在重症监护后呼吸护理环境中，对于需要长时间机械通气的患者，入院前气管切开术与更好的预后相关。

Preadmission tracheostomy is associated with better outcomes in patients with prolonged mechanical ventilation in the postintensive care respiratory care setting.

作者信息

Huang Chun-Ta, Lin Jou-Wei, Ruan Sheng-Yuan, Chen Chung-Yu, Yu Chong-Jen

机构信息

Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.

Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yunlin, Taiwan.

出版信息

J Formos Med Assoc. 2017 Mar;116(3):169-176. doi: 10.1016/j.jfma.2016.05.005. Epub 2016 Jul 9.

DOI:10.1016/j.jfma.2016.05.005

PMID:27401698

Abstract

BACKGROUND/PURPOSE: Prolonged mechanical ventilation (PMV) is the most common situation where tracheostomy is indicated for intensive care unit (ICU) patients. However, it is unknown if this procedure confers survival benefits on PMV patients in a post-ICU setting.

METHODS

Patients who were admitted to the specialized weaning unit from 2005 to 2008 and received PMV were included in this study. On admission, data pertaining to patient characteristics, physiologic status, and type of artificial airway (tracheostomy vs. no tracheostomy) were obtained. Outcomes of tracheostomized and nontracheostomized patients were evaluated using multivariate Cox proportional hazards and propensity score-matching models. The primary outcome of interest was 1-year survival.

RESULTS

A total of 401 patients (mean age 74.4 years, 204 male) were identified. In multivariate analyses, higher Acute Physiology and Chronic Health Evaluation II score [hazard ratio (HR) = 1.061, 95% confidence interval (CI) = 1.016-1.107] and presence of comorbidities, including congestive heart failure (HR = 1.562, 95% CI = 1.119-2.181), malignancy (HR = 1.942, 95% CI = 1.306-2.885), and liver cirrhosis (HR = 2.373, 95% CI = 1.015-5.544), were independently associated with 1-year mortality. An association between having tracheostomy and a better 1-year outcome was observed (HR = 0.625, 95% CI = 0.453-0.863). The matched cohort study also demonstrated a favorable 1-year survival for tracheostomized patients, and these patients had significantly lower in-hospital mortality (24% vs. 36%, p = 0.049) and risk of ventilator-associated pneumonia (10% vs. 20%, p = 0.030) than nontracheostomized ones.

CONCLUSION

Preadmission tracheostomy may be associated with better outcomes of PMV patients in a post-ICU respiratory care setting. The findings suggest that this procedure should be recommended before PMV patients are transferred to specialized weaning units.

摘要

背景/目的：对于重症监护病房（ICU）患者而言，需要长期机械通气（PMV）是气管切开术最常见的适应证。然而，在ICU后的环境中，该手术是否能使PMV患者获得生存益处尚不清楚。

方法

本研究纳入了2005年至2008年入住专门的撤机病房并接受PMV的患者。入院时，获取了有关患者特征、生理状态和人工气道类型（气管切开术与未行气管切开术）的数据。使用多变量Cox比例风险模型和倾向得分匹配模型评估行气管切开术和未行气管切开术患者的结局。主要关注的结局是1年生存率。

结果

共确定了401例患者（平均年龄74.4岁，男性204例）。在多变量分析中，急性生理与慢性健康状况评估II评分较高[风险比（HR）=1.061，95%置信区间（CI）=1.016 - 1.107]以及存在合并症，包括充血性心力衰竭（HR = 1.562，95% CI = 1.119 - 2.181）、恶性肿瘤（HR = 1.942，95% CI = 1.306 - 2.885）和肝硬化（HR = 2.373，95% CI = 1.015 - 5.544），均与1年死亡率独立相关。观察到行气管切开术与更好的1年结局之间存在关联（HR = 0.625，95% CI = 0.453 - 0.863）。匹配队列研究也显示行气管切开术患者1年生存率良好，且这些患者的院内死亡率（24%对36%，p = 0.049）和呼吸机相关性肺炎风险（10%对20%，p = 0.030）显著低于未行气管切开术的患者。