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Purpose: Telemedicine Critical Care (TCC) improves adherence to evidence based protocols associated with improved mortality among patients receiving invasive mechanical ventilation (IMV). We sought to evaluate the relationship between hospital availability of TCC and outcomes among patients receiving IMV., Materials and Methods: We performed a cross-sectional study of 66,522 adults who received IMV for non-postoperative acute respiratory failure at 318 non-federal hospitals in New York, Massachusetts, Maryland, and Florida in 2018. Hospital-level TCC availability was ascertained from the 2018 American Hospital Association Annual Survey. The primary outcome was in-hospital mortality. Secondary outcomes included the composite of tracheostomy or reintubation and duration of IMV. We used two-level hierarchical multivariable regression models to investigate the association between TCC availability and outcomes., Results: 20,270 (30.5%) patients were admitted into 89 TCC-available hospitals. There was no difference between TCC and non-TCC-available hospitals in mortality (odds ratio [OR] 0.94, 99% confidence interval [CI] 0.84-1.05), composite of tracheostomy or reintubation (OR 0.95 [0.82-1.11], or duration of IMV (OR 0.95 [0.83-1.09]). There was no difference in outcomes among the subgroup of patients with acute respiratory distress syndrome., Conclusions: Hospital TCC availability was not associated with improved outcomes among patients receiving IMV., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Amyotrophic lateral sclerosis (ALS) entails a risk of acute respiratory failure (ARF). The decision to admit such patients to the intensive care unit (ICU) is difficult given the inexorable prognosis of ALS. To fuel this discussion, this study describes the ICU and post-ICU survival of ALS-related ARF., Material and Methods: Retrospective cohort analysis over 10 years (university hospital setting, ALS reference center)., Results: Of 90 patients (66 men, median age: 67 [IQR 59-71], median interval since ALS diagnosis: 26.5 months [14-53], ALSFRS-R: 19 [12-30], bulbar signs 73%), 48 were managed by noninvasive ventilation (NIV) only, 7 were already tracheotomized upon admission, 12 were tracheotomized during the ICU stay (advance care planning project), 18 were already intubated before admission, 5 received oxygen and physiotherapy only. Median ICU stay was 4 days [2-9] with 20% mortality. Median hospital stay was 10 days [5-22] with 33% mortality. The 3-month and one year mortality wer 46% and 71%. Hospital mortality was higher in patients with more severe respiratory acidosis and higher simplified acute physiology scores on admission., Conclusions: The prognosis of ALS-related ARF requiring ICU admission resembles that of ARF complicating other conditions with high short-term mortality (e.g. lung cancer)., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Up to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, the financial impact of early tracheostomies remain unknown., Objectives: To conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients., Methods: We extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations., Results: The average weighted cost of ICU stay in patients with an early tracheostomy was $4316 less when compared to patients with late tracheostomy (95% CI: 403-8229). Subgroup analysis revealed that very early tracheostomies (<4days) cost on average $3672 USD less than late tracheostomies (95% CI: -1309, 10,294) and that early tracheostomies (<10days but >4) cost on average $6385 USD less than late tracheostomies (95% CI: -4396-17,165)., Conclusion: This study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost-effectiveness of early tracheostomy in the critically ill population., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: This study was performed to elucidate the current clinical features and outcomes of tetanus using a national inpatient database in Japan., Materials and Methods: We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively investigate patients with tetanus from July 2010 to March 2016. We examined the patients' characteristics; the proportions of patients requiring tracheal intubation, mechanical ventilation, and tracheostomy; and the discharge status., Results: We identified 499 patients who were diagnosed with tetanus. No patient had a diagnosis of tetanus neonatorum or obstetric tetanus. The median age was 74years. Overall, 53.5% of the patients required intubation and mechanical ventilation. Among patients who required intubation and mechanical ventilation, 80.6% started it within 3days of admission, and 77.5% required tracheostomy during hospitalization. The median duration of mechanical ventilation was 23days. The median length of hospitalization was 35days. The proportions of patients who were discharged to home and to locations other than home were 58.1% and 35.1%, respectively. The in-hospital mortality was 6.8%., Conclusion: The present study suggests that acute-care physicians should be ready to provide intensive care for patients with tetanus and cooperate with medical social workers and families for subsequent long-term nursing care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Trauma patients admitted to the intensive care unit (ICU) are at heightened risk for oropharyngeal dysphagia and pulmonary aspiration. Timely and appropriate referrals for dysphagia may reduce mortality rates and hospital readmissions. This study sought to identify predictors of dysphagia in a large cohort of patients with multiple traumatic injuries., Methods: The Trauma Registry Database was queried for admissions at a level 1 trauma center from 2012 to 2016 who underwent instrumental swallowing evaluations. Relevant demographics, injuries, and interventions known to be associated with dysphagia were collected. The Dysphagia Outcome and Severity Scale (DOSS) was utilized to define severity of dysphagia. Regression analyses were performed to identify predictors of dysphagia., Results: Two hundred and sixty two patients met criteria. Multivariate analyses found injury severity (p<0.01), tracheostomy (p<0.05), TBI (p<0.05), and cervical spinal bracing (p<0.001) to be predictors of dysphagia development. Furthermore, length of ICU stay (p<0.01) and cervical spinal bracing (p<0.01) were associated with a greater severity of dysphagia., Conclusions: Oropharyngeal dysphagia is a common complication in trauma patients. Our results propose a set of predictors that should be considered when identifying critically injured patients at risk for dysphagia., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Currently, there is a lack of evidence-based guidelines on the proper protocol for feeding infants with a tracheostomy in the neonatal intensive care unit (NICU). The purpose of this study was to provide preliminary insight into the outcomes of these infants in one mid-Atlantic pediatric hospital., Design and Methods: Retrospective and descriptive. The study team reviewed 114 patient records, 42 of which met the inclusion criteria. Data were organized based on: 1) general demographics and history; b) feeding-related variables at multiple points; c) speech-related variables, including assessments and swallowing studies; d) respiratory variables at multiple points; and, e) discharge data. Other variables included birth-related information, ventilation settings and feeding modifications., Results: Infants were placed into three groups at discharge based on feeding outcomes. Forty-three percent were discharged on full oral feeds, 38% on combined oral and gavage, and 19% of infants were discharged on full gavage feeds. Informal analysis showed that all three categories of infants gained weight during hospitalization, different PEEP pressures and different lengths of hospitalization were observed among the groups, and infant characteristics (e.g., APGAR, gestational ages) were similar across groups., Conclusions: Overall results provide insight into factors that may be predictive of feeding status at discharge for infants with a tracheostomy in an NICU., Practical Implications: Results of this study can provide important insight into the feeding outcomes of infants in a NICU with a tracheostomy and can hopefully lead to additional research to help determine the most efficacious procedures for feeding this patient population., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Endotracheal self-extubation (ESE) is a serious health care concern. We designed this study to test our hypothesis that not all patients with ESE are successful in spontaneous breathing and reintubation has negative impact on outcomes., Methods: Data on all 39 patients of ESE in our surgical and trauma intensive care unit (ICU) in 2012 were prospectively collected and retrospectively analyzed., Results: There were 42 episodes of ESE in 39 of 939 intubated patients (frequency, 4.0%), with 54% of events requiring reintubation. Pre-ESE positive end-expiratory pressure was higher and Pao2/fraction of inspired oxygen ratio was lower, and the post-ESE respiration rate was higher in the reintubated group. On univariate analysis, weaning and spontaneous breathing trial before ESE were favorable predictors for nonreintubation. Multivariate regression analysis demonstrated that agitation before ESE was an independent predictor of reintubation. The need for reintubation was associated with increased risk of pulmonary infectious complications, ventilator days, the need for tracheostomy, and ICU and hospital LOS. The financial costs for ventilator days and ICU rooms were significantly higher in patients with reintubation., Conclusion: Not all patients were fine after ESE. We have not decreased the frequency of ESE or improved outcomes if the patients were reintubated. The need for reintubation was not only associated with a high pulmonary complication rate but also prolonged duration on mechanical ventilation and hospital/ICU stay and increased the hospital costs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Patterns of death after trauma are changing due to advances in critical care. We examined mortality in critically injured patients who survived index hospitalization., Methods: Retrospective analysis of adults admitted to a Level-1 trauma center (1/1/2000-12/31/2010) with critical injury was conducted comparing patient characteristics, injury, and resource utilization between those who died during follow-up and survivors., Results: Of 1,695 critically injured patients, 1,135 (67.0%) were discharged alive. As of 5/1/2012, 977/1,135 (86.0%) remained alive; 75/158 (47.5%) patients who died during follow-up, died in the first year. Patients who died had longer hospital stays (24 vs. 17 days) and ICU LOS (17 vs. 8 days), were more likely to undergo tracheostomies (36% vs. 16%) and gastrostomies (39% vs. 16%) and to be discharged to rehabilitation (76% vs. 63%) or skilled nursing (13% vs. 5.8%) facilities than survivors. In multivariable models, male sex, older age, and longer ICU LOS predicted mortality. Patients with ICU LOS >16 days had 1.66 odds of 1-year mortality vs. those with shorter ICU stays., Conclusions: ICU LOS during index hospitalization is associated with post-discharge mortality. Patients with prolonged ICU stays after surviving critical injury may benefit from detailed discussions about goals of care after discharge., (Published by Elsevier Inc.)

Purpose: Acute kidney injury (AKI) is a common occurrence after lung transplantation (LTx). Whether transient AKI or early recovery is associated with improved outcome is uncertain. Our aim was to describe the incidence, factors, and outcomes associated with transient AKI after LTx., Materials and Methods: We performed a retrospective cohort study of all adult recipients of LTx at the University of Alberta between 1990 and 2011. Our primary outcome transient AKI was defined as return of serum creatinine below Kidney Disease-Improving Global Outcome AKI stage I within 7days after LTx. Secondary outcomes included occurrence of postoperative complications, mortality, and long-term kidney function., Results: Of 445 LTx patients enrolled, AKI occurred in 306 (68.8%) within the first week after LTx. Of these, transient AKI (or early recovery) occurred in 157 (51.3%). Transient AKI was associated with fewer complications including tracheostomy (17.2% vs 38.3%; P<.001), reintubation (16.4% vs 41.9%; P<.001), decreased duration of mechanical ventilation (median [interquartile range], 69 [41-142] vs 189 [63-403] hours; P<.001), and lower rates of chronic kidney disease at 3 months (28.5% vs 51.1%, P<.001) and 1 year (49.6% vs 66.7%, P=.01) compared with persistent AKI. Factors independently associated with persistent AKI were higher body mass index (per unit; odds ratio [OR], 0.91; 95% confidence interval, 0.85-0.98; P=.01), cyclosporine use (OR, 0.29; 0.12-0.67; P=.01), longer duration of mechanical ventilation (per hour [log transformed]; OR, 0.42; 0.21-0.81; P=.01), and AKI stages II to III (OR, 0.16; 0.08-0.29; P<.001). Persistent AKI was associated with higher adjusted hazard of death (hazard ratio, 1.77 [1.08-2.93]; P=.02) when compared with transient AKI (1.44 [0.93-2.19], P=.09) and no AKI (reference category), respectively., Conclusions: Transient AKI after LTx is associated with fewer complications and improved survival. Among survivors, persistent AKI portends an increased risk for long-term chronic kidney disease., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Multidisciplinary tracheostomy teams have been implemented in acute hospitals over the past 10 years. This systematic review of the literature and meta-analysis aimed to assess the effect of tracheostomy teams on patient outcomes., Materials and Methods: We conducted an electronic search of the literature in the following databases: MEDLINE, CINAHL, EMBASE, and AMED. Inclusion/exclusion criteria were applied, and included articles were assessed against quality criteria. Qualitative synthesis and meta-analysis were completed., Results: Seven studies were included. The studies were all pre-post cohort designs of low-moderate quality. Meta-analysis showed that tracheostomy teams were associated with reductions in total tracheostomy time (4 studies; mean difference, 8 days; 95% confidence interval, 6-11; P < .01; I(2) = 0%) and hospital length of stay (LOS) (3 studies; mean difference, -14 days; 95% confidence interval, -39 to 9; P = .23; I(2) = 50%). Reductions in intensive care unit LOS (3 studies) and increases in speaking valve (3 studies) use were also reported with tracheostomy teams., Conclusion: There is low-quality evidence that multidisciplinary tracheostomy care contributes to a reduction in total tracheostomy time and increase speaking valve use for patients leading to improved quality of life. There is insufficient evidence to determine that multidisciplinary tracheostomy teams reduce hospital or intensive care unit LOS., (Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study is to evaluate the outcomes of hospitalized morbidly obese inpatients., Methods: In this retrospective cohort study, we reviewed the records of all adult morbidly obese patients (defined as body mass index [BM]) >40 kg/m(2) upon admission) admitted to tertiary university hospital from 2000 to 2008. Primary outcome was hospital mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), need for and duration of mechanical ventilation (MV), and tracheostomy rates. We divided patients into quartiles based on their admission BMI. Baseline characteristics and outcomes were reported for each quartile., Results: Over the 8-year period, we reviewed 897 admissions for 545 patients. The median number of admissions was 1 per patient (mean, 2.44 ± 2.9), with a range of 1 to 20. A total of 40.9% had more than one admission. Morbidly obese patients were more likely to be admitted to a medical service. Higher BMI quartiles had higher rates of ICU admission, MV, and rate of tracheostomy. Although the higher BMI quartiles had longer hospital LOS, hospital mortality did not significantly differ., Conclusions: As BMI increases, utilization of medical resources also increases such as ICU admission, MV, longer hospital LOS, and tracheostomy. Although overall BMI interquartile mortality rates do not differ significantly in our study, utilization of valuable and costly hospital resources is a major challenge facing health care delivery. Our findings indicate the need for increased efforts and novel strategies for treatment, prevention, and resource allocation to deal with this emerging challenge., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy., Objective: The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients., Patients and Method: A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m(2)., Results: The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 +/- 9 kg/m(2) vs 22 +/- 3 kg/m(2) for the nonobese patient group (P < .001). The obese patients required 18 +/- 7 days of mechanical ventilation, on average, before PT vs 16 +/- 7 days for the nonobese patients (P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively (P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients (P = .2)., Conclusion: Percutaneous tracheostomy using the fiberoptic bronchoscopy-assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.

Objective: The purpose of this study was to assess current practice of performing tracheostomies in critically ill cardiac surgical patients, to establish complication rates, and to identify areas of this clinical practice that could be improved., Design: Retrospective observational study., Setting: A cardiothoracic intensive care unit in a teaching hospital., Participants: The most recent series of 100 tracheostomies performed in patients admitted to the intensive care unit., Interventions: Percutaneous or surgical tracheostomy for respiratory management., Measurements and Main Results: A total of 95 patients had 1 tracheostomy performed. One patient had a tracheostomy performed twice, and 1 patient had a tracheostomy performed 3 times; these repetitions were caused by recurrent respiratory failure. The median time from tracheal intubation to tracheostomy was 5 days (range, 1-23 days; interquartile range, 4-8 days), and median period between insertion and decannulation was 20 days (range, 2-77 days; interquartile range, 12-25 days). The most common reason for insertion was an anticipated long weaning time (55%) followed by insertion after failed extubation (32%). The Ciaglia percutaneous dilational technique was used for 89% of tracheostomies, whereas surgical techniques were used for 8%. The most common complication was either complete or partial obstruction of the tracheostomy tube (24%) followed by infection of the tracheostomy site in 18% (17/94) and bleeding at the time of insertion (11%)., Conclusion: The percutaneous dilational technique of tracheostomy was used predominantly in this unit. The median time from tracheal intubation to tracheostomy was 5 days. The most common complications were bleeding at the time of insertion, obstruction of the tracheostomy tube, and stomal infection.