Tracheostomy practice in adults with acute respiratory failure

Transcription

1 本檔僅供內部教學使用檔案內所使用之照片之版權仍屬於原期刊公開使用時, 須獲得原期刊之同意授權 Tracheostomy practice in adults with acute respiratory failure Bradley D. Freeman, MD, FACS; Peter E. Morris, MD, FCCP Crit Care Med 2012 Vol. 40, No. 10 Department of Surgery (BDF), Washington University School of Medicine Presenter: R 黃柏森

2 Introduction Tracheostomy patients: need ventilator, ICU, hospital, and posthospital discharge resources Efforts to refine tracheostomy practice: improve the quality and resource of care Most reports: benefits, risks, and technical aspects Minority: optimal tracheostomy practice in acute respiratory failure Recommendations based on evidence, and outline directions for future research

3 Indications and Rationale for Tracheostomy Placement in the Setting of Acute Respiratory Failure Difficult airways: maxillofacial trauma, angioedema, obstructing upper airway tumors, or anatomic characteristics Prolonged mechanical ventilation(more common) Advantage: promote oral hygiene and pulmonary toilet, enhance patient comfort airway security, and allow oral nutrition and speech facilitate weaning(suppose)

4 Facilitate weaning? Airflow resistance: turbulence: extrinsic compression and inspissated secretions tube diameter tube length Tracheostomy: rigid, shorter length and removable inner cannula (to allow for evacuation of secretions) Safer and easier to manage when failure of liberation of mechanical ventilation Ambiguous criteria for selecting patients for tracheostomy

5 Project Impact administrative database analysis(106)

6 Timing of Tracheostomy in Acute Respiratory Failure 1960s early tracheostomy for inflexible material and used a low volume, high-pressure cuff stomal hemorrhage and infection rates >30%, rates of tracheal stenosis >50% and mortality rates as high as 4% Stauffer JL, Olson DE, Petty TL: Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med 1981; 70:65 76 optimal tracheostomy timing evaluation: mortality, development of infectious complications, duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS

7 Project Impact database analysis 43,916 patients

8 Italy French England

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10 Terragni et al 6 8 days vs days no pneumonia. Randomized at 72 hrs if PaO2 <60 (Fio2 = 0.5,PEEP = 8 cm H2O) 419 randomized 209 early tracheostomy; 145 [66.2%] underwent early tracheostomy; 210 late tracheostomy, 119 [56.7%] underwent late tracheostomy No effect on prevalence of VAP, ICU LOS, or mortality. Early tracheostomy associated with shortened duration of mechanical ventilation

11 Troullet et al 5 days vs. 15 days Postcardiac surgery at day 4 who fail screening test for weaning or spontaneous breathing trial 109 early tracheostomy 107 prolonged intubation; 29 patients [27%] in the prolonged intubation group underwent tracheostomy No effect on duration of mechanical ventilation, ICU LOS, or Hospital LOS. Early tracheostomy was associated with less use of sedation, less haloperidol use for agitation, and earlier mobility

12 TracMan 1 4 days vs. >10 days days 1 4 following ICU admission if clinician determines that there is a high likelihood of >7 days of continued ventilatory support 455 assigned to early tracheostomy; 454 assigned to late tracheostomy; 207 patients late tracheostomy[45.5%] underwent this procedure No effect on mortality, ICU LOS, or hospital LOS. Early tracheostomy was associated with fewer days of sedation.

13 Shortage Terragni exclude COPD, anatomic deformity of the neck, history of prior tracheostomy, and active pneumonia(away from reality) TracMan majority of patients liberated from MV(<4 days)(few sample) do not address subpopulations (such as patients with acute neurological injury, stroke, or progressive neurological disorders)

14 Conclusion about timing At least 2 wks following the onset of acute respiratory failure to insure need for ongoing ventilatory support Require multiple general anesthetics Difficult to manage agitation although potentially reversible cognitive impairment Significant comorbidities

15 Technique of Tracheostomy Placement In 1985, Ciaglia: percutaneous dilational tracheostomy (PDT) with the aid of bronchoscopy PDT vs surgical tracheostomy: Bedside performed convenience and lower risk of transport quick less blood loss fewer cost and lower rates of infectious complications compressive effect on minor bleeding and serve as a barrier to infection highly morbid complications tracheal laceration, aortic injury, and esophageal perforation

16 Causion of PDT Contraindications ambiguous surface neck anatomy difficult airway unstable cervical spine Should not be for establishment of emergent airway Necessity of back-up for surgical airway management

17 Conclusions and Future Directions timing of tracheostomy does not influence duration of mechanical ventilation, ICU LOS but beneficial effect of this intervention on sedation use, patient comfort, and earlier mobility Future study: risk-adjusted comparison of rates of tracheostomy or in-hospital mortality of tracheostomy Analyzing factors: the primary disease process, acuity of illness, comorbid conditions, use of and adherence to protocols directing weaning, sedation, and other aspects of care

18 Thanks for your attention