU length of stay. They performed early tra-cheotomybetweendays3---5andlatetracheotomybetween days 10 and 14 of endotracheal intubation. Blot et al.12
compared twogroups of patients with early tracheotomy versusprolongedintubationandfoundnodatafavoringearly tracheotomy,so proposednot toapplyearly tracheotomy besidesselectedpatientgroups.
We have found shorter hospital length of stay in the patientswithearly tracheotomyin ourstudy.Mean hospi-tal length of stay for early and late tracheotomy groups were17.4 and31.0 daysrespectively. The differencewas statisticallysignificant.
Yavaset al.13 have comparedsurgical andPT and
con-cluded that both methods can be used in ICU but with lowerinfectionratewithearlytracheotomy.Lesniketal.14
showedthat patientswithearly tracheotomyhave signifi-cantlylowermechanicalventilatorstaycomparedwithlate tracheotomyinthestudywheretheyappliedtracheotomy onthefourth day of endotrachealintubation totheearly tracheotomygroup. These findings arecoherent with the resultsofourstudy.
Both percutaneous and surgical tracheotomies have complicationssuchashaemorrhage,subcutaneous emphy-sema, tracheal damage, wound infection, pneumotho-rax and pneumomediastinum.15 Holdgaard et al.16 have
compared surgical and percutaneous tracheotomies and illustrated superiority of percutaneous technique. Freid-manetal.17displayedcomplicationratesforpercutaneous
and surgical tracheotomies as 12% and 42% respectively. As a resultof these data PT has gradually become more preferablemethod.Comparedwithsurgicaltracheotomy,PT reducesexpenditurebecauseofshorteningoftimespentin operationroomandsparingoperationroomcrewneed.18,19
Conclusions
EarlyPTshortensmechanicalventilationdurationtimeand ICUlengthofstay.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Plummer AL, Gracey DR. Concensus conference on artificial airways in patients receivingmechanical ventilation. Chest. 1989;96:178---80.
2.Marsh HM, Gillespie DJ, Baumgartner AE. Timing of tra-cheostomyinthecriticallyillpatients.Chest.1989;96:190---3.
3.WhitedRE.Aprospectivestudyoflaryngotrachealsequelaein termintubation.Laryngoscope.1984;94:367---77.
4.AtinkayaC,S¸ahinE,KutlayH,etal.Theroleofdynamicstentsin postintubationtrachealstenosis.KlinJMedSci.2003;23:310---8.
5.Akıncı ˙IÖ,Tu˘grulS,ÖzcanP,etal.Comparisonofpercutaneous dilatationalandforcepsguidedtracheostomytechniques.Türk AnestReanCemMecmuas.2001;29:547---50.
6.MaziakDE,MeadeMO,ToddTR.Thetimingoftracheotomy:a systematicreview.Chest.1998;114:605---9.
7.Rumbak MJ, Newton M, Truncale T, et al. A prospective, randomized,studycomparingearlypercutaneousdilatational tracheotomyto prolonged translaryngealintubation (delayed tracheotomy)incriticallyillmedicalpatients.CritCareMed. 2004;32:1689---94.
8.Rodriguez JL, Steinberg SM, Luchetti FA, et al. Early tra-cheostomy for primary airway management in the surgical criticalcaresetting.Surgery.1990;108:655---9.
9.DurbinJrCG.Tracheostomy:why,when,andhow?RespirCare. 2010;55:1056---68.
10.Zagli G, Linden M, Spina R, et al. Early tracheostomy in intensivecareunit:aretrospectivestudyof506casesof video-guidedCiagliaBlueRhinotracheostomies.JTrauma.2010;68: 367---72.
11.Sugerman HJ,WolfeL,PasqualeMD, etal. Multicenter, ran-domized,prospective trial ofearly tracheostomy.JTrauma. 1997;43:741---7.
12.BlotF,SimilowskiT,TrouilletJL,etal.Earlytracheotomyversus prolongedendotrachealintubationinunselectedseverelyillICU patients.IntensiveCareMed.2008;34:1779---87.
13.YavasS,YagarS,MaviogluL,etal.Tracheostomy:howandwhen shoulditbedoneincardiovascularsurgeryICU?JCardSurg. 2009;24:11---8.
14.Lesnik I, Rappaport W, Fulginiti J, et al. The role of early tracheostomy in blunt, multiple organ trauma. Am Surg. 1992;58:346---9.
15.KansuL,AydinE,AvciS.Apercutaneoustracheotomy compli-cation:trachealstenosis:casereport.TurkiyeKlinikleriJMed Sci.2008;28:773---7.
tracheostomy.Aclinicalrandomisedstudy.ActaAnaesthesiol Scand.2000;44:1029.
17.FriedmanY,FildesJ,MizockB,etal.Comparisonof percuta-neousandsurgicaltracheostomies.Chest.1996;1108:480---5.
18.BacchettaMD,GirardiLN,SouthardEJ, etal.Comparisonof open versus bedside percutaneous dilatationaltracheostomy
inthecardiothoracicsurgicalpatient:outcomesandfinancial analysis.AnnThoracSurg.2005;79:1879---85.
