February 10, 2012 (Houston, Texas) — Changing tracheostomy tubes early (before day 7) is associated with earlier ability to tolerate a speaking valve and allows patients to take nourishment by mouth sooner, researchers reported here at the Society of Critical Care Medicine 41st Critical Care Congress.
"The first tracheostomy tube change is usually done between day 7 and day 14 after insertion, but we noticed a wide variability between different attendings in our practice," Ulrich Schmidt, MD, from the Massachusetts General Hospital, Boston, told Medscape Medical News. "Our hypothesis was that the sooner you change it, the sooner patients will be able to communicate verbally and take things by mouth."
Dr. Schmidt and his group enrolled 130 patients who were admitted to their respiratory care unit after tracheostomy placement. Of these patients, 38 underwent a tracheostomy change before day 7 and 92 underwent it after day 7. All patients were similar in terms of age, APACHE score, and comorbidities.
As they hypothesized, the researchers found that patients who had their tracheostomy tubes changed earlier ate and spoke sooner.
Most of the patients in the early group had their tracheostomy tubes changed on day 5; in the late group, they were changed on day 10.
Patients in the early group were more likely to be liberated from the ventilator on day 7 (100% vs 45%; P = .0001) and to tolerate a speaking valve earlier (7 vs 12 days; P = .001) than in the late group. They were also able to tolerate oral intake significantly earlier (10 vs 20 days; P = .04).
Patients in the early group also had a shorter stay in the intensive care unit (ICU) (11 vs 17 days; P = .001) and in the hospital (P = .048) than the late group
There was no difference in mortality and there were no complications associated with tracheostomy change.
"The finding that early patients had shorter ICU stays was rather surprising; I cannot explain why," Dr. Schmidt said in an interview with Medscape Medical News. "This was not a randomized controlled trial, and we only had 130 patients, so our findings could be due to chance," he cautioned.
He also pointed out that the study did not determine whether patients in the early group were more satisfied with their care than patients in the late group.
"Based on these data, patients are being changed on day 5 when possible at our center," Dr. Schmidt said.
"Changing earlier than day 5 is probably going to put the patient at risk for complications. There are enough reports in the literature that changing earlier produces more complications. Also, if you are able to change a tracheostomy tube on day 3 after you placed it, you have to ask yourself whether you really needed to place a trach in the first place," he said.
Charu Paranjape, MD, from the Akron General Hospital in Ohio, who moderated the poster session, told Medscape Medical News that the preferred tracheostomy technique at his hospital is percutaneous tracheostomy.
"Our preference is to do percutaneous all the time. Tracheostomy patients are typically the ones who the surgeons want to go slow on when it comes to weaning them. They don't want the nurses changing their trach tube without notifying them," he said. "Still, this study is interesting because it shows that if you start weaning patients earlier, the outcomes could be better."
Dr. Schmidt and Dr. Paranjape have disclosed no relevant financial relationships.
Society of Critical Care Medicine (SCCM) 41st Critical Care Congress: Abstract 515. Presented February 6, 2012
Medscape Medical News © 2012 WebMD, LLC
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