TY - JOUR
T1 - Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit
AU - Kollef, Marin H.
AU - Ahrens, Thomas S.
AU - Shannon, William
PY - 1999/10/7
Y1 - 1999/10/7
N2 - Objective: To identify clinical predictors for tracheostomy among patients requiring mechanical ventilation in the intensive care unit (ICU) setting and to describe the outcomes of patients receiving a tracheostomy. Design: Prospective cohort study. Setting: Intensive care units of Barnes- Jewish Hospital, an urban teaching hospital. Patients: 521 patients requiring mechanical ventilation in an ICU for >12 hours. Interventions: Prospective patient surveillance and data collection. Measurements and Main Results: The main variables studied were hospital mortality, duration of mechanical ventilation, length of stay in the ICU and the hospital, and acquired organ- system derangements. Fifty-one (9.8%) patients received a tracheostomy. The hospital mortality of patients with a tracheostomy was statistically less than the hospital mortality of patients not receiving a tracheostomy (13.7% vs. 26.4%; p = .048), despite having a similar severity of illness at the time of admission to the ICU (Acute Physiology and Chronic Health Evaluation [APACHE] II scores, 19.2 ± 6.1 vs. 17.8 ± 7.2; p = .173). Patients receiving a tracheostomy had significantly longer durations of mechanical ventilation (19.5 ± 15.7 days vs. 4.1 ± 5.3 days; p < .001) and hospitalization (30.9 ± 18.1 days vs. 12.8 ± 10.1 days; p < .001) compared with patients not receiving a tracheostomy. Similarly, the average duration of intensive care was significantly longer among the hospital nonsurvivors receiving a tracheostomy (n = 7) compared with the hospital nonsurvivors without a tracheostomy (n = 124; 30.9 ± 16.3 days vs. 7.9 ± 7.3 days; p < .001). Multiple logistic regression analysis demonstrated that the development of nosocomial pneumonia (adjusted odds ratio [AOR], 4.72; 95% confidence interval [CI], 3.24-6.87; p < .001), the administration of aerosol treatments (AOR, 3.00; 95% CI 2.184.13; p < .001), having a witnessed aspiration event (AOR, 3.79; 95% CI, 2.30-6.24; p = .008), and requiring reintubation (AOR, 2.21; 95% CI, 1.54-3.18; p = .028) were variables independently associated with patients undergoing tracheostomy and receiving prolonged ventilatory support. Among the 44 survivors receiving a tracheostomy in the ICU, 38 (86.4%) were alive 30 days after hospital discharge and 31 (70.5%) were living at home. Conclusions: Despite having longer lengths of stay in the ICU and hospital, patients with respiratory failure who received a tracheostomy had favorable outcomes compared with patients who did not receive a tracheostomy. These data suggest that physicians are capable of selecting critically ill patients who most likely will benefit from placement of a tracheostomy. Additionally, specific clinical variables were identified as risk factors for prolonged ventilatory assistance and the need for tracheostomy.
AB - Objective: To identify clinical predictors for tracheostomy among patients requiring mechanical ventilation in the intensive care unit (ICU) setting and to describe the outcomes of patients receiving a tracheostomy. Design: Prospective cohort study. Setting: Intensive care units of Barnes- Jewish Hospital, an urban teaching hospital. Patients: 521 patients requiring mechanical ventilation in an ICU for >12 hours. Interventions: Prospective patient surveillance and data collection. Measurements and Main Results: The main variables studied were hospital mortality, duration of mechanical ventilation, length of stay in the ICU and the hospital, and acquired organ- system derangements. Fifty-one (9.8%) patients received a tracheostomy. The hospital mortality of patients with a tracheostomy was statistically less than the hospital mortality of patients not receiving a tracheostomy (13.7% vs. 26.4%; p = .048), despite having a similar severity of illness at the time of admission to the ICU (Acute Physiology and Chronic Health Evaluation [APACHE] II scores, 19.2 ± 6.1 vs. 17.8 ± 7.2; p = .173). Patients receiving a tracheostomy had significantly longer durations of mechanical ventilation (19.5 ± 15.7 days vs. 4.1 ± 5.3 days; p < .001) and hospitalization (30.9 ± 18.1 days vs. 12.8 ± 10.1 days; p < .001) compared with patients not receiving a tracheostomy. Similarly, the average duration of intensive care was significantly longer among the hospital nonsurvivors receiving a tracheostomy (n = 7) compared with the hospital nonsurvivors without a tracheostomy (n = 124; 30.9 ± 16.3 days vs. 7.9 ± 7.3 days; p < .001). Multiple logistic regression analysis demonstrated that the development of nosocomial pneumonia (adjusted odds ratio [AOR], 4.72; 95% confidence interval [CI], 3.24-6.87; p < .001), the administration of aerosol treatments (AOR, 3.00; 95% CI 2.184.13; p < .001), having a witnessed aspiration event (AOR, 3.79; 95% CI, 2.30-6.24; p = .008), and requiring reintubation (AOR, 2.21; 95% CI, 1.54-3.18; p = .028) were variables independently associated with patients undergoing tracheostomy and receiving prolonged ventilatory support. Among the 44 survivors receiving a tracheostomy in the ICU, 38 (86.4%) were alive 30 days after hospital discharge and 31 (70.5%) were living at home. Conclusions: Despite having longer lengths of stay in the ICU and hospital, patients with respiratory failure who received a tracheostomy had favorable outcomes compared with patients who did not receive a tracheostomy. These data suggest that physicians are capable of selecting critically ill patients who most likely will benefit from placement of a tracheostomy. Additionally, specific clinical variables were identified as risk factors for prolonged ventilatory assistance and the need for tracheostomy.
KW - Critical care
KW - Intensive care unit
KW - Mechanical ventilation
KW - Nosocomial pneumonia
KW - Respiratory failure
KW - Tracheostomy
UR - http://www.scopus.com/inward/record.url?scp=0032857985&partnerID=8YFLogxK
U2 - 10.1097/00003246-199909000-00003
DO - 10.1097/00003246-199909000-00003
M3 - Article
C2 - 10507588
AN - SCOPUS:0032857985
SN - 0090-3493
VL - 27
SP - 1714
EP - 1720
JO - Critical care medicine
JF - Critical care medicine
IS - 9
ER -