Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis

McCredie, Victoria; Alali, Aziz S.; Scales, Damon C.; Adhikari, Neill K. J.; Rubenfeld, Gordon D.; Cuthbertson, Brian H.; Nathens, Avery B.

doi:10.1007/s12028-016-0297-z

Cited by 107 publications

(89 citation statements)

References 53 publications

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“…There continues to be controversy regarding the optimal timing of TT. Performing an early TT in neurologic ICU patients may reduce long-term mortality, duration of ventilation, and ICU-LOS [27]. In an earlier study, Koh et al [28] even reported that patients undergoing elective tracheostomies at earlier time points had shorter ICU stays compared with patients who were given extubation trials before TT.…”

Section: Discussionmentioning

confidence: 99%

Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients

et al. 2017

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Background: Both delayed and premature extubation increase complication rate, the need for tracheostomy (TT), the duration of intensive care unit stay, and mortality. In this study, we therefore investigated factors associated with primary TT and predictors for extubation failure (EF) in a sample of severely affected ventilated stroke patients. Methods: One hundred eighty five intubated stroke patients were prospectively analyzed in this observational study. Patients not meeting predefined clinical and respiratory extubation criteria received a TT. All other patients were extubated and followed up for the need of reintubation. Characteristics of patients with and without extubation attempt were examined. Additionally, within the group of extubated patients, subgroups of successfully vs. unsuccessfully extubated patients were compared. Clinical factors associated with reintubation, including a previously established semi-quantitative airway score, were determined and predictors of EF were assessed. Results: Ninety-eight of 185 patients (53%) were primarily extubated; EF rate was 37% (36 patients). Eighty-seven (47%) were tracheostomized without a prior extubation attempt. Primarily tracheostomized patients had more severe strokes, which were more often hemorrhagic, presented with a lower level of consciousness, needed neurosurgical intervention more often, had a higher rate of obesity, and were more frequently intubated because of suspicion of compromised protective reflexes. EF was independently predicted by prior neurosurgical treatment and low airway management scores. No differences were found for the ability to follow simple commands and classical weaning criteria. Conclusion: Airway management decisions in intubated stroke patients represent a clinical challenge. Classical weaning criteria and parameters reflecting the patient's state of consciousness are not reliably predictive of extubation success. Criteria more closely related to airway safety and secretion handling may provide the most relevant information and should therefore be assessed by specific clinical scoring systems.

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Section: Discussionmentioning

confidence: 99%

Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients

et al. 2017

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“…The number needed to treat for an additional beneficial outcome (NNTB) was around 11. Also, the probability of discharge from the ICU was higher at day 28 (14). However, the timing (early versus late) TT placement is controversial.…”

Section: Resultsmentioning

confidence: 99%

“…Placement of a TT also allows for direct access to the airway and improved suctioning from the lower airways (11). In addition, data suggests that patients are more comfortable with TT than with endotracheal intubation (12), allowing for earlier discontinuation of analgesia and sedation, which is helpful in facilitating patients to awaken, be weaned from ventilation, and begin early mobilization regimens (13,14).…”

Section: Evidenced-based Clinical Problem Solving Articlementioning

confidence: 99%

“…Such delay may significantly impair nutritional status of stroke patients with dysphagia, as guidelines recommended early initiation of enteral nutritional support for the critically ill (15,16). There is also evidence that early tracheostomy (ET) can improve patient-important outcomes such as mortality, duration of MV and ICU length of stay (14), however this remains controversial (17). Based on this we propose the combined placement of PEG and TT in the same setting as the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure.…”

Section: Evidenced-based Clinical Problem Solving Articlementioning

confidence: 99%

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How should this patient with repeated aspiration pneumonia be managed and treated?—a proposal of the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure

et al. 2016

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Cerebrovascular accident (CVA) is commonly seen among the elderly with a substantial proportion of patients suffering from long-term dysphagia and/or an inability to protect their airway. This potentially imposes on them an increased risk of malnutrition and aspiration pneumonia. In this article, we present a patient with malnutrition and dysphagia secondary to CVA. We propose a procedure for which we will name the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure for placement of percutaneous endoscopic gastrostomy (PEG) and tracheostomy tube (TT) at the same time. The medical literature was systematically reviewed for both PEG and tracheostomy, aiming to provide the state-of-the-art evidence for clinical use of the PENlIGhT procedure. In clinical practice, the PENlIGhT procedure is indicated for patients who are expected to have prolonged swallowing disturbance and mechanical ventilation. Some prediction tools and scores can be helpful to identify such groups of patients. Patients with poor neurological outcomes who require prolonged maintenance of life are also good candidates for the PENlIGhT procedure.

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“…In subarachnoid hemorrhage patients, performing early (days 1–7) versus later (days 8–20) tracheostomy resulted in less pneumonia, less respiratory adverse events, shorter duration of mechanical ventilation, and ultimately earlier decannulation [9]. In an analysis of 10 trials in acute brain injured patients, early tracheostomy was found to reduce long-term mortality, duration of mechanical ventilation, and ICU length of stay; however delaying tracheostomy resulted in an increased probability of not needing a tracheostomy [10]. Assessing need for tracheostomy at day 7 has been recommended [11].…”

Section: Discussionmentioning

confidence: 99%

Abnormal Breathing Patterns Predict Extubation Failure in Neurocritically Ill Patients

Punj

Nattanmai

George

et al. 2017

Case Reports in Critical Care

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In neurologically injured patients, predictors for extubation success are not well defined. Abnormal breathing patterns may result from the underlying neurological injury. We present three patients with abnormal breathing patterns highlighting failure of successful extubation as a result of these neurologically driven breathing patterns. Recognizing abnormal breathing patterns may be predictive of extubation failure and thus need to be considered as part of extubation readiness.

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Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis

Cited by 107 publications

References 53 publications

Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients

Tracheostomy, Extubation, Reintubation: Airway Management Decisions in Intubated Stroke Patients

How should this patient with repeated aspiration pneumonia be managed and treated?—a proposal of the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure

Abnormal Breathing Patterns Predict Extubation Failure in Neurocritically Ill Patients

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