Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan.
Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka 565-0871, Japan.
Auris Nasus Larynx. 2023 Apr;50(2):276-284. doi: 10.1016/j.anl.2022.06.002. Epub 2022 Jun 13.
Tracheostomy is a common procedure with potential prognostic advantages for patients who require prolonged mechanical ventilation (PMV). Early recommendations for patients with coronavirus disease 2019 (COVID-19) suggested delayed or limited tracheostomy considering the risk for viral transmission to clinicians. However, updated guidelines for tracheostomy with appropriate personal protective equipment have revised its indications. This study aimed to evaluate the association between tracheostomy and prognosis in patients with COVID-19 requiring PMV.
This was a multicenter, retrospective cohort study using data from the nationwide Japanese Intensive Care PAtient Database. We included adult patients aged ≥16 years who were admitted to the intensive care unit (ICU) due to COVID-19 and who required PMV (for >14 days or until performance of tracheostomy). The primary outcome was hospital mortality, and the association between implementation of tracheostomy and patient prognosis was assessed using weighted Cox proportional hazards regression analysis with inverse probability of treatment weighting (IPTW) using the propensity score to address confounders.
Between January 2020 and February 2021, 453 patients with COVID-19 were observed. Data from 109 patients who required PMV were analyzed: 66 (60.6%) underwent tracheostomy and 38 (34.9%) died. After adjusting for potential confounders using IPTW, tracheostomy implementation was found to significantly reduce hospital mortality (hazard ratio [HR]: 0.316, 95% confidence interval [CI]: 0.163-0.612). Patients who underwent tracheostomy had a similarly decreased ICU and 28-day mortality (HR: 0.269, 95% CI: 0.124-0.581; HR 0.281, 95% CI: 0.094-0.839, respectively). A sensitivity analysis using different definitions of PMV duration consistently showed reduced mortality in patients who underwent tracheostomy.
The implementation of tracheostomy was associated with favorable patient prognosis among patients with COVID-19 requiring PMV. Our findings support proactive tracheostomy in critically ill patients with COVID-19 requiring mechanical ventilation for >14 days.
气管切开术是一种常见的手术，对于需要长时间机械通气（PMV）的患者具有潜在的预后优势。早期针对 2019 年冠状病毒病（COVID-19）患者的建议建议延迟或限制气管切开术，因为存在将病毒传播给临床医生的风险。然而，具有适当个人防护设备的气管切开术的最新指南已经修改了其适应证。本研究旨在评估 COVID-19 患者中 PMV 与气管切开术与预后的相关性。
这是一项多中心、回顾性队列研究，使用了全国性日本重症监护患者数据库的数据。我们纳入了因 COVID-19 入住重症监护病房（ICU）且需要 PMV（>14 天或直至进行气管切开术）的年龄≥16 岁的成年患者。主要结局为医院死亡率，并使用倾向评分处理混杂因素的逆概率处理加权（IPTW）加权 Cox 比例风险回归分析评估气管切开术的实施与患者预后之间的关系。
2020 年 1 月至 2021 年 2 月期间，观察到 453 例 COVID-19 患者。对需要 PMV 的 109 例患者的数据进行了分析：66 例（60.6%）进行了气管切开术，38 例（34.9%）死亡。使用 IPTW 调整潜在混杂因素后，发现气管切开术的实施显著降低了医院死亡率（风险比[HR]：0.316，95%置信区间[CI]：0.163-0.612）。进行气管切开术的患者 ICU 死亡率和 28 天死亡率也相应降低（HR：0.269，95%CI：0.124-0.581；HR 0.281，95%CI：0.094-0.839）。使用不同的 PMV 持续时间定义进行敏感性分析，结果一致显示气管切开术组患者死亡率降低。
对于需要 PMV 的 COVID-19 患者，气管切开术的实施与患者预后良好相关。我们的研究结果支持对需要机械通气>14 天的 COVID-19 危重症患者进行积极的气管切开术。
