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Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit

Kollef, Marin H. MD, FACP; Ahrens, Thomas S. RN, DNSc; Shannon, William PhD

Clinical Investigations
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Objective: To identify clinical predictors for tracheostomy among patients requiring mechanical ventilation in the intensive care unit (ICU) setting and to describe the outcomes of patients receiving a tracheostomy.

Design: Prospective cohort study.

Setting: Intensive care units of Barnes-Jewish Hospital, an urban teaching hospital.

Patients: 521 patients requiring mechanical ventilation in an ICU for >12 hours.

Interventions: Prospective patient surveillance and data collection.

Measurements and Main Results: The main variables studied were hospital mortality, duration of mechanical ventilation, length of stay in the ICU and the hospital, and acquired organ-system derangements. Fifty-one (9.8%) patients received a tracheostomy. The hospital mortality of patients with a tracheostomy was statistically less than the hospital mortality of patients not receiving a tracheostomy (13.7% vs. 26.4%; p = .048), despite having a similar severity of illness at the time of admission to the ICU (Acute Physiology and Chronic Health Evaluation [APACHE] II scores, 19.2 ± 6.1 vs. 17.8 ± 7.2; p = .173). Patients receiving a tracheostomy had significantly longer durations of mechanical ventilation (19.5 ± 15.7 days vs. 4.1 ± 5.3 days; p < .001) and hospitalization (30.9 ± 18.1 days vs. 12.8 ± 10.1 days; p < .001) compared with patients not receiving a tracheostomy. Similarly, the average duration of intensive care was significantly longer among the hospital nonsurvivors receiving a tracheostomy (n = 7) compared with the hospital nonsurvivors without a tracheostomy (n = 124; 30.9 ± 16.3 days vs. 7.9 ± 7.3 days; p < .001). Multiple logistic regression analysis demonstrated that the development of nosocomial pneumonia (adjusted odds ratio [AOR], 4.72; 95% confidence interval [CI], 3.24-6.87; p < .001), the administration of aerosol treatments (AOR, 3.00; 95% CI, 2.18-4.13; p < .001), having a witnessed aspiration event (AOR, 3.79; 95% CI, 2.30-6.24; p = .008), and requiring reintubation (AOR, 2.21; 95% CI, 1.54-3.18; p = .028) were variables independently associated with patients undergoing tracheostomy and receiving prolonged ventilatory support. Among the 44 survivors receiving a tracheostomy in the ICU, 38 (86.4%) were alive 30 days after hospital discharge and 31 (70.5%) were living at home.

Conclusions: Despite having longer lengths of stay in the ICU and hospital, patients with respiratory failure who received a tracheostomy had favorable outcomes compared with patients who did not receive a tracheostomy. These data suggest that physicians are capable of selecting critically ill patients who most likely will benefit from placement of a tracheostomy. Additionally, specific clinical variables were identified as risk factors for prolonged ventilatory assistance and the need for tracheostomy.

From the Departments of Medicine, Pulmonary and Critical Care Division (Dr. Kollef), and the Division of General Medical Sciences (Dr. Shannon), Washington University School of Medicine; and the Department of Nursing (Mr. Ahrens), Barnes-Jewish Hospital, St. Louis, MO.

Supported, in part, by institutional funds and a grant from the Barnes-Jewish-Christian Innovations in Health Care Program.

© 1999 Lippincott Williams & Wilkins, Inc.