Bice Thomas, Nelson Judith E, Carson Shannon S
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York.
Semin Respir Crit Care Med. 2015 Dec;36(6):851-8. doi: 10.1055/s-0035-1564872. Epub 2015 Nov 23.
The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging.
需要长期机械通气并接受气管切开术的慢性危重症患者数量正在稳步增加。对于需要长期机械通气的患者，有人提出早期气管切开术可缩短机械通气时间和重症监护病房住院时间，降低死亡率，并提高患者舒适度。然而，这些益处很难在临床试验中得到证实。那么，如何确定为患者进行气管切开术的合适时机呢？在此，我们回顾气管切开术的潜在益处和后果、气管切开术时机的现有证据、围绕气管切开术决策的沟通，以及以患者为中心的气管切开术方法。预计住院期间能存活的需要机械通气超过10天的患者可能会从气管切开术中获益，但涉及常规早期气管切开术的方案并不能改善患者预后。然而，患有神经损伤且有望实现有意义恢复的患者，可能会从早期气管切开术中获益。在预后较差的慢性危重症患者中，气管切开术不太可能带来益处，只有在符合患者价值观、目标和偏好时才应进行。在这种情况下，就气管切开术和预后与患者及替代决策者进行沟通变得至关重要。在可预见的未来，围绕气管切开术的决策仍将具有现实意义且颇具挑战性。
