To further examine the major determinants for tracheostomy in each of these 6 diagnostic subgroups, we looked at the relationships between the underlying diagnosis, the use of invasive monitoring, and the time during which mechanical ventilation was required (Table 5, Fig 1). In addition, we noted whether tracheostomy was discontinued at hospital dismissal or continued. Our bias led us to believe that the major positive determinants would be (1) time of needed intubation (>7-10 days) and (2) anticipation of future need for tracheostomy, whereas the major negative determinants would be (3) anticipation of imminent death (not wishing to add unnecessary charges to the patient bill), or (4) anticipa tion of imminent recovery and easy extubation. This is borne out by our findings. Read the rest of this entry »
Archive for the ‘Tracheostomy’ Category
Current Pragmatic Experience
With this controversy in mind, the philosophic position adopted since 1974 by the Critical Care Service at Mayo in conjunction with our medical and surgical colleagues has been that tracheostomy should be considered at day 10 of intubation and performed then unless extubation or de^th was imminent. To examine this in practice, we reviewed the Mayo experience with prolonged mechanical ventilation since 1970 and reexamined a patient series collected in 1982-83 and published in 1986. In Table 2 tne number of patients who required mechanical ventilatory support in ICUs in two Mayo-affiliated hospitals is shown for selected years from 1970 to 1984. Pulmonary artery catheter use in patients in general medical and surgical units (not cardiac surgical, not coronary care) is also shown. Fairly stable mortality rates were noted and these were comparable to data from other centers.
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Late Tracheal Stenosis
Late tracheal stenosis after tracheostomy has received sporadic attention in case reports since at least 1964. In follow-up of 237 patients (120 responding) who had more than 3 days of intubation in a large multidisciplinary ICU at Victoria Hospital, 52 were intubated 7 days or less, and only 1 of these had necessary surgical removal of a granuloma; 63% had no complication. Of 17 intubated more than 7 days, 48% had no complication, and the remainder had minor complications—most frequently hoarseness, which did not persist. Of patients who had tracheostomy after prolonged intubation, only 23% were free from complications. These authors concluded that tracheostomy should be avoided as long as possible, but that frequent evaluation of the larynx should be undertaken after 7 days.
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To best answer the question how long patients should be intubated before receiving tracheostomy, we need to answer subsidiary sets of questions: What are the advantages and disadvantages of tracheostomy and prolonged endotracheal intubation? What are the comparative complication rates? What are the major mechanisms causing complications? Can the rates of complication be modified? and What is the current pragmatic experience from use of tracheostomy in the critically ill, and can a maximum time be set for prolonged oral or nasal endotracheal intubation in different diagnostic groups? Read the rest of this entry »