Intensive Care Unit, University Hospital Virgen de la Salud, Toledo, Spain.
Intensive Care Unit, Vall d'Hebron University Hospital, Barcelona, Spain.
Chest. 2022 Jan;161(1):121-129. doi: 10.1016/j.chest.2021.06.015. Epub 2021 Jun 17.
During the first wave of the COVID-19 pandemic, shortages of ventilators and ICU beds overwhelmed health care systems. Whether early tracheostomy reduces the duration of mechanical ventilation and ICU stay is controversial.
Can failure-free day outcomes focused on ICU resources help to decide the optimal timing of tracheostomy in overburdened health care systems during viral epidemics?
This retrospective cohort study included consecutive patients with COVID-19 pneumonia who had undergone tracheostomy in 15 Spanish ICUs during the surge, when ICU occupancy modified clinician criteria to perform tracheostomy in Patients with COVID-19. We compared ventilator-free days at 28 and 60 days and ICU- and hospital bed-free days at 28 and 60 days in propensity score-matched cohorts who underwent tracheostomy at different timings (≤ 7 days, 8-10 days, and 11-14 days after intubation).
Of 1,939 patients admitted with COVID-19 pneumonia, 682 (35.2%) underwent tracheostomy, 382 (56%) within 14 days. Earlier tracheostomy was associated with more ventilator-free days at 28 days (≤ 7 days vs > 7 days [116 patients included in the analysis]: median, 9 days [interquartile range (IQR), 0-15 days] vs 3 days [IQR, 0-7 days]; difference between groups, 4.5 days; 95% CI, 2.3-6.7 days; 8-10 days vs > 10 days [222 patients analyzed]: 6 days [IQR, 0-10 days] vs 0 days [IQR, 0-6 days]; difference, 3.1 days; 95% CI, 1.7-4.5 days; 11-14 days vs > 14 days [318 patients analyzed]: 4 days [IQR, 0-9 days] vs 0 days [IQR, 0-2 days]; difference, 3 days; 95% CI, 2.1-3.9 days). Except hospital bed-free days at 28 days, all other end points were better with early tracheostomy.
Optimal timing of tracheostomy may improve patient outcomes and may alleviate ICU capacity strain during the COVID-19 pandemic without increasing mortality. Tracheostomy within the first work on a ventilator in particular may improve ICU availability.
在 COVID-19 大流行的第一波疫情期间，呼吸机和 ICU 床位短缺使医疗系统不堪重负。早期气管切开术是否能缩短机械通气和 ICU 住院时间存在争议。
以 ICU 资源为重点的无失败日结局是否有助于确定在病毒性流行期间，医疗资源负担过重的情况下，行气管切开术的最佳时机？
这是一项回顾性队列研究，纳入了在西班牙 15 个 ICU 接受气管切开术的连续 COVID-19 肺炎患者，在疫情高峰期，当 ICU 入住率改变了行气管切开术的临床医生标准时，COVID-19 患者被纳入其中。我们比较了在不同时间（插管后≤7 天、8-10 天和 11-14 天）进行气管切开术的倾向评分匹配队列中，28 天和 60 天的无呼吸机天数和 28 天和 60 天的 ICU 和医院床位无占用天数。
在 1939 名因 COVID-19 肺炎入院的患者中，682 名（35.2%）接受了气管切开术，其中 382 名（56%）在 14 天内进行了气管切开术。早期气管切开术与 28 天的无呼吸机天数更多相关（≤7 天与>7 天[纳入分析的 116 名患者]：中位数为 9 天[四分位距（IQR），0-15 天]与 3 天[IQR，0-7 天]；两组间差异，4.5 天；95%置信区间，2.3-6.7 天；8-10 天与>10 天[纳入分析的 222 名患者]：6 天[IQR，0-10 天]与 0 天[IQR，0-6 天]；差异为 3.1 天；95%置信区间，1.7-4.5 天；11-14 天与>14 天[纳入分析的 318 名患者]：4 天[IQR，0-9 天]与 0 天[IQR，0-2 天]；差异为 3 天；95%置信区间，2.1-3.9 天）。除了 28 天的无病床天数外，早期气管切开术的所有其他终点均有改善。
气管切开术的最佳时机可能会改善患者的预后，并在不增加死亡率的情况下缓解 COVID-19 大流行期间的 ICU 容量压力。特别是在呼吸机上的第一次工作时进行气管切开术可能会提高 ICU 的可用性。
Zotero 插件