Division of Pulmonary and Critical Care, Department of Medicine, NYU Langone Health, NYU Grossman School of Medicine, New York, NY.
Department of Cardiothoracic Surgery, NYU Langone Health, NYU Grossman School of Medicine, New York, NY.
Crit Care Med. 2021 Jul 1;49(7):1058-1067. doi: 10.1097/CCM.0000000000004969.
To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers.
Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis.
Critical care units at two large metropolitan hospitals in New York City.
Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation.
Bedside percutaneous dilational tracheostomy with modified visualization and ventilation.
Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection.
In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.
评估经皮扩张气管切开术对需要机械通气的 2019 年冠状病毒病患者的影响，以及对医护人员的风险。
前瞻性队列研究；患者于 2020 年 3 月 11 日至 4 月 29 日入组。最后一次随访日期为 2020 年 7 月 30 日。我们使用倾向评分匹配方法来比较结果。研究结果在数据收集和分析之前制定。
纽约市两家大型都市医院的重症监护病房。
541 例确诊为严重 2019 年冠状病毒病呼吸衰竭需要机械通气的患者。
床边经皮扩张气管切开术，改良可视化和通气。
停止机械通气所需的时间、总住院时间和整体患者生存率。在 541 例患者中，有 394 例患者符合气管切开术的条件。116 例为早期经皮扩张气管切开术，机械通气后中位时间为 9 天（四分位距，7-12 d），89 例为晚期经皮扩张气管切开术，机械通气后中位时间为 19 天（四分位距，16-24 d）。与未行气管切开术的患者相比，行早期经皮扩张气管切开术的患者机械通气停止的可能性更高（绝对差异 30%；p < 0.001；成功停止的危险比，2.8；95%置信区间，1.34-5.84；p = 0.006），死亡率更低（绝对差异 34%；p < 0.001；死亡的危险比，0.11；95%置信区间，0.06-0.22；p < 0.001）。与行晚期经皮扩张气管切开术的患者相比，行早期经皮扩张气管切开术的患者机械通气停止率更高（绝对差异 7%；p < 0.35；成功停止的危险比，1.53；95%置信区间，1.01-2.3；p = 0.04），幸存者的机械通气中位时间更短（绝对差异，-15 d；p < 0.001）。所有实施所有经皮扩张气管切开术的医护人员均无严重急性呼吸综合征冠状病毒 2 感染的临床症状或任何阳性实验室检查结果。
在接受机械通气的 2019 年冠状病毒病患者中，早期改良经皮扩张气管切开术对患者和医护人员均安全，并可改善临床结局。
