Nancy A. Melville

January 25, 2013

SAN JUAN, Puerto Rico — After prolonged mechanical ventilation, patients transition faster when a tracheostomy collar is used than when pressure support is used, investigators reported here at the Society of Critical Care Medicine 42nd Critical Care Congress.

On average, patients were breathing on their own 4 days faster with the tracheostomy collar.

 
The importance of 4 fewer days on a ventilator is profound.
 

Although there were no significant differences in mortality between the 2 groups at 1 year, the importance of 4 fewer days on a ventilator is profound, lead investigator Amal Jubran, MD, professor of medicine and section chief of the division of pulmonary and critical care at the Edward Hines Jr. Veterans Administration Hospital in Illinois, told Medscape Medical News.

"Any day a patient is spared from the ventilator is a benefit.... The risk of ventilator-associated pneumonia increases about 1% per day each day a patient is on the ventilator, and the mental stress a patient endures is huge," said Dr. Jubran. "The inability to be mobile or to talk leads to a profound sense of helplessness."

Pressure support and tracheostomy collars are the 2 most common methods used in long-term acute care hospitals. In this study, the investigators evaluated 316 patients who were on mechanical ventilation for more than 21 days.

After adjustment for covariates, weaning was more successful with the tracheostomy collar than with pressure support (hazard ratio, 1.43; 95% confidence interval, 1.03 - 1.98; = .033.)

Outcomes for Patients on Prolonged Ventilation

Outcome Tracheostomy Collar
(n = 161)
Pressure Support
(n = 155)
P Value
Successful weaning 15 days 19 days .004
Percentage weaned 53% 45%
Mortality at 1 year 66% 60%


Dr. Jubran said the tracheostomy collar helps give clinicians confidence when making the decision to take a patient off ventilation, which could explain why these patients were generally weaned faster.

"When a patient is on a tracheostomy collar, he is getting no assistance at all from the ventilator — he is breathing entirely on his own — and the clinician watching the patient gets a clear view of how much respiratory work the patient is doing," she explained. "With pressure support, however, the ability to judge whether the patient could be weaned is clouded because the ventilator is still providing some assistance; it's hard to eyeball the patient to determine just how much he is doing and how much the ventilator is doing."

The study initially involved 500 patients on prolonged ventilation who were given a 5-day ventilation screening procedure after being transferred to a long-term acute care hospital.

Although the 316 patients randomized did not tolerate the procedure, 184 — more than a third — were successfully weaned from ventilation within a few days of arrival.

Patients Off Ventilation Within Days

According to session moderator Samuel Tisherman, MD, from the University of Pittsburgh School of Medicine in Pennsylvania, that's a striking figure. "I think this is something people in the ICU really need to look at. We send patients out of the ICU and, in a lot of situations, we never find out what happens to them next."

The fact that "as many as a third of patients who had been on ventilators for more than 21 days were weaned from them as soon as they left the ICU and were under the care of someone else should cause us to take another look at how we are handling these patients," Dr. Tisherman told Medscape Medical News.

He was less surprised to see a faster weaning time with the tracheostomy collar; he agrees that the approach gives a more clear-cut breathing challenge to the patient, leading to easier and faster clinical decision making.

"I'm not really surprised by the results, he said. "They confirm that it's really our figuring out whether the patient is ready to come off the ventilator that can slow things down."

"This is like many other things we do; we try these fancy or more expensive approaches. Sometimes just getting back to the basics of letting someone try to breathe on their own can give you your answer," Dr. Tisherman explained.

Patients on ventilators consume about 37% of intensive care unit costs, and the expense associated with long-term acute care hospitals exceeds $1 billion.

This study received funding from the National Institutes of Health. Dr. Jubran and Dr. Tisherman have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 42nd Critical Care Congress. Late-breaker abstract. Presented January 22, 2013.

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